Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy

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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy

              Building a National Resilience Strategy
              Alcohol and Drug Misuse and
              Suicide and the Millennial
              Generation — a Devastating Impact
JUNE 2019
Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
    Trust for America’s Health (TFAH) is a nonprofit, nonpartisan public health policy, research, and advocacy organization that promotes
    optimal health for every person and community and makes the prevention of illness and injury a national priority.

    Well Being Trust is a national foundation dedicated to advancing the mental, social, and spiritual health of the nation. Created to include
    participation from organizations across sectors and perspectives, Well Being Trust is committed to innovating and addressing the most
    critical mental health challenges facing America and to transforming individual and community well-being.

    This report was supported by generous grants from Well Being Trust and the Robert Wood Johnson Foundation. Opinions expressed
    within the report are that of TFAH and Well Being Trust and do not necessarily reflect the views of the Robert Wood Johnson Foundation.

    TFAH Board of Directors                                                                                Trust for America’s Health
    Gail Christopher, D.N.                             David Lakey, M.D.                                   John Auerbach, MBA
    Chair of the TFAH Board                            Chief Medical Officer and Vice Chancellor for       President and CEO
    President and Founder                              Health Affairs
                                                                                                           J. Nadine Gracia, M.D., MSCE
    Ntianu Center for Healing and Nature               The University of Texas System
                                                                                                           Executive Vice President and COO
    Former Senior Advisor and Vice President
                                                       Octavio Martinez Jr., M.D., DPH, MBA, FAPA
    W.K. Kellogg Foundation
                                                       Executive Director                                  Lead Author
    David Fleming, M.D.                                Hogg Foundation for Mental Health                   Rhea K. Farberman, APR
    Vice Chair of the TFAH Board                       The University of Texas at Austin                   Director of Strategic Communications and Policy
    Vice President of Global Health Programs                                                               Research
                                                       Karen Remley, M.D., MBA, MPH, FAAP
    PATH                                                                                                   Trust for America’s Health
                                                       Senior Fellow
    Robert T. Harris, M.D.                             De Beaumount Foundation
    Treasurer of the TFAH Board                        Former CEO and Executive Vice President             Contributors
    Senior Medical Director                            American Academy of Pediatrics                      John Auerbach, MBA
    General Dynamics Information Technology                                                                President and CEO
                                                       John Rich, M.D., MPH
                                                                                                           Trust for America’s Health
    Theodore Spencer                                   Co-Director
    Secretary of the TFAH Board                        Center for Nonviolence and Social Justice           Molly Warren, S.M.
    Founding Board Member                              Drexel University                                   Senior Health Policy Researcher and Analyst
                                                                                                           Trust for America’s Health
    Stephanie Mayfield Gibson, M.D.                    Eduardo Sanchez, M.D., MPH
    Senior Physician Advisor and Population Health     Chief Medical Officer for Prevention and Chief of   Benjamin F. Miller, Psy.D.
    Consultant                                         the Center for Health Metrics and Evaluation        Chief Strategy Officer
    Former Senior Vice President, Population Health,   American Heart Association                          Well Being Trust
    and Chief Medical Officer
                                                       Umair A. Shah, M.D., MPH                            Albert Lang
    KentuckyOne Health
                                                       Executive Director                                  Director of Communications
    Cynthia M. Harris, Ph.D., DABT                     Harris County (Texas) Public Health                 Well Being Trust
    Director and Professor
                                                       Vince Ventimiglia, J.D.
    Institute of Public Health
                                                       Chairman, Board of Managers
    Florida A&M University
                                                       Leavitt Partners

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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Introduction and Discussion
In 2017, more than 152,000 Americans died from alcohol- and drug-induced fatalities and suicide.
That’s the highest number ever recorded and more than twice as many as in 1999.1 The largest
number of these deaths, almost half, were the result of drug overdoses—more than the peak
annual total from HIV, guns, or car crashes.2 Trust for America’s Health and Well Being Trust have
called for immediate and sustained attention and investment in a National Resilience Strategy to
address this rising death toll.3

Increases in alcohol, drug, and suicide             Research suggests that the United States            a mix of challenges unique to their
deaths have affected all age groups and all         urgently needs evidence-based policies              generation, many of which are discussed
communities, but the impact on people in            and programs, including those that                  in this report, including the opioid crisis,
their 20s and early 30s has been especially         are community- or population-specific,              the skyrocketing costs of education and
pronounced. In particular, the number               to help stem the nation’s tidal wave of             housing, and entering the job market
of drug deaths among young adults has               deaths of despair. This issue brief is a            during the great recession.
increased by 400 percent during the last            continuation of Trust for America’s
                                                                                                        Definitions of the Millennial generation
two decades, in large part fueled by the            Health (TFAH) and Well Being Trust’s
                                                                                                        are not always consistent across data
opioid crisis.4 Drug deaths accounted for           Pain in the Nation: The Drug, Alcohol and
                                                                                                        sources and organizations. Often there are
nearly seven deaths per 100,000 people              Suicide Crises and the Need for a National
                                                                                                        differences in age ranges or age groupings
nationally across all age groups in 1999.           Resilience Strategy series. It focuses on
                                                                                                        in data sets about Millennials. For this
By 2017, that number increased to 22.7              young adults, ages 20 to 34, often called
                                                                                                        reason, multiple data sets, with varying
deaths per 100,000 across all age groups.5          Millennials. The Pain in the Nation series
                                                                                                        age ranges, were used for this report. For
But for young adults ages 18 to 34 in 2017,         helps inform and create a comprehensive
                                                                                                        example, data sets covering those 18–25
there were nearly 31 drug-overdose deaths           National Resilience Strategy.
                                                                                                        or 25–34 or 30–35 are included in this
per 100,000 people.6 Meanwhile, alcohol
                                                    Millennials are generally thought of as             report, but the main theme is consistent:
death rates for young adults ages 18 to
                                                    people born between 1981 and 1996,                  alcohol, drugs, and suicide are having
34 went up 69 percent between 2007 and
                                                    making them ages 23 to 38 in 2019.8                 a profoundly negative impact on many
2017, and suicide deaths for the same age
                                                    Millennials faced and continue to face              young adults and their families.
group and same years went up 35 percent.7

  Percent increase in drug related                    Percent increase                                     Percent increase
  deaths, 2007 – 2017,                                in alcohol induced                                   in suicide deaths,
  18 to 34 year olds                                  deaths, 2007 – 2017,                                 2007 – 2017,
                                                      18 to 34 year olds                                   18 to 34 year olds

        108%                                                 69%                                                35%
SOURCE: Trust for America’s Health and Well Being Trust analysis of National Center for Health Statistics, CDC data

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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
                                       Since the late 1990s, deaths from alcohol, drug misuse and
                                       suicide have been steadily on the rise for all age groups,
                                       including the Millennials.

                                       Alcohol, Drug, and Suicide Deaths Among Young Adults: Ages 20–34, 1999–2017

                                                                  Alcohol-induced deaths        Drug-induced deaths

                                                                  Suicide deaths                Alcohol, Drug and Suicide deaths combined
                                       SOURCE: Trust for America’s Health and Well Being Trust analysis of National Center for Health
                                       Statistics data, CDC.9

                                       Huge increases in drug-related deaths, especially those involving synthetic opioids
                                       Opioids and the lethality of synthetic               increase in drug death rates between
                                       opioids have had a deadly impact on                  1999 and 2017 was 329 percent.14
                                       18- to 34-year-olds.11 Between 1999
                                                                                            Even more alarming were the increases in
                                       and 2017, opioid overdose death rates
                                                                                            the percentage of synthetic opioid deaths.
                                       among 18- to 34-year-olds increased by
                                                                                            Within a one-year period (2016–2017),
                                       more than 500 percent.12 During the
                                                                                            double- and triple-digit percent increases
                                       same period, the increase in synthetic
                                                                                            in synthetic opioid deaths occurred for
                                       opioid death rates among young
                                                                                            both sexes, all races and ethnicities, and
                                       adults increased by a staggering 6,000
                                                                                            in all regions of the country.15
                                       percent.13 The age group’s overall

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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Drug-Induced Deaths Per 100,000, by Opioid Involvement Among Young Adults,
Ages 20-34, 1999-2017

     Non-Opioid-Involved Drug Overdoses                       Overdoses related to opioids

SOURCE: Trust for America's Health and Well Being Trust analysis of National Center for Health
Statistics, CDC data

Suicide rates also on the rise
Young adults experienced larger                      the number of deaths from suicide in
proportional increases in suicide deaths             that combined age group increasing
when compared with other age groups,                 nearly 20 percent.18,19
except, alarmingly, children and
                                                     In 2017, suicide was one of the leading
adolescents. Between 2016 and 2017,
                                                     causes of death, second only to
suicide rates increased by 4 percent
                                                     unintentional injury, for people ages
across all age categories, the largest
                                                     15 to 34. By comparison, suicide deaths
annual increase since at least 1999,
                                                     were the fourth leading cause of death
when the dataset begins.
                                                     for 35- to 54-year-olds and the eighth
Over the past decade, suicide increased              leading cause of death for people ages 55
in nearly every state, but there were                to 64.20 Between 2000 and 2016, the most
substantial variations by demographic                common means of suicide for men were
group.16 For 18- to 34-year-olds, there              firearms. A 2017 Pew Research Center
was a 35 percent increase in suicide                 survey found that 43 percent of 18- to
deaths over the past decade. For                     29-year-olds either personally owned a
35- to 54-year-olds during that same                 firearm or lived with someone who did.21
time frame, suicide rates increased by               For women, the most common method
14 percent; for 55- to 74-year-olds, it              was poisoning or overdose.22
increased by 24 percent; and for people
                                                     More males die by suicide than females.
over 75, it increased by 14 percent.17
                                                     Between 2008 and 2017, the age-adjusted
Between 2011 and 2016, suicide was the               suicide death rate increased from 11.6 per
second leading cause of death for 15- to             100,000 to 14 per 100,000. Among males,
24-year-olds and 25- to 34-year-olds, with           the increase was from 19 per 100,000 to
                                                                                                  TFAH • WBT •   5
Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
22.4 per 100,000. Among females, the rate            the last month and suicide-related
                                       increased from 4.8 per 100,000 in 2008 to            outcomes (including suicide ideation,
                                       6.1 per 100,000 in 2017.23 Suicides by men           plan, attempts, and deaths) are increasing
                                       typically involve more lethal means than             sharply. Between 2008 and 2017, that
                                       attempts by women.                                   distress increased by 71 percent among
                                                                                            young adults ages 18 to 25. The survey
                                       According to a 2018 review of the
                                                                                            found less consistent and weaker increases
                                       National Survey of Drug Use and Health,
                                                                                            among adults ages 26 and over.24
                                       serious psychological distress during

                                       Alcohol, Drug and Suicide Deaths per 100,000 by Select Demographics: Young
                                       Adults, Ages 20-34, 2017

                                       SOURCE: Trust for America’s Health and Well Being Trust analysis of National Center for Health
                                       Statistics (CDC) data.10

                                       The impact of substance use disorders and suicide among
                                       young adults is at an all-time high, and young adults are dying at
                                       alarmingly high rates.

                                       Alcohol-related deaths on the rise
                                       During the last two decades, people                  increase in alcohol deaths for people
                                       in their 20s and 30s have experienced                ages 35 to 54 was 22 percent, and for
                                       the largest proportional increases in                people 55 to 74, it was 45 percent.26
                                       alcohol-induced deaths compared with
                                                                                            Among all age groups, about 88,000
                                       other age groups. The rate of alcohol-
                                                                                            people die of alcohol-attributable causes
                                       induced deaths doubled for 18- to
                                                                                            per year (including injury deaths, like
                                       34-year-olds between 1999 and 2017.25
                                                                                            car crashes, where excessive alcohol
                                       Between 2007 and 2017, there was a                   consumption is a contributing factor),
                                       69 percent increase in the number of                 making excessive alcohol consumption
                                       alcohol deaths among people ages 18                  the third leading cause of preventable
                                       to 34. During the same time period, the              death in the United States today.27
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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Young adults have a number of elevated
risk factors. People in their 20s and 30s
have certain risk factors that increase
their vulnerability to alcohol, drugs, and
suicide. Research shows that, typically,
the frontal lobes of the brain, home to a
number of key functions, such as impulse
control, are not fully developed until the
mid- to late-20s.28

Young adults often take more risks in
sexual and drug-use behaviors compared
with other adults.29 Furthermore, there
are disproportionate numbers of people
in this age category who are involved in
high-stress environments—for example, in
correctional facilities. In 2016, 42 percent
of the federal and state prison population     care, education, and food make up the
were between ages 20 and 34.31                 majority of that spending.34

Millennials also make up the highest           The costs of healthcare, and concerns
percentage of enlisted U.S. military           about how much care will cost, are
personnel. In 2016, 80 percent of U.S.         additional stressors for most Americans,
Army Servicemembers were between               including young adults, and can cause
ages 20 and 34.30                              people not to seek care in a timely
                                               manner. A 2019 poll found that one
In addition, today’s Millennials faced         in four people skipped a medical
the run-away costs of higher education.        treatment due to the cost of treatment.35
Many have large amounts of college
debt, which creates financial strain and       Finally, Millennials hit the housing
a reduced ability to purchase a home           market at a difficult time. Between 2011
or afford other goods and services that        and 2017, home prices increased by 48
might offer greater security, particularly     percent while incomes across all age
compared with prior generations. Of            groups grew by just 15 percent.36
households headed by someone younger           Many Millennials lack the protective
than 35, 40 percent have outstanding           factors that other age groups typically
student-loan debt.32 Young people with         had. Many Millennials are less likely
college debt typically spend close to half     to live in the kind of supportive
of their income on loan payments.33            circumstances that can help them
The costs of raising children can be           recover from trauma and adversity
additional stressors for Millennials.          compared with earlier generations.
According to the U.S. Department of            About six in 10 Millennials (57 percent)
Agriculture, it costs $14,000 annually         have never been married.37 Intimate-
to raise a child until age 17; that’s a        partner violence most commonly first
total of nearly $240,000. Housing, child       occurs between 18 and 24.38 Many

                                                                                           TFAH • WBT •   7
Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Millennials begin their work lives with      parties or religion.43,44
                                       few financial safety nets. While more
                                                                                    There are few specialized preventive
                                       than one-third (35 percent) of the U.S.
                                                                                    efforts targeting young adults. While there
                                       workforce are Millennials, they are less
                                                                                    has been considerable research into the
                                       likely to have health insurance than older
                                                                                    best, evidence-based practices for children
                                       workers.39 In 2017, 14 percent of 18- to
                                                                                    and adolescents’ well-being, there is
                                       24-year-olds and 17.2 percent of 25- to
                                                                                    limited attention devoted to Millennials’
                                       34-year-olds lacked health insurance.
                                                                                    well-being. Several effective interventions
                                       Young adults, ages 25 to 34 were almost
                                                                                    for children take advantage of the access
                                       twice as likely to lack health insurance
                                                                                    that schools offer. Similarly, for those in
                                       compared with middle-age and older
                                                                                    college, there are preventive interventions
                                       adults, ages 45 to 64.40
                                                                                    for behavioral health, such as alcohol-
                                       Millennials also had to cover or repay       awareness and suicide-prevention
                                       the costs of college tuition and finding     programs. But, for those not in college
                                       jobs during an economic recession.           or beyond college, the research and
                                       More Millennial households live in           opportunities for interventions are sparse.
                                       poverty than those of other age groups,
                                                                                    This issue brief focuses on four areas
                                       and they are less likely to own a home
                                                                                    related to alcohol and drug use and
                                       than previous generations were at the
                                                                                    suicide by people in their 20s and early
                                       same age.41 Millennials head the largest
                                                                                    30s. Those areas of focus are:
                                       number of single-mother households in
                                       the United States.42                         1. Risk and resilience factors;

                                       Many Millennials lack other forms            2. A
                                                                                        ccess to health insurance and quality
                                       of social capital that have historically        mental health and substance use
                                       assisted young generations, such as             disorder care and services;
                                       the sense of community offered in a
                                                                                    3. T
                                                                                        he multigenerational impact of
                                       place of worship. Compared with their
                                                                                       alcohol, drugs, and suicide; and
                                       grandparents’ generation, Millennials
                                       are less likely to be connected to major     4. The criminal justice system.
                                       societal institutions such as political

                                       “My family and I are among the millions of Americans affected by
                                       substance use disorders. My younger brother has struggled with this
                                       disease, which started with untreated depression leading to opioid
                                       pain reliever misuse. Like many with co-occurring mental health and
                                       substance use disorder conditions, my brother has cycled in and
                                       out of incarceration. I tell my family’s story because far too many
                                       are facing the same worries for their loved ones. We all ask the
                                       same question: how can I contribute to ending the opioid crisis and
                                       helping those suffering with addiction?”45
                                       Jerome M. Adams, M.D., MPH
                                       Vice Admiral, U.S. Public Health Service, 20th Surgeon General of the United States

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Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Recognize childhood risk and protective
factors and emphasize prevention in the
developmental years.
Research shows that many different life circumstances, often rooted
in childhood trauma and early adversity, can lead to substance
misuse and mental health problems .46 Every child who has adverse
childhood experiences will not necessarily have a substance use
disorder as an adult; however, such experiences put children at
increased risk of developing substance use disorders and suicidal
ideation later in life.47 For this reason, we are devoting a section
of this report to the many ways that childhood experiences
impact adult behaviors. It’s also important to remember that the
childhood experiences of today’s Millennials not only impact them,
but they also impact future generations—today’s children. It is also
worth noting that both risk and protective factors are malleable:
experiences and interventions can shape them.48

Among the known risk factors for           other types of mental health problems
adolescent and young adult substance       include emotional self-regulation, good
misuse are family conflict and family-     coping skills, engagement and
management problems, a history             connections in multiple contexts (for
of family substance misuse, poverty,       example, school, peers, athletics,
inequity, family violence, mental health   employment, religion, culture), strong
problems, low academic achievement         family bonds, and opportunities for
and academic failure, high availability    positive social involvement.51
of alcohol, peer substance use,
                                           Interventions designed to strengthen
and permissive community norms and
                                           these protective factors have proved
laws when it comes to substance use.49
                                           effective in preventing substance misuse.
An additional risk factor for young
adult substance misuse is the fact that
the brain is continuing to develop and
mature through adolescence (which
                                             CASE STUDY:
contributes to risk-taking behavior).        Guiding Good Choices teaches parents of middle schoolers to strengthen bonding in
In addition, the brain in adolescence        their families through age-appropriate opportunities for family interaction, to express
and young adulthood is vulnerable to         positive feelings, and to adopt family conflict-management approaches. The program
environmental stressors, which may lead      also guides parents in setting clear expectations and applying discipline, as well as
to poor decision-making.50                   teaching their children coping strategies. Research shows the program successfully
Protective factors that help guard           inhibits alcohol and marijuana use among middle schoolers.52
against substance use disorders and

                                                                                                     TFAH • WBT •   9
Alcohol and Drug Misuse and Suicide and the Millennial Generation - a Devastating Impact - PAIN IN THE NATION: Building a National Resilience Strategy
Protective factors can also increase         through referrals) their students’ mental
                                        the likelihood that a child will stay        health needs. All schools should be safe
                                        in school and succeed in school, and         and supportive learning environments.56
                                        they can lessen the risk that a child will   All children should have an equal
                                        become involved with the child welfare       opportunity to learn in an appropriate
                                        or criminal justice system.53 According      and inclusive school environment.
                                        to the U.S. Department of Health
                                        and Human Services, Administration
                                                                                     believing that the adults and peers
                                        for Children and Families Children’s
                                                                                     at their schools care about them as
                                        Bureau, the programs that most
                                                                                     individuals and are invested in their
                                        effectively build resilience in children
                                                                                     education—has been shown to be a
                                        and adolescents both reduce risk factors
                                                                                     strong protective factor, lowering the
                                        and build protective factors.54
                                                                                     likelihood of chronic absenteeism,
                                                                                     allowing students to experience less
                                          CASE STUDY:                                emotional distress, and reducing the
                                                                                     likelihood of teen pregnancy and
                                          The Life Skills Training Program, a
                                                                                     substance use.57,58 The impact of these
                                          three-year prevention curriculum for
                                                                                     protective factors has been shown to last
                                          middle school students, teaches drug-
                                                                                     into early adulthood.59,60
                                          resistance skills, self-management
                                          skills, and general social skills          One initiative that addresses school-
                                          in addition to providing useful            connectedness, the Caring School
                                          information. Over the past 20 years,       Community Program, aims to
                                          evaluations have found the program         strengthen elementary school students’
                                          reduces the prevalence of tobacco,         “sense of community” at school. The
                                          alcohol, and illicit drug use by 50 to     program includes a set of mutually
                                          87 percent, and when combined with         reinforcing approaches to classroom,
                                          booster sessions, it reduces long-         school, and family involvement (for
                                          term substance misuse by as much           example, morning and closing circle
                                          as 66 percent, with effects lasting        activities, in which students practice
                                          beyond the high school years.55            social skills and get to know one
                                                                                     another; weekly class meetings, in which
                                                                                     students address common concerns and
                                        Promote the important role for               current issues; weekly home connection
                                        schools—from early childhood                 activities, in which students learn to
                                        through college.                             talk to their families about the social-
                                        Children, teens, and some young adults       development topics covered in class).
                                        spend about half of their waking hours       These activities target the development
                                        in school, putting schools in a strong       of social and emotional skills, and they
                                        position to promote the well-being of        promote positive peer, teacher-student,
                                        students. Schools can be places that         and home-school relationships.61 Among
                                        identify the early indications of risk       the 40 schools that implemented the
                                        and take steps to reduce the likelihood      program in St. Louis, Missouri, there
                                        of negative health outcomes by               was a 54 percent improvement in
                                        assisting families and providing links to    math achievement and a 46 percent
                                        appropriate services. School, college,       improvement in communication-arts
                                        and university personnel should be well-     achievement, as well as a reduction
                                        trained to identify and address (typically   in the number of discipline referrals,
10   TFAH • WBT •
which were down by an average of 48          seek Medicaid reimbursement for all
referrals per year (even as the number       eligible students.70 Top school alcohol-
of referrals went up by an average of 88     and drug-prevention programs show
per year in control schools).62              impressive results, including a $3.80 to
                                             $34 return for every $1 invested.71
Punitive school policies, such as
zero-tolerance policies that lead to         By leveraging Medicaid reimbursement
suspensions and expulsions, contribute       to bring mental health services to
to increased risk factors for substance      students, schools can free up funds for
misuse.63 Also, such policies have a         other activities (including extending
differential impact on students of color,    services to other low-income children
who are overrepresented in rates of          who do not qualify for Medicaid)
school expulsions and suspensions.64         and avoid more costly services in the
                                             future through prevention and early
Schools are the ideal settings to
                                             intervention.72,73 For example, the
provide behavioral health services,65
                                             Oakland Unified School District in
and in fact they provide the majority
                                             California bills Medicaid for therapy
of such care: 70 percent of all children
                                             and assistance provided by psychiatric
receiving mental health services do so at
                                             social workers; the Los Angeles Unified
school.66,67 Yet of the 5 million students
                                             School District uses Medicaid funds to
who need mental health treatment, it is
                                             help pay for screenings, equipment,
estimated that 80 percent do not receive
                                             and services at medical and mental
it.68 Schools reach nearly all children
                                             health clinics; and the Lafourche
and are increasingly providing on-site or
                                             Parish School District in Louisiana
linked mental health services.69 School-
                                             uses Medicaid funds to support many
based or linked services can improve
                                             of the preventive services provided
access for those most at-risk, including
                                             under Medicaid’s Early and Periodic
children enrolled in Medicaid.
                                             Screening, Diagnosis, and Treatment
Whereas previously schools could
                                             program, such as mental health
only receive Medicaid reimbursement
                                             screenings and treatment services.74,75
for certain students, schools can now
                                                                                        TFAH • WBT •   11
Ensure access to prevention and treatment services.
     Substance use disorder is a brain disease that requires effective and sustained treatment.76
     Tragically, only an estimated one in 10 Americans with a substance use disorder receive appropriate
     treatment.77 Young adults, ages 18 to 25, have the largest proportion of substance misuse of any age
     group, according to the Substance Abuse and Mental Health Services Administration (SAMHSA),78
     yet only 7.2 percent of them receive care for their disease at a specialty care facility.

                                                                                                did require that, if plans did include
                                                                                                mental health coverage, such coverage
                                                                                                must be on par with physical health
                                                                                                services. But a growing body of evidence
                                                                                                suggests that such parity in coverage is
                                                                                                not always available. A 2015 patient survey
                                                                                                conducted by the National Alliance on
                                                                                                Mental Illness found that patients with
                                                                                                private insurance were denied coverage
                                                                                                for mental health services twice as often as
                                                                                                denial rates for other medical services.86

                                                                                                More recently, a 2019 court ruling, Wit v.
                                                                                                United Behavioral Healthcare (UBH), found
                                                                                                that UBH, which manages behavioral
                                                                                                health services for a number of large
                                                                                                insurance providers, including United
     Barriers to treatment for substance use    use disorders fell by more than 5
                                                                                                Healthcare, rejected tens of thousands
     disorders and mental illness include       percent.82 In addition, the ACA increased
                                                                                                of patients’ treatment claims for mental
     nonexistent or inadequate insurance        the number of insured young adults by
                                                                                                health and substance use disorders based
     coverage, gaps in the behavioral health    allowing them to stay on their parents’
                                                                                                on defective medical review criteria.87
     workforce, and stigma surrounding          policies until they turned 26.83 This
     mental health and substance use            provision contributed to a 45 percent           While cost barriers created by a lack
     disorders.79 According to a 2018 U.S.      reduction in uninsured 18- to 25-year-          of insurance coverage are significant,
     Government Accountability Office           olds between 2010 and 2015,84 but the           they are not the only barriers to care.
     report, there are gaps in substance use    uninsured rate was highest for 26-year-         Others include an undersupply of
     services for young adults, including       olds in 2017, presumably due to young           appropriately trained and credentialed
     insufficient access to recovery services   adults aging out of their parents’ plans.85     mental and behavioral health
     and a shortage of treatment providers.80                                                   professionals, including an undersupply
                                                And yet, even when people have health
                                                                                                of practitioners with specific training
     According to the U.S. Census Bureau,       insurance and recognize a need for
                                                                                                in substance use disorders treatment.88
     people ages 25 to 34 and 35 to 44 were     treatment, it isn’t always available to them.
                                                                                                According to the U.S. Department of
     the two largest groups of uninsured        The Mental Health Parity and Addiction
                                                                                                Health and Human Services, about 111
     people in the United States in 2016.       Equity Act (MHPAEA) became law in
                                                                                                million Americans live in areas with a
     That year, about one in four uninsured     2008. It requires health insurers to cover
                                                                                                shortage of mental health professionals.89
     people were 25- to 34-year-olds.81 The     mental health and substance misuse
     Affordable Care Act (ACA) was a historic   services at the same levels as physical         Primary settings also need to better
     and pivotal point of progress. After       healthcare services. While the MHPAEA           integrate behavioral health treatment
     it became law, the rates of uninsured      did not require private insurers to include     with a whole-person approach to
     people with mental illness and substance   coverage for mental health services, it

12     TFAH • WBT •
care.90,91,92,93 However, many regulatory
and reimbursement policies create
obstacles to the integration of such
services, sometimes requiring separate
waiting rooms, medical records, and
contractual agreements among different
agencies. Millennials are likely to be
more comfortable than older patients
accessing behavioral healthcare via
telehealth services, but such an option
is not widespread. This pattern of
policies that make it more challenging
to access behavioral health services
prompted then–Representative Patrick
Kennedy, in his recommendations
to the President’s Commission on            particularly in the light of the fact that     All completion-rate data should be viewed
Combating Drug Addiction and the            racial and ethnic minorities experience        within a “barriers” lens—including by
Opioid Crisis, to make the following        larger proportional increases in               asking, what are the specific barriers
remark: “Until we treat brain diseases      suicide deaths compared with other             to treatment access, continuation, and
the same way we treat other diseases,       population groups.98                           completion that a population group faces,
our country will never stem the tide of                                                    and what programs and policies need to
                                            A 2013 study found that Blacks
these deaths of despair.”94                                                                be in place to help remove those barriers?
                                            and Latinos were 3.5 to 8.1 percent
Access and equity                           less likely than Whites to complete            More evidence-based, culturally
                                            substance use disorder treatment,              sensitive, and linguistically appropriate
While overall rates of mental disorders
                                            possibly due to socioeconomic factors          behavioral health and suicide-
for most minority groups are largely
                                            such as unemployment and housing               prevention programs are needed. A
similar to those for Whites, numerous
                                            instability.99,100 Subsequent evidence         study published in Health Affairs107
studies have found that racial and ethnic
                                            has found that many people of color            found that a more diverse mental health
minorities are less likely than Whites to
                                            anticipate discrimination when seeking         workforce, as well as improved provider
seek mental health treatment.95 Service
                                            mental healthcare or treatment for             and patient education, were important
cost or lack of insurance coverage was
                                            substance use disorders, avoid care            to eliminating mental health disparities.
the most frequently cited reason for not
                                            altogether, or experience discrimination       Such programs need to be tailored to
using mental health services across all
                                            in care, which leads them to withdraw.         the community or population and need
racial and ethnic groups.96 Barriers that
                                            This, ultimately, leads to a poor initiation   to recognize the specific life events
keep many young adults from being
                                            to and completion of treatment.101,102,103     known to trigger addiction, relapse, and
able to access treatment for substance
                                            Overall, White Americans are significantly     suicide.108 Certain transition periods of
use disorders or mental health problems
                                            more likely to complete treatment for          particular relevance to Millennials are
are present in all communities, but
                                            a substance use disorder compared              associated with higher rates of suicide.
racial and ethnic minorities can face
                                            with Blacks and Latinos, regardless            For example, a 2015 study found that
unique barriers to care, including a
                                            of the substance used,104 though               the rate of suicide among deployed
fundamental mistrust of healthcare
                                            these differences vary widely across           and non-deployed veterans who served
systems and providers, discrimination, a
                                            metropolitan statistical areas.105 These       between 2001 and 2007 was highest
lack of culturally informed care, and in
                                            trends are not limited to Black and            during the three years immediately after
some cases limited English proficiency.97
                                            Latino communities; Asian American             leaving military service.109 Financial
Continuation of care can be another         and Pacific Islanders had faster growth        pressures, another stress point for many
problem for communities of color. This      in the rate of admissions to substance use     Millennials, are another factor known to
care gap has serious consequences,          disorder treatment than other groups.106       increase suicide risk.

                                                                                                    TFAH • WBT •    13
Address the multigenerational impact of
                                        substance misuse and suicide.
                                        When alcohol and drug misuse or suicide touch young adults,
                                        the impact is often multigenerational.110

                                        According to SAMHSA, between 2007               also increasing in some parts of the
                                        and 2012, on average about 21,000               country—in some areas, at rates higher
                                        pregnant women (ages 15 to 44) used             than opioid-involved deliveries.120
                                        opioids for non-medical purposes in the
                                                                                        The effects of NAS vary. It can cause
                                        past month.111 According to the Centers
                                                                                        behavioral problems and challenges
                                        for Medicare and Medicaid Services,
                                                                                        with self-regulation—factors predictive
                                        substance misuse–related illness and
                                                                                        of academic failure.121,122 Children
                                        death particularly affects pregnant
                                                                                        born with NAS were more likely to
                                        women, and substance misuse is now a
                                                                                        have a developmental delay or a speech
                                        leading cause of maternal death.112
                                                                                        or language impairment in early
                                        Research shows that pregnant women              childhood compared with children
                                        who use opioids may deliver a newborn           born without NAS.123
                                        with neonatal abstinence syndrome
                                                                                        According to the National Association for
                                        (NAS).113 NAS happens when a fetus
                                                                                        Children of Addiction, children whose
                                        becomes physically dependent on opioids
                                                                                        parents have substance misuse problems
                                        or other drugs due to the mother’s
                                                                                        do not generally do as well in school—
                                        drug use while pregnant. When dealing
                                                                                        due to higher rates of absenteeism,
                                        with NAS, it is important to protect the
                                                                                        truancy, and suspension—as students
                                        infant’s health while also ensuring that
                                                                                        from families without such issues.124
                                        the mother receives adequate treatment
                                        for her opioid disorder.114                     What’s the impact of a parent’s
                                                                                        substance use or suicide on their
                                        An infant with NAS may experience
                                        withdrawal symptoms, such as tremors,
                                        fever, seizures, and difficulty feeding.115 A   In 2005, 2.5 million children lived with
                                        study of Medicaid-financed births found         their grandparents, who provided for
                                        a 383 percent increase in the number            the child’s care. By 2015, that number
                                        of infants born with NAS between 2000           increased to 2.9 million children,
                                        and 2012 across 26 states.116 In 2014, the      according to child welfare officials, due
                                        annual healthcare cost of NAS to society        in large measure to the opioid crisis.125
                                        was estimated to be $462 million.117            Additionally, children of parents with
                                                                                        substance use disorders are more
                                        Between 1999 and 2014, the rate of              likely to be placed in foster care, and
                                        opioid use disorders identified during          foster care placements are growing.126
                                        birth hospitalizations quadrupled from          According to the National Association
                                        an estimated 1.5 per 1,000 delivery             for Children of Addiction, about one in
                                        hospitalizations to 6.5 per 1,000,118           four children in the United States lives
                                        and the number of newborns with                 in a family with a parent who is addicted
                                        NAS grew from 1.2 per 1,000 hospital            to drugs or alcohol.127 Of the 400,000
                                        births to 5.6 per 1,000 births in 2012.119      children in out-of-home foster care at
                                        Amphetamine-related deliveries are

14   TFAH • WBT •
any time,128 more than 60 percent of           be abused and over four times more
infants and 40 percent of children are         likely to be neglected than children
from families with active alcohol and          of parents without substance use
drug misuse.129,130 Overall, the number        disorders.135 Furthermore, when a child
of infants with NAS reported to child          is subject to abuse or neglect, they
welfare services has increased steadily,       are at risk for anxiety and personality
most markedly between 2010 and                 disorders, which in turn put them at
2014.131 One study of county-level data        risk for later alcohol and drug misuse
found that substance misuse prevalence         in their own lives136 and can heavily
was a predictive factor for complex            influence the way they eventually
and severe cases of child maltreatment,        parent their future children.137
though whether this always results in
                                               Parents’ alcohol use disorders can
removing a child from his or her home
                                               also have a heavily negative impact
varies from state to state.132 There is also
                                               on children. Model programs have
research showing that increasing access
                                               effectively helped mothers achieve
to opioid use disorder treatments for
                                               sobriety and have reduced state custody
parents who need such treatment can
                                               placements of children.
have a positive impact on families in
the child welfare system, including by
increasing permanency.133
                                                 CASE STUDY:
In addition to the trauma of being
removed from home and family,                    Sobriety Treatment and Recovery Teams (START) is a Kentucky-based program for
parents’ substance misuse can put                families with parental substance use disorders and issues of child abuse and/
children at high risk for abuse, neglect,        or neglect that helps parents get sober and helps keep children with their parents
exposure to criminal activity, and               when possible and safe. Mothers who participated in START achieved sobriety at
exposure to the chemicals involved in            nearly twice the rate of those not in START, and children in START families were half
drug production.134 Children whose               as likely to be placed in state custody. For every dollar spent on START, Kentucky
parents misuse alcohol and other                 avoided spending $2.22 on foster care.138
drugs are three times more likely to

                                                                                                        TFAH • WBT •   15
Improve substance use disorder treatment services within the
     criminal justice system and as people transition out of the system.
     Any discussion of the linkage between substance use disorders, particularly the opioid crisis, and
     the justice system should first acknowledge that there are social determinants of drug use just as
     there are social determinants of health. Addressing those social determinants—access to quality
     education, safe housing, transportation, and employment opportunities among others—and
     applying public health responses rather than criminal justice responses to the crisis need to be
     central parts of the solution to the drug misuse epidemic.139

     Until that happens, alcohol and drug          The differential impact of the criminal       criminal justice system who have an opioid
     use disorders will continue to be             justice system on minority groups             use disorder, medications to treat these
     frequent gateways to unemployment             is also salient. People of color are          disorders are rarely available within the
     and interactions with the criminal            overrepresented in the criminal justice       system. And, for those prisoners who
     justice system.140,141 The criminalization    system. For example, Blacks represent         do receive medication-based treatment
     of mental health and substance misuse         13.3 percent of the U.S. population but       while incarcerated, the treatment
     conditions often begins in the juvenile       are 35.4 percent of the prison population.    is often discontinued upon release,
     justice system. An estimated 65 to 70         Similarly, Latinos are 17.6 percent of        putting individuals who were formerly
     percent of youth in the juvenile justice      the U.S. population and 21.6 percent of       incarcerated at high risk for relapse and
     system have a mental health condition         the prison population.148 Furthermore,        overdose. One solution is to increase
     and are much more likely to have              data shows that racial status impacts         the number of drug courts and mental
     experienced traumatic victimization           sentencing, including evidence of racial      health courts across the country. Drug
     and adverse childhood experiences             discrimination in sentencing. Minorities,     courts divert people found guilty of less
     compared with the general population.142      particularly young Black and Latino           serious charges—often drug charges or
     Incarcerating these young people rather       males, often receive longer sentences         nonviolent crimes committed by people
     than providing them with community-           than do Whites.149,150                        with substance use disorders—into
     based behavioral health services increases                                                  treatment programs instead of prison.156
                                                   Unfortunately, criminal justice systems
     the likelihood of adult incarceration and                                                   Similarly, mental health courts divert
                                                   often don’t leverage opportunities
     other adverse outcomes.143                                                                  people who are convicted of a crime
                                                   to address the nation’s substance use
                                                                                                 and who suffer from a mental illness
     According to the Bureau of Justice            problem through treatment programs.151
                                                                                                 into treatment and community-based
     Statistics, as of 2016, 42 percent of those   SAMHSA reports that, for many people
                                                                                                 services when possible. In mental health
     in state and federal prisons nationwide       with a substance use disorder, contact
                                                                                                 courts, a judge oversees the treatment
     are ages 20 to 34 and make up the             with the criminal justice system is often
                                                                                                 and supervision process and facilitates
     highest proportion of prisoners.144           their first opportunity for treatment.152
                                                                                                 collaboration among the court, mental
     Nearly half the people in federal prisons,    Increasingly, the criminal justice system
                                                                                                 health providers, and other community-
     47 percent, had been sentenced for drug       offers incentives for individuals convicted
                                                                                                 based service providers.157 Finally,
     offenses.145 There is increasing evidence     of crimes to avoid or reduce their
                                                                                                 communities should train police and
     that incarcerated people are more likely      sentences by entering and remaining in
                                                                                                 other first-responders to recognize people
     to have mental health and substance use       treatment, but the justice system should
                                                                                                 with substance use disorders and then
     disorders—driven in part by trauma and        do more to leverage these treatment
                                                                                                 refer them for treatment.
     adverse childhood experiences—than            opportunities when appropriate.153,154
     the population as a whole. Incarceration      A 2019 National Academies of Sciences,        Prisons’ unique characteristics and
     is often an impediment to receiving           Engineering and Medicine report155            environments present regulated
     adequate mental health and substance          found that, despite the large number          opportunities to provide treatment for
     use disorder care.146,147                     of people entering or already in the          people with substance use disorders;

16     TFAH • WBT •
unfortunately, prisons also present
barriers to such treatment. If more
prisons made a range of treatment
options available—including
medication-based treatments, such
as methadone, buprenorphine, or
naltrexone—then more incarcerated
individuals could receive treatment.

It is critical that recovery supports
continue after release.158 According to
the National Institute on Drug Abuse,
people convicted of crimes who complete
a prison-based treatment program and
who continue with treatment after
release have the best outcomes: they
are more likely learn to manage relapse
                                                 incarcerated who received treatment in
risks and to develop a drug-free peer
                                                 prison is critical. This care should include
network.159 People leaving correctional
                                                 help enrolling in health insurance
facilities without treatment and recovery
                                                 and transitioning to community-based
supports face particularly high overdose
                                                 treatment and recovery supports.
risks. First, people recently released
                                                 Research shows that alternative models of
from prison often return to the same
                                                 probation that include substance misuse
settings that triggered their drug use
                                                 recovery supports and that address
to begin with. Worse, their tolerance to
                                                 mental health issues can both improve
drugs likely decreased while in prison.160
                                                 outcomes and reduce costs.166
Finally, once back in their communities
after prison, the drugs available are often      Employment post-treatment or
stronger than what they used before              incarceration is also an important element
incarceration.161,162,163                        in helping young adults to overcome a
                                                 substance use disorder. During an October
According to SAMHSA, in-prison
                                                 2018 news interview, U.S. Centers for
substance use disorder treatment,
                                                 Disease Control and Prevention (CDC)
particularly when followed by community-
                                                 Director Dr. Robert Redfield talked
based recovery supports, not only reduces
                                                 about the importance of employment
relapse rates; it also prevents recidivism.164
                                                 opportunities for people in recovery and
Post-release supports include a specific
                                                 called on the business community to
transition plan to community-based
                                                 help people in recovery benefit from the
treatment programs; access to counseling,
                                                 “dignity of a job.” He said corporations
including in some cases medication
                                                 can help celebrate the success of people
services; and vocational and employment
                                                 who go into recovery and help to sustain
assistance. People leaving incarceration
                                                 that recovery by providing employment
who have completed a prison-based
                                                 opportunities.167 Research shows that
treatment program and who continue
                                                 employment leads to higher graduation
with treatment in the community have
                                                 rates from drug courts;168,169 unfortunately,
the best outcomes.165
                                                 there is a persistent lack of employment
For all of these reasons, follow-up care         resources for those seeking substance use
for individuals who were formerly                disorder treatment.170

                                                                                                 TFAH • WBT •   17
                                        The following recommendations would establish programs and
                                        advance policies that address many of the root causes of substance
                                        use disorders and mental health issues for young adults. This
                                        includes policies that concentrate on creating the conditions and
                                        resources that help people avoid the problems of alcohol and drug
                                        misuse or suicidal ideation in the first place—that is, a focus on
                                        prevention as well as screening and treatment. Drug and alcohol
                                        misuse and suicide can create lasting harm for future generations;
                                        this means that effective solutions will have lasting benefits.

                                        Assure patient access to evidence-based prevention, screening
                                        and treatment.
                                        l    ake screening for and treatment
                                            M                                           l   Routinely employ the many well-tested
                                            of mental health and substance use              screening tools for mental health
                                            disorders part of routine healthcare;           issues and substance use disorders.
                                            improve pain care coordination
                                                                                        l   Widely implement healthcare system
                                            among providers; and educate patients
                                                                                            and provider education programs,
                                            about pain medications.
                                                                                            like the Zero Suicide Initiative (see case
                                        l    ake behavioral healthcare,
                                            M                                               study below), to improve care for those
                                            including screenings, a routine part of         who seek help and to prevent suicides.
                                            healthcare, including primary care, and
                                            offer it in a nonjudgmental manner.

                                            CASE STUDY:
                                            The Zero Suicide Initiative is a            a mental health problem, they must
                                            comprehensive approach focused on           assign patients to appropriate care,
                                            improving depression care in health         which includes cognitive behavioral
                                            systems by integrating suicide prevention   therapy, medication, group counseling,
                                            into primary and behavioral healthcare.     or new care models, such as same-
                                            The model requires primary care doctors     day psychiatric evaluations, drop-in
                                            to screen every patient during every        group-therapy visits, and hospitalization
                                            visit with two questions: (1) How often     if necessary. The Henry Ford Health
                                            have you felt down in the past two          System reports reduced suicide rates
                                            weeks? (2) How often have you felt little   among its behavioral health patients
                                            pleasure in doing things? High scores       by up to 89 percent thanks to the
                                            lead to more questions about sleep          Zero Suicide model.171 The National
                                            disturbances, changes in appetite, and      Institute of Mental Health is studying the
                                            thoughts of hurting oneself. Providers      efficacy of the model in a large study of
                                            must indicate that they completed the       approximately 170 outpatient behavioral
                                            screening on each patient’s medical         clinics serving more than 80,000
                                            record. And when providers recognize        patients in New York state.172

18   TFAH • WBT •
l    linicians should refer their patients
    C                                           l    tates and health systems should
    to appropriate mental, behavioral,              invest in and expand Prescription
    and substance use disorder treatment            Drug Monitoring Programs to track
    services in the community as needed.            controlled substance prescriptions.
    Clinicians and trained personnel                States and health systems should
    should also assist patients in making the       create or expand drug-disposal
    necessary arrangements to access care.          programs to ensure that patients
                                                    dispose of expired or unused
l    tate and federal policymakers should
                                                    medications properly and that
    eliminate the regulatory and legal
                                                    someone other than the patient with
    obstacles to the integration of physical
                                                    the prescription does not use it.
    and behavioral care, including by
    streamlining the ability to share patient   l    DC’s opioid prescribing guidelines,
    records. Payers and health systems              which have led to reduced opioid
    should create reimbursement and                 prescribing, should continue to be
    financial incentives to prioritize the          followed. Clinicians should take care
    integration of care and wrap-around             to make prescribing decisions that
    services for patients. Wrap-around              are consistent with the guidelines, i.e.
    services typically include job training         prescribing decisions that account for
    or housing-assistance programs. When            the patient’s unique circumstances.
    possible, physical and behavioral               For example, ones that address the
    services should be co-located to ease           pain control needs associated with
    care integration and patient access.            cancer and surgical procedures.132

                                                                                               TFAH • WBT •   19
l   Protect and expand access to                 the elimination of the individual
                                            evidence-based and culturally                 mandate (as of 2019) to assess the
                                            appropriate mental and behavioral             impact it has on the number of young
                                            substance misuse treatment. Fully             adults without health insurance.
                                            enforce the 2008 MHPAEA. Create
                                                                                      l   I ncrease health insurance coverage
                                            true parity between coverage for
                                                                                          for medication-based treatments, such
                                            mental and behavioral health
                                                                                          as methadone, buprenorphine, and
                                            insurance and coverage for physical
                                                                                          naltrexone. Increase evidence-based,
                                            conditions. Coverage for mental and
                                                                                          behaviorally based, or multimodal
                                            behavioral health must be available
                                                                                          interventions for substance use
                                            within Medicaid and private insurance
                                                                                          disorders for patients who need it.
                                            coverage, including adequate in-
                                                                                          Medication Assisted Treatment (MAT)
                                            network provider availability with
                                                                                          repeatedly shows better treatment
                                            reasonable wait times and out-of-
                                                                                          outcomes than treatment programs
                                            pocket expenses.
                                                                                          that do not include MAT.173,174
                                        l   As mandated by the ACA, parents’
                                                                                      l    tate governments should establish
                                            health insurance policies should
                                                                                          or strengthen licensing and oversight
                                            continue to cover young people up
                                                                                          requirements and procedures to ensure
                                            to age 26. Maintain additional critical
                                                                                          that all substance misuse treatment
                                            ACA reforms, such as financial
                                                                                          programs and recovery facilities are
                                            assistance within the marketplace
                                                                                          using evidence-based interventions.
                                            system, to help students and young
                                            professionals afford health insurance.    l    trengthen critical behavioral health
                                            Create or reinstate programs that             infrastructure, like the National
                                            specifically target young adults,             Suicide Prevention Lifeline, to ensure
                                            such as enrollment navigators, to             that calls are answered in a timely
                                            help young people transition from             manner and that follow-up outreach is
                                            their parents’ health insurance               available to those at a high risk of self-
                                            to the marketplace options as                 harm. Suicide-prevention programs
                                            needed. Consider tax credits and/             should be expanded to leverage text-
                                            or expanded Medicaid eligibility for          and app-based services.
                                            people under 26 whose parents do
                                            not have health insurance. Monitor

20   TFAH • WBT •
    The Jed Foundation’s suicide prevention      adults by building community-level
    program empowers teenagers and young         partnerships and by educating students,
    adults with the skills and support they      families, and communities about how
    need to navigate their transitions into      to recognize and support someone
    adulthood and to thrive as adults. The       who is struggling with a mental health
    program, based on a comprehensive            issue. In 2017, the foundation built
    public health approach to promoting          on its comprehensive approach
    mental health and preventing suicide,        and, in partnership with the Steve
    works with schools (at the high school       Fund, developed the Equity in Mental
    and college level nationwide) to help        Health Framework, which provides 10
    them evaluate and strengthen their           recommendations and implementation
    mental health, substance misuse, and         strategies to help colleges and
    suicide-prevention programs. It creates      universities better support the mental
    support systems for teens and young          health of students of color.175

l   Address barriers to treatment—like              misuse treatment has access to it.
    the lack of providers in rural areas             Professional education, licensing, and
    or the need for more residential                 credentialing bodies should create
    treatment programs for pregnant and              programs, appropriate trainings, and
    postpartum women—by growing the                  credentialing for such providers.
    federally funded Behavioral Workforce
                                                 l   Hospitals should ensure that individuals
    Education and Training program,
                                                     in crisis can connect to behavioral health
    adopting the use of telemedicine, and
                                                     services in a timely manner. Hospitals
    increasing student loan repayment
                                                     should expand the “spoke-and-hub”
    programs for practitioners working in
                                                     model of connecting those in emergency
    underserved areas. A robust, diverse,
                                                     or intensive care for a substance use
    well-trained, and accessible mental
                                                     disorder to ongoing community-based
    and behavioral health workforce is
                                                     treatment and services.
    necessary to ensure that anyone who
    needs mental health or substance

Use pricing strategies to limit consumption of alcohol by
adolescents and young adults.
l   Alcohol pricing strategies, such as             States should consider imposing higher
    increasing the cost of alcoholic beverages       taxes on alcohol sales and should strictly
    through taxes, are associated with               enforce existing underage drinking laws
    decreased overall alcohol consumption,           by holding sellers and hosts liable for
    including young adult consumption.176            serving minors.

                                                                                                  TFAH • WBT •   21
Reduce the multigenerational impact of substance use disorders.
                                        l    xpand innovative programs—like
                                            E                                               the recently enacted Family First
                                            the new Center for Medicare and                 Prevention Services Act, which
                                            Medicaid Innovation Maternal Opioid             supports prevention services for
                                            Misuse model—that provide services              families in crisis to help reduce foster
                                            to mothers with an opioid use or                care placements and includes support
                                            other substance use disorder and their          for relatives caring for children who
                                            children; this will both help more              are candidates for foster care.
                                            people and continue to build the
                                                                                        l   Hospitals and birthing centers
                                            evidence base.
                                                                                            should screen new mothers for
                                        l   The federal and state governments              substance use disorders and mental
                                            should make it a priority to implement          health issues at delivery.

                                            CASE STUDY:
                                            Nurse-Family Partnership (NFP) works        mothers with the care and support they
                                            with young, low-income, first-time          need to ensure a healthy pregnancy and
                                            pregnant women who are not ready to         birth. The model has dramatic benefits
                                            take care of a child. NFP establishes a     for society. For instance, when Medicaid
                                            trusted relationship with these women       pays for NFP services, the federal
                                            by providing home visits with a public      government gets a 54 percent return on
                                            health nurse, who meets with the mother     its investment through lower enrollment
                                            from pregnancy until the child turns two    rates in future Medicaid and nutrition
                                            years old. Home visits connect first-time   support programs.179

                                        Invest more in research on and education about non-opioid and
                                        non-drug pain treatments.
                                        l    he federal government and the
                                            T                                               drug treatment options. Research
                                            pharmaceutical industry should                  should specifically look at the question
                                            invest in and advance research on               of best treatment approaches for
                                            nonaddictive pain-control medications           young adults. Additional research gaps
                                            and research on non-pharmacological             include how to stop the progression
                                            interventions for pain control.                 of substance misuse into a disorder
                                            Healthcare providers should educate             and how, to best leverage technology
                                            their patients about the dangers of             and social media to end the substance
                                            addictive medications and about non-            misuse epidemic.

22   TFAH • WBT •
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