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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PAIN IN THE NATION:
ISSUE BRIEF
Building a National Resilience Strategy
Alcohol and Drug Misuse and
Suicide and the Millennial
Generation — a Devastating Impact
JUNE 2019
Acknowledgements
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
2 TFAH • WBT • PaininTheNation.org
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
TFAH • WBT • PaininTheNation.org 3
A LOOK AT THE DATA TELLS THE STORY.
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
4 TFAH • WBT • PaininTheNation.org
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 • PaininTheNation.org 5
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
6 TFAH • WBT • PaininTheNation.org
THIS BRIEF FOCUSES ON THE MILLENNIAL
GENERATION FOR SEVERAL REASONS:
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 • PaininTheNation.org 7
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
8 TFAH • WBT • PaininTheNation.org
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 • PaininTheNation.org 9
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
School-connectedness—students
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 • PaininTheNation.orgwhich 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 • PaininTheNation.org 11Ensure 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 • PaininTheNation.orgcare.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 • PaininTheNation.org 13Address 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
children?
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 • PaininTheNation.organy 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 • PaininTheNation.org 15Improve 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 • PaininTheNation.orgunfortunately, 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 • PaininTheNation.org 17Recommendations
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 • PaininTheNation.orgl linicians should refer their patients
C l tates and health systems should
S
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
S
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,
C
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 • PaininTheNation.org 19l 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
S
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
S
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 • PaininTheNation.orgCASE STUDY:
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 • PaininTheNation.org 21Reduce 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 • PaininTheNation.orgYou can also read
