Many of the discussions in this Proceedings thus far have focused on the research and evidence emerging to support broader and more upstream interventions. To be effective, health systems will also need to leverage the support and programming provided by the federal government. This chapter focuses on several federal agency perspectives, including the Administration for Children and Families (ACF), the National Institute on Drug Abuse (NIDA), and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Lauren Behsudi, senior advisor at ACF, highlighted how ACF, under the umbrella of the Department of Health and Human Services (HHS), is working to prevent substance use disorder and improve behavioral health outcomes for youth and families. She said ACF has focused on engaging young people, caregivers, community leaders, and tribal partners.
Behsudi commented that ACF participates in the Behavioral Health Coordinating Council, recently established by the Secretary of Health and Human Services, which is a broad, internal-facing effort to improve behavioral health for all Americans.1 Five committees operate within the Council, with one specifically focused on children and youth. Through this child-
1 For more on the Behavioral Health Coordinating Council, see https://www.hhs.gov/about/news/2021/05/18/hhs-announces-3-billion-in-american-rescue-plan-funding-for-samhsa-blockgrants.html
and youth-focused subcommittee, HHS has been able to advance work promoting the well-being of children and youth, and leverage expertise across the agency.
Amy Goldstein, chief of the Prevention Research Branch at NIDA, explained that her office is located within the National Institutes of Health (NIH), under the HHS umbrella. NIDA funds research on prevention and treatment of substance use disorders, as well as research to understand the etiology of substance use and addiction. She acknowledged that many previous workshop speakers spoke about the need for a redesign of the behavioral health and prevention systems, but noted that there is also a need to understand intervention delivery within the current system.
Goldstein added that NIDA has recently focused more research on racial equity and social determinations of health. As part of this, NIDA is considering how to cultivate more scientists from diverse backgrounds, looking at their own workplace to enhance racial equity, and thinking about research gaps and how to fund research that addresses social determinants directly.
Christopher O’Connell, deputy director of the Center for Substance Abuse Prevention at SAMHSA, explained that his office supports NIH research and funds grants for states and local entities. He shared an important example in the recently announced HHS overdose prevention strategy, which has four key components: primary prevention, harm reduction, evidence-based treatment, and recovery support. In prevention, SAMHSA is examining community engagement strategies and trying to provide better data to grantees. He shared that SAMHSA is continually considering how to engage communities and how to work with families and parents. SAMHSA works with families that provide care for people who overdose, and makes sure the families understand treatment and recovery options.
SAMHSA has also spent time looking at harm reduction, and how to reverse overdoses or link people who have had an overdose to different treatment options, O’Connell said. SAMHSA recently announced their first-ever harm reduction grant, which will serve as a pilot process for the agency. O’Connell acknowledged differences in definitions of harm reduction, and noted that while some harm reduction focuses primarily on treatment, opportunities for harm reduction can begin after initiation of substance use to prevent misuse or dependence.
Initial discussion centered on the widespread misinformation seen during the COVID-19 response, the shift in trust of scientists and public health officials by the public, and how agencies are addressing these challenges. Goldstein noted the pandemic presents an opportunity to talk to the public about prevention in new ways, and suggested considering how this moment can be leveraged to foster a culture of prevention. The pandemic taught investigators to think about novel methods of delivering interventions, she noted. Behsudi added that the surgeon general recently released an advisory on protecting youth mental health, which can be used to generate discussions about prevention and early engagement (Office of the Surgeon General, 2021). O’Connell added that it was exciting to see many people introduced to public health during the COVID-19 pandemic and added that this is an opportunity to leverage public interest to address mental health and substance use in new ways.
Vinu Ilakkuvan, PoP Health, asked the panelists to comment on investing in infrastructure in a way that stimulates partnership and encourages sustainability. Goldstein said she has been working to change the culture around prevention grants, and encourages applicants to think more thoroughly about factors supporting sustainability, identifying who is delivering the intervention, where is it taking place, and what happens when grant funding ends. This also includes a role for federal agencies in collaborating and understanding how grants work at different agencies and who qualifies for funding. She also suggested bolstering teams at the federal level with more multidisciplinary expertise to help investigators with things like marketing, dissemination, and sustainability. Behsudi explained that ACF prioritizes a whole-family approach across ACF programs, and are working with program offices and grantees to consider youth and family perspectives in the development of policy and programs. She said childhood is an opportunity in prevention programs to bring together several key players, take a whole-family approach, and focus further upstream to help connect families to resources. O’Connell added that due to COVID-19, SAMHSA added significant funding to its substance abuse prevention and treatment block grants. While this increased funding is not guaranteed for the future, it does support sustainability in the short term, O’Connell said. He also suggested supporting community coalitions that work across sectors, including the private sector, to promote mental health and well-being. He added that SAMHSA is trying to support its grantees in branding campaigns and working with corporate partners.
There was also a discussion about collaboration across government agencies, including child welfare and juvenile justice departments, to cre-
ate a whole-of-government approach. Behsudi noted that the ACF’s Office of Early Childhood Development works very closely with the Department of Education, and they are both focusing on strengthening the social-emotional health of children and their families.2 She also discussed multiagency working groups focused on policy solutions, which offer an opportunity to think collectively and strengthen family-centered policies. O’Connell added that SAMHSA alone cannot meet all the prevention needs of the country, so the agency is working to identify creative opportunities for collaboration and integration at the federal level. He said SAMHSA links collaboration at the federal level with work at the community level to ensure a ripple effect that amplifies positive outcomes. He noted that SAMHSA is working to integrate prevention into school-based services. O’Connell also explained the feedback loop that exists between NIH and SAMHSA that focuses on what happens with research in communities and relays new information to the researchers. To help inform this process, SAMHSA examines quarterly data from grantees to evaluate common challenges that multiple groups may be experiencing and to identify best practices that can be shared across the spectrum to amplify effects. He contrasted this approach to implementing a grant for five years and then evaluating the results of that grant by itself. A second component of this feedback loop focuses on equity, he said. While some grantees are able to use advanced data collection and analysis capabilities to evaluate risk factors and disparities at a more granular level, not all grantees have the capacity to do so. O’Connell’s team at SAMHSA is working with multiple data sources and registries to support those communities that need more insight on their individual needs to make informed decisions.
Behsudi added that ACF is focused on advancing equity across programs for children and families as well. Putting the data into context has helped ACF understand the impact of programming and how to better serve children and families who are impacted by substance use disorder and also involved in different systems, including the foster care system.
As a final comment on funding, Ken Shatzkes, senior program officer at the Foundation for Opioid Response Efforts, highlighted the prevention continuum they are working in and noted that treatment for the parent is often prevention for the child. He added that many of the principles of recovery are the same for prevention. However, from a funding perspective, Shatzkes said, there is some money set aside for prevention, some for treatment, and some for recovery, sending the message that these are separate activities. There may be an effective treatment program that could incorporate prevention services, but programs would have to find a different
2 For additional information, see https://www.acf.hhs.gov/ecd/policy-guidance/dear-colleague-social-emotional-development-and-mental-health
set of funds to support that, he commented. Goldstein acknowledged this challenge, and said federal agency practices do not always match up to the reality of intervention programming—for example, the line between treatment and prevention is not always clear in practice, while federal funding may be directly targeted at treatment and prevention as separate practices. O’Connell suggested trying to better understand the pieces within grants that might be interpreted by some states as overly restrictive, and working to help them find solutions. He also noted that SAMHSA is building the Office of Recovery, for which part of the intention will be to have staff assigned to different centers to see how prevention is being integrated into recovery and vice versa.
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