We've responded to the substance misuse crisis as if it's only about opioids

We've responded to the substance misuse crisis as if it's only about opioids
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Just a few days ago, we learned that life expectancy had risen for the first time since 2014 and saw the first decline in drug overdose deaths since 2012. 

While this is great news that should be celebrated, we also found that suicides continue to rise and overdose deaths involving synthetic opioids, cocaine, and psychostimulants (a category that includes drugs like methamphetamine, amphetamine, and methylphenidate) continued to increase.

These mixed results are direct because the United States plays Whac-A-Mole when it comes to addressing pervasive mental health and substance misuse problems — focusing on a recent problem area without addressing underlying conditions. 


In the last several years, the mole we’ve been whacking is opioid misuse, particularly prescription opioid use. Congress provided considerable funds to prevent and treat such specific misuse a few years ago. Consequently, in the new data, we’ve seen a decline in deaths related to prescription opioids. 

We shouldn’t have needed this latest release to know isolated efforts haven’t had widespread success— another report from earlier this month found that alcohol-related deaths doubled in the last 18 years from 35,914 deaths to 72,558 in 2017. And, in some states, the number of deaths related to meth have sky-rocketed, increasing by more than 400 percent in just six years.

While Congress was wise to allocate billions to fight the scourge of opioid misuse, in hindsight, the nature of the problem was too narrowly characterized. States that received funding were originally limited from supporting a more extensive range of substance misuses prevention programs, such as Recovery High Schools, Nurse-Family Partnerships, and a myriad of other proven interventions.

This narrow allocation of funding, limited to a type of substance misuse, was partially addressed in recent appropriations actions, but intervention initiatives that are too narrow continue to be problematic. 

In addition, opioid prevention legislation and funding have often solely focused on treating or saving the lives of those who were already addicted. Treatment counseling and detox beds have been funded and prioritized. Overdose reversal with the use of naloxone/narcone was rapidly expanded. These approaches were necessary and lifesaving. 

But, as important as treatment is, it must be paired with support for prevention or we will never make the necessary progress, i.e., unless substance misuse is fought on all fronts, we’ll continue playing Whac-A-Mole with people’s lives, seeing one drug of choice replaced by another.


To improve the mental and physical health and well-being of all, any legislation or regulation must focus on addressing the social and economic conditions in people’s lives that increase the risk of unhealthy behaviors. 

As such, our nation must broaden our approach by focusing on reducing risk factors, like trauma (especially among our youngest) and the impact of poverty and racism. 

Quite simply, by tackling the conditions that elevate the risk of drug and alcohol misuse, we can also reduce the risks for other substance misuses — the as yet ‘unwhac’d’ moles— and for mental illness and suicide.

To get beyond Whac-A-Mole to steady and sustained improvements in quality of life for all, we should focus the work, on several federal interventions, most of which can be undertaken right now:

  1. Ensure that hospital payment models and quality programs incentivize assessing mental health and substance misuse at every interaction as a vital sign — not only during well visits. This should include integrating screening and treatment into episode-based payment models for health conditions for which there are frequent behavioral health comorbidities, such as cardiovascular diseases, cancers, and pulmonary diseases.

  2. Create incentives in policy reforms that improve school culture and/or student mental health and provide additional financing for schools that implement effective strategies that reduce disparities in belonging and safety for students that identify as LGBTQ, including specialized services for suicide prevention for LGBTQ youth. 

  3. Make Medicaid coverage for women up to one year postpartum a mandatory eligibility category for coverage and include measures of screening and effective coordination of care for maternal behavioral health in hospital incentive programs for care transitions and quality/safety. 

  4. Ensure that the Indian Health Service and Veteran’s Health Administration is engaged in the same reform efforts as the Centers for Medicare and Medicaid Services for mental health and substance misuse and increase funding to build capacity.

  5. Make it impermissible to use any information related to seeking mental health or substance use treatment for any aspect of immigration enforcement and provide funding to disseminate this information to immigrants and for education about the availability of such services as part of immigration services.

  6. Provide long-term funding for states to continue programs like Money Follows the Person and the Balancing Incentive Program to ensure people with intellectual and developmental disabilities and mental health conditions have consistent access to comprehensive, high-quality services and supports outside of institutional settings.

  7. Allow Medicaid funds to be used for reimbursing the education of housing authorities about the risks of housing insecurity and what resources are available to meet those needs

  8. Create incentives in funding programs that go to municipalities that have created effective policies or strategies for ensuring access to affordable housing.

  9.  Increase incentives for individuals to join the mental health and substance use treatment workforce and for training programs to actively recruit and effectively train diverse individuals to meet underserved needs and provide more culturally competent care.

  10. Create a seed fund that supports primary care providers, especially Federally Qualified Health Centers and Rural Health Centers, in developing the necessary capacity to begin seeking sustainable reimbursement for integrated behavioral care services (which could be effectively paired with parity initiatives).

Benjamin F. Miller is the chief policy officer for Well Being Trust, a national foundation advancing the mental, social, and spiritual health of the nation. Dr. Miller is the lead author of "Healing the Nation: Advancing Mental Health and Addiction Policy," and was founding director of the Eugene S. Farley Jr. Health Policy Center in Aurora, Colo., where he remains a senior adviser. 

John Auerbach is the president and CEO of Trust for America’s Health, a D.C.-based policy, research and advocacy organization. He has previously held senior public health positions at the local, state and federal levels.