Substance use prevention and treatment

Before making investments in substance use treatment and prevention programs, city and county leaders should ensure this strategy addresses local needs.

The Urban Institute and Mathematica have developed indicator frameworks to help local leaders assess conditions related to upward mobility, identify barriers, and guide investments to address these challenges. These indicator frameworks can serve as a starting point for self-assessment, not as a comprehensive evaluation, and should be complemented by other forms of local knowledge.

The Urban Institute's Upward Mobility Framework identifies a set of key local conditions that shape communities’ ability to advance upward mobility and racial equity. Local leaders can use the Upward Mobility Framework to better understand the factors that improve upward mobility and prioritize areas of focus. Data reports for cities and counties can be created here.

Several indicators in the Upward Mobility Framework may be improved with investments in high-quality substance use treatment and prevention programs. To measure these indicators and determine if investments in this strategy could help, examine the following:

• Access to healthcare: Ratio of residents to primary care physicians. These data are available from the U.S. Department of Health and Human Services Area Health Resource File.

• Safety from crime: Reported property crimes per 100,000 people and reported violent crimes per 100,000 people. These data are available from the Federal Bureau of Investigation’s Uniform Crime Reporting Program.

• Safety from trauma: Number of deaths due to injury per 100,000 people. These data are available from the National Center for Health Statistics Mortality File and the CDC’s WONDER database.

Mathematica's Education-to-Workforce (E-W) Indicator Framework helps local leaders identify the data that matters most in helping students and young adults succeed. Local leaders can use the E-W framework to better understand education and workforce conditions in their communities and to identify strategies that can improve outcomes in these areas.

Several indicators in the E-W Framework may be improved with investments in this strategy. To measure these indicators and determine if investments in this strategy could help, examine the following:

• Mental and emotional well-being: Percentage of youth with mental or emotional health needs as identified by a universal screening tool.

• Physical development and well-being: Percentage of students meeting benchmarks on self-rated surveys of physical health, such as the California Healthy Kids Survey Physical Health & Nutrition module.

• Access to health, mental health, and social supports: Ratio of number of workers or students to number of health, mental health, and social services FTE staff (for example, school nurses, psychologists, and social workers).

• Childhood experiences: Percentage of individuals with fewer than three adverse childhood experiences (ACEs).

• Flexible service delivery: Substance use treatment and prevention programs must be delivered in a mode that is accessible to all participants. Depending on circumstances, this could include on-site facilities (particularly necessary in the case of medication delivery), or virtually or by telephone when in-person meetings are not possible. Mobile options, like mobile narcotics programs such as methadone vans and vending machines that dispense harm reduction supplies, provide easier delivery, especially for marginalized populations that face difficulties accessing care. Flexible delivery may be particularly important in rural contexts or in Native American communities that have experienced high rates of substance use and overdose.

• Address multiple risk factors: Prevention programming should be developed around the risk factors and root causes associated with drug use. Programming should inform residents about drug harms and provide protective measures and support. Target environmental factors (such as access to alcohol or other drugs) and individuals at risk (including those who have experienced peer pressure, adverse childhood experiences, and family drug use). Experts say programs should also consider socioeconomic factors such as poverty and financial hardship and emphasize developing life skills, academic success, and family management. Prevention outreach should extend to community-based services for out-of-school youth who may be experiencing housing instability.

• Tailored to participant needs or circumstances: Interventions and programming should be tailored to meet the needs and experiences of particular people, including those of different races, ethnicities, ages, and life experiences. These may include adolescents who have lost a parent to drug use, pregnant women, and mothers who want to remain with their children while in treatment. Other target demographics that may benefit from tailored programming are people 55 or older who use substances, the LGBTQ+ community, and individuals with mental health issues. Successful youth programming may focus on building confidence and social-emotional skill development through education, sports, the arts, and more.

• Wraparound services: Successful substance use treatment programs typically incorporate wraparound services to support individuals through the recovery process. Post-recovery services can include job and vocational training, housing assistance and placement, and continued access to peer counseling. Some models focus on recovery-based housing accommodations and programs to establish recovery-friendly workplaces that are stigma-free and welcoming to individuals re-entering the workforce.

• Peer support: A critical support mechanism of recovery is peer counseling from individuals who have gone through similar addiction experiences and recovery processes. Through shared understanding and respect, peer counselors working with individuals or in groups can reduce the likelihood of relapse and extend the reach of treatment beyond a clinical setting into the daily environment of the patient.

• Build trust and respect for the individual: Experts say substance use services should help individuals take the first step toward reducing drug use, entering treatment, and eventually navigating recovery. This requires understanding an individual’s unique path to recovery, which oftentimes involves frequent setbacks and recurrence of use. Interventions should be designed to build trust with residents to bring them into the treatment and recovery community, emphasizing improving health and well-being, family relationships, and vocational responsibility.

• Hire staff with adequate cultural competency: Programs should prioritize hiring staff that represent the communities they serve, have lived experiences in common with those they engage with, and recognize cultural sensitivities that may be at play. Given the history of harm and marginalization many communities have experienced during the decades-long “war on drugs” and in healthcare institutions, participants may be hesitant to engage with services.

• Distribute services equitably: Services should not only be distributed in alignment with current needs but also in a manner that redresses historical inequities in access to treatment. This is particularly critical given the recent significant increases in drug use and overdose among Black, Hispanic, and Native American populations. Experts also encourage placing substance use treatment services in homeless shelters, mental health facilities, and other locations that provide care to those with overlapping conditions.

• Language access: Given the scope of the addiction and overdose crisis across races and ethnicities, it is important to ensure that services are available in multiple languages. This can make it easier for users to understand treatment protocols, ease fears of entering treatment, and build trust between healthcare providers and patients.

• Prevention advocates: Creating a multi-sector coalition of prevention advocates can help ensure that programs are comprehensive, culturally aware, and reaching the right people. A prevention coalition might include leaders from health systems, education, law enforcement, and community-based organizations.

• Substance use organizations and healthcare agencies: To ensure that all individuals in need are reached, social service agencies, healthcare institutions, and recovery and treatment organizations should coordinate their activities. This coordination can also help identify potential gaps in services.

• Law enforcement: Given law enforcement’s role in monitoring drug flows and carrying out interdiction, federal law enforcement agencies and local police are in a position to inform health providers and substance use agencies about potentially lethal drugs on the market and the drug hotspots where they are sold. They can also issue alerts about the presence of fentanyl and fentanyl-laced counterfeit drugs that users take unwittingly and may cause overdose.

• Community-based organizations: Many communities, including those of color, have suffered disproportionately from the drug crisis. To secure buy-in from residents about programs such as harm reduction, which maintain a drug presence in communities and can, therefore, be controversial, inform residents about the benefits these may provide for individuals and communities. Experts note that harm reduction programs can reduce not only drug use but also street crime and are associated with fewer overdose deaths.

• Government leaders: Because some innovative drug policies go against long-held public beliefs about the nature of addiction, prevention, and treatment, support from elected leaders can be difficult to secure. Engaging political leaders is essential for creating buy-in on both funding (including newly available monies from the national opioids settlement) and staffing for pilot programs and expansions to existing services.

• Open pathways to treatment: Only a small percentage of individuals with substance use disorder receive treatment, often due to lack of insurance, distance from a treatment facility, and concerns about the difficulties of recovery. Public health departments, treatment centers, and community-based organizations can help residents obtain financial support (i.e., Medicaid), find transportation in both urban and rural settings, and receive peer counseling to encourage entry into treatment. Meanwhile, harm reduction programs, which do not mandate treatment, also play a role by providing a nonjudgmental environment in which to build trust with patients to move them into treatment when they are ready.

• Consider diversion: Jurisdictions can facilitate the reduction of drug use and access to treatment in a legal setting, such as drug courts, which operate in all 50 states and combine treatment with incentives and sanctions as tools to improve health and public safety. Offenders with a drug dependency are given the option of diversion from jail to clinical treatment and offered other supports. Another model diverts drug offenders before they enter the criminal justice system and places them in treatment programs. Studies show that drug courts can reduce drug use and re-arrest, especially in more complex cases in which the individual has not responded to other interventions. 

• Strengthen regulations: Community-wide solutions to substance use can include legislation, such as regulating alcohol outlet density or raising alcohol and marijuana taxes in jurisdictions where recreational and medical cannabis are legal. Other measures in these communities may include better oversight of underage consumption and unlicensed retail cannabis operations, mandates requiring warning labels for certain groups, such as pregnant women, and restrictions on the level of THC, the psychoactive component of marijuana, which in strong doses can lead to cannabis use disorder and other negative impacts.

• Overdose rates and causes: With more than 1 million people having been killed in drug-related overdoses in the U.S. since 2000 and upwards of 100,000 fatalities annually, jurisdictions must track the progression of overdoses closely. In addition, healthcare providers and social service agencies need to know as precisely as possible the cause of each overdose, or if multiple drugs were involved, due to increased polysubstance use.

• Participant demographics: Collecting data concerning race, ethnicity, gender, and age of drug users and overdose victims is standard practice and can help service providers target priority populations with specialized services and outreach. Jurisdictions can design more targeted education and prevention programs based on affected populations and their needs and also determine the best locations for detox, harm reduction, and treatment facilities that are closest to residents.

• Harm reduction impact: For harm reduction services to gain more traction and support from elected officials and communities, advocates need data showing the extent to which programs reduce drug use and street crime, contain the spread of infectious diseases, mitigate the overdose rate, and facilitate individuals entering treatment. Experts point out that research is just beginning to track new overdose prevention centers and their impact on overdose rates, treatment referrals, and treatment entries.

• Broader trends: Surveillance surveys provide data on risk factors, consumption rates, mental health, addiction, and more. Examples include the Youth Risk Behavior Survey (YRBS) and the Behavioral Risk Factor Surveillance System (BRFSS), which track substance use based on the past month's use of alcohol, marijuana, etc.