Reforming the Response to Substance Use:
A Drug Policy for the 21st Century
16th Annual Summer Institute: Innovations and
Essentials for Advancing Health
Sedona, AZ
July 16, 2015
David K. Mineta
Deputy Director, Demand Reduction
Office of National Drug Control Policy (ONDCP)
Office of National
Drug Control Policy
• Component of the Executive Office of the President
• Coordinates drug-control activities and related
funding across the United States Government
• Produces the U.S. Government’s annual National
Drug Control Strategy
National Drug Control Strategy
• The President’s science-based plan to
reform drug policy:
1)Prevent drug use before it ever
begins through education
2)Expand access to treatment for
Americans struggling with addiction
3)Reform our criminal justice system
4)Support Americans in recovery
• Coordinated the Federal effort on
112 action items
• Signature initiatives:
– Prescription Drug Abuse
– Prevention
– Drugged Driving
Substance Use Prevalence
Past Month Illicit Drug Use among Persons
Aged 12 or Older: 2013
Illicit Drugs
1
24.6
Marijuana
19.8
Psychotherapeutics
6.5
Cocaine
1.5
Hallucinogens
1.3
Inhalants
0.5
Heroin
0.3
0
5
10
15
20
Numbers in Millions
25
30
1 Illicit
Drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or
prescription-type psychotherapeutics used nonmedically.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 26,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresultsAlts2013.htm#fig2.1
5
Past Month Illicit Drug Use among Persons Aged
12 or Older, by Age: 2002-2013
Percent Using in Past Month
25
20.2+
20.3+
20
19.4+
20.1+
21.4
21.6
21.4
19.8+ 19.8+ 19.7+
21.3
21.5
9.5+
8.8
18 to 25
15
11.6+ 11.2+
10.6+
10
5.8+
5.6+
5.5+
9.9+
9.8+
9.6+
9.3
5.8+
6.1+
5.8+
5.9+
10.1+ 10.1+ 10.1+
6.3+
6.6+
6.3+
7.0 7.3
12 to 17
26 or Older
5
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 26,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#fig2.6
6
Past Month Illicit Drug Use among Persons
Aged 12 or Older, by Race/Ethnicity: 2002-2013
Percent Using in Past Month
12
10
9.7
9.7
8.5+
8
8.7+
8.3+
8.7+
+
8.1+ 8.1
8.0
6
7.2+
7.2+
7.6+
9.8
8.5+
6.9+
4
3.5
2
3.8
3.1
3.1
11.3
10.7
3.6
9.5
8.2+
6.6+
4.2
10.0
8.3+
9.7
8.8+
10.5
10.0
9.1
8.7+
7.9
8.1
8.4
3.7
3.5
3.8
9.2
8.3
3.7
9.5
8.8
Black or
African
American
White
Hispanic
or Latino
6.2+
3.6
Asian
3.1
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
Note: Sample sizes for American Indians or Alaska Natives, Native Hawaiians or Other Pacific Islanders, and persons
of two or more races were too small for reliable trend presentation for these groups.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 26,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#fig2.12
Past Month Use of Selected Illicit Drugs among
Persons Aged 12 or Older: 2002-2013
Percent Using in Past Month
10
8.3+
8.2+
8
6.2+
6.2+
2.7
0.9+
7.9+
8.1+
8.3+
6.1+
6.0+
6.0+
5.8+
2.7
2.5
2.7
2.9+
2.8+
1.0+
0.8+
1.0+
1.0+
6
4
2
0
0.5
8.0+
0.4
0.4+
0.4
0.4
0.8+
0.4
9.2
9.4
7.3
7.5
2.4
2.6
2.5
0.6
0.5
0.6
0.6
0.5
0.4+
0.4
0.5
8.7+
8.9
8.7+
6.7+
6.9+
7.0+
2.8+
2.7
Illicit Drugs
8.1+
Marijuana
6.1+
2.5
0.7+
0.4
0.7
0.5
Psychotherapeutics
Cocaine
Hallucinogens
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 26,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#fig2.2
We Don’t Have Time to Wait
PRESCRIPTION DRUG ABUSE EPIDEMIC
In 1999, there was one drug
overdose death every 30 minutes.
In 2013, there was one drug
overdose death every 12 minutes.
Heroin Use and Non-Medical Use of Pain Relievers in the
Past Year among Persons Aged 12 or Older: 2002-2013
Number of Users (Thousands)
Persons Aged 12 or Older
14,000
1,400
12,000
1,200
10,000
Non-medical users of pain relievers
1,000
8,000
800
6,000
600
4,000
Heroin users
2,000
400
200
0
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).
Prescription Drug Abuse
Prevention Plan
• Coordinated effort across
the Federal Government
• Four focus areas:
1) Education
2) Prescription Drug
Monitoring Programs
3) Proper Disposal of
Medication
4) Enforcement
Overdose Prevention and Education
The National Drug Control Strategy supports comprehensive
overdose prevention efforts, to include:
• Public education campaigns about signs of overdose,
emergency interventions, “Good Samaritan” laws where they
exist, and connecting people to substance use disorder
treatment.
• Training and availability of emergency interventions, naloxone
for first responders (including campus police).
• Education among health care providers to inform patients
using opioids (and their family members/caregivers) about
overdose.
• Naloxone co-prescribing.
Opioid Overdose Resuscitation
• The American Society of Anesthesiologists (ASA) has created a
card explaining how to recognize and respond to an opioid
overdose.
• The card, called “Opioid
Overdose Resuscitation,” is
available for download on
the ASA Web site. We ask all
of you to disseminate this
card as widely as possible.
• To download the card, go to:
http://www.asahq.org/WhenSecondsCount/resources
Substance Use Prevalence
Among Youth
Substance Use
Prevalence Among Youth
In 2013:
• 2.2 million adolescents were current illicit
drug users
• 2.9 million adolescents who were current
alcohol users
• An estimated 1.3 million adolescents were
classified with a substance use disorder
Source: Substance Abuse and Mental Health Services [SAMHSA] (2014). Substance Use and Mental health Estimates from the
2013 National Survey on Drug Use and Health: Overview of Findings. Retrieved on June 3, 2015 from:
http://www.samhsa.gov/data/sites/default/files/NSDUH-SR200-RecoveryMonth-2014/NSDUH-SR200-RecoveryMonth-2014.pdf
Escalation of Drug Use
During the Teen Years
Percent Reporting Past Month Use
25
20
15
10
5
Age
9/2014
Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).
65+
60-64
55-59
50-54
45-49
40-44
35-39
30-34
26-29
25
24
23
22
21
20
19
18
17
16
15
14
13
12
0
Escalation of Alcohol Use
During the Teen Years
Percent Reporting Past Month Use
70
60
50
40
30
20
10
Age
9/2014
Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014).
65+
60-64
55-59
50-54
45-49
40-44
35-39
30-34
26-29
25
24
23
22
21
20
19
18
17
16
15
14
13
12
0
Percent Using in Past Month, Aged
12-20
Current, Binge, and Heavy Alcohol Use
Among Persons Aged 12 to 20,
By Gender: 2013
25
23.0 22.5
20
15.8
15
12.4
10
4.6
5
2.7
0
Current
Binge
Male
Heavy
Female
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June
3, 2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#7.1.2
Past Month Marijuana Use among Youth,
By Gender: 2002-2013
Percent Using in Past Month, Aged 12-17
10
9.1+
8.6
9.0+
7.5
8
6
8.4
8.1
7.5
6.9+
7.2+
7.2+
8.4
7.5
7.3
7.1
6.2
6.5
5.8
6.1
6.3
6.4
6.7
7.9
Male
7.0
Female
6.2
4
2
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+
Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 3,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#7.1.2
Perceived Great Risk of Marijuana Use
Among Youth: 2002-2013
Percent Perceiving Great Risk, Aged 12-17
60
51.5+
54.4+ 54.7+ 55.0+ 54.2+ 54.6+
52.8+
49.0+
50
47.2+
44.8+ 43.6+
39.5
40
32.4+
30
34.9+ 35.0+ 34.0+ 34.6+ 34.4+ 33.4+
30.3+ 29.6+
27.6+ 26.5+
24.2
20
Smoke Marijuana
Once or Twice
a Week
Smoke Marijuana
Once a Month
10
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 3,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#7.1.2
12th Graders’ Past Year Marijuana Use vs.
Perceived Risk of Occasional Marijuana Use
60
Percent Reporting
50
40
30
20
10
Perceived risk is significantly lower from 2013 to 2014.
0
Past Year Use
Perceived Risk
Source: University of Michigan, 2014 Monitoring the Future study (December 2014).
12/2014
Perceived Great Risk of Use of Selected Illicit Drugs
Once or Twice a Week among Youth: 2002-2013
Percent Perceiving Great Risk, Aged 12-17
90 82.5+ 82.6+ 81.4+ 81.8+ 81.2+
+ 81.3+
81.0
80
70
79.8+
76.2+
60
50
40
51.5+
80.7+
76.9+
79.8+
76.4+
79.9+
76.1+
79.7
80.0
79.8
78.1
78.9
78.4
Heroin
Cocaine
74.1+ 73.8+ 71.7+
71.3+ 70.4
70.6
69.7
LSD
79.2
74.7+
80.9+ 80.4
78.9
79.1 78.4
54.4+ 54.7+ 55.0+ 54.2+ 54.6+ 52.8+
78.3
49.0+ 47.2+
44.8+ 43.6+
30
Marijuana
39.5
20
10
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 3,
2015 from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#7.1.2
Alcohol and Illicit Drug Dependence or Abuse
Among Youth: 2002-2013
Percent Dependent or Abusing in Past Year, Aged 12-17
10
9
8.9+
8.9+
8.8+
8.0+
8.1+
8
7
6
5
4
7.7+
7.7+
7.1+
5.9+
5.6+
5.9+
5.1+
6.0+
7.3+
6.9+
6.1+
5.5+
5.4+
5.4+
4.9+
4.6+
4.7+
5.2
4.6+
5.3+
4.7+
4.6+
4.3+
4.6+
4.3+
4.0+
4.6+
3
2
3.8+
3.4+
Alcohol or
Illicit Drugs
3.5
Illicit Drugs
Alcohol
2.8
1
0
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
+ Difference between this estimate and the 2013 estimate is statistically significant at the .05 level.
Source: SAMHSA. (2014). Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings. Retrieved on June 3, 2015
from: http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.htm#7.1.2
Students with an average grade of ‘D’* or lower are more
likely to be substance users compared to students whose
grade average is better than ‘D’
Percent Reporting Use in the Past Month
Persons Aged 12 to 17 Who Were Enrolled in the Past Year, 2013
24
21
"D" or lower grade average
Grade average better than "D"
19.7
20.9
17.6
18
14.3
15
12
9
8.4
6.8
5.1
6
6.2
3
0
Any Illicit
Drug
Marijuana
Cigarettes Binge Use of
Alcohol**
*Average Grade for Last Completed Grading Period
**Binge Use of Alcohol is drinking five or more drinks on the same occasion on at least one day in the past 30 days.
Source: SAMHSA, 2013 National Survey on Drug Use and Health, Detailed Tables. (September 2014).
9/2014
Persistent Marijuana Users Show a
Significant IQ Drop between
Childhood and Midlife
Average Point Difference in IQ score
(IQ at age 13 – IQ at age 38)
Followed 1,037 individuals from birth to age 38. Tested marijuana use at ages
18, 21, 26, 32, and 38. Tested for IQ at ages 13 and 38.
2
0
-2
-4
-6
-8
Non-users
used
1 Dx
used
2 Dx
used
3 Dx
Meier, MH, Caspi A. Amber, A. Harrington H. Persistent cannabis users show neuropsychological decline from childhood to
midlife. Proc. Natl. Acad. Sci USA, 2012 Aug 27.
Prevention
• Each dollar invested in a proven school-based prevention
program can reduce social costs, including those related to
substance use, by an average of $18.1
• Effective drug prevention happens
on the local level.
• Prevention must be comprehensive:
– evidence-based interventions in
multiple settings
– tested public education campaigns
– sound public policies
1
Miller, T. and Hendrie, D. Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis, DHHS Pub. No. (SMA) 07-4298.
Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 2008.
Examples of Risk and Protective Factors
Risk Factors
Domain
Early Aggressive Behavior
Individual
Poor Social Skills
Individual
Lack of Parental Supervision
Family
Substance Use
Peer
Drug Availability
School
Poverty
Community
Protective Factors
Self-Control
Positive Relationships
Parental Monitoring & Support
Academic Competence
Anti-Drug Use Policies
Strong Neighborhood Attachment
Reduce these
Elevate these
Effective Prevention Programs
Source: Preventing Drug Use: A Research-Based Guide, NIDA, 2nd Ed, 1997
Reforming Treatment and Care
CONTINUUM OF CARE
Treatment and Care
From Acute Care Model
To Chronic Care Model
•
•
•
•
•
•
•
•
Enters Treatment
Completes Assessment
Receives Treatment
Discharged
Prevention
Early Intervention
Treatment
Recovery Support
Services
Source: McLellan AT, Starrels JL, Tai B, Gordon AJ, Brown R, Ghitza U, Gourevitch M, Stein J, Oros M, Horton T, Lindblad R, Jennifer
McNeely J. Can substance use disorders be managed using the chronic care model? Review and recommendations from a NIDA consensus
group. Public Health Reviews. 2014;34: epub ahead of print
Three Distinctions Among
Collaborative Models1
• Coordinated: Routine screening for behavioral health
problems in primary care settings, but delivery of
services may occur in different settings.
• Co-located: Medical services and behavioral health
services located in the same facility.
• Integrated: Medical services and behavioral health
services located either in the same facility or in separate
locations.
1
Collins, C. Hewson, D., L., Munger, R., & Wade, T. (2010). Evolving Models of Behavioral Health Integration in Primary Care.
Milbank Memorial Fund .
Screening, Brief Intervention, and
Referral to Treatment (SBIRT)
• Enhances access and care for people with substance use
disorders.
• Need to focus on integration of substance use disorders
into primary care.
• Screening is essential for case identification and clinical
decision making.
• Referrals to specialty treatment are critical to increased
access to care.
• Brief Interventions do not appear to be as effective for
reducing drug use as for reducing alcohol use.*
• We need to find new/better interventions in primary care.
* Brief Intervention for Problem Drug Use in Safety-Net Primary Care Settings: A Randomized Clinical Trial. Peter Roy-Byrne, et al.
JAMA. 2014;312(5):492-501. doi:10.1001/jama.2014.7860.
Screening and Brief Intervention for Drug Use in Primary Care: The ASPIRE Randomized Clinical Trial. Richard Saitz, MD, et al.
JAMA. 2014;312(5):502-513. doi:10.1001/jama.2014.7862.
Medications Currently Available
For Nicotine Use Disorder
• Nicotine Replacement Therapies (NRT)
• Bupropion
• Varenicline
For Alcohol Use Disorder
•
•
•
•
Disulfiram
Naltrexone
Acamprosate
Naltrexone Depot
For Opioid Use Disorder
•
•
•
•
Methadone
Naltrexone (Vivitrol)
Buprenorphine
Buprenorphine/Naloxone
Principles of Drug Addiction Treatment, National Institutes of Health – National Institute on Drug Abuse
Recovery
SERVICE AND SUPPORTS
Recovery Support Services
• Services and supports for persons prescribed buprenorphine
in office-based settings
• Recovery support services and engagement with broader
recovery community for persons in opioid treatment
programs
• Service coordination for individuals in treatment with
medications, both office-based and through opioid treatment
programs
• Inform and engage recovery community
– Treatment with medications
– Identifying overdoses and preventing overdose deaths
– Welcoming and support of those in MAT
Supporting Adolescents and Young
Adults in Recovery at Schools and in
Higher Learning Institutions
• Schools are logical places to reach youth in
need of recovery support services
• Promising school-based recovery models:
– Alternative peer groups
– Recovery high schools
– Collegiate Recovery Programs
Stigma and Language
Addict
Hitting Bottom
Junkie
Crack Head
Substance Abuse/Abuser
Dirty Urine
Clean Urine
Habit/Drug Habit
September is National Alcohol and
Drug Addiction Recovery Month
• Celebrate those
in recovery
• Share stories of
recovery
• Plan and hold an
event during
Recovery Month
Visit www.recoverymonth.gov for more information
Federal Drug Budget Trends
Historical Federal Drug Control Spending ($B)
30
Total Drug Control Spending
24.9
21.7
19.9
20
24.6
27.6
25.7
24.5
26.3
24.4
23.8
21.8
20.6
18.6
Demand Reduction Spending
9.2
10
8.2
7.9
8.2
8.6
9.2
9.1
8.4
9.1
11.6
12.3
10.8
9.2
0
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
NOTE: The years denoted are fiscal years (FY); FY 2015 information represents enacted Budget
authority, and FY 2016 information represents Budget authority requested by the President.
Drug Policy Funding Priorities
The President’s FY 2016 Budget includes:
• $68.0 million to expand the CDC’s Prescription Drug Overdose Prevention
program to all 50 U.S. States and to strengthen and evaluate state-level
prescription drug overdose prevention.
• $25.1 million to expand SAMHSA’s Medication-Assisted Treatment for
Prescription Drug and Opioid Addiction program.
• $12.0 million for SAMHSA grants to help states purchase naloxone, equip
first responders in high-risk communities, and support education on the use
of naloxone and other overdose death prevention strategies.
• $10.0 million for SAMHSA’s new Strategic Prevention Framework for
Prescription Drugs program to target Rx drug abuse and misuse.
• $5.6 million for the CDC to address the rising rate of heroin-related overdose
deaths by working to collect near real-time emergency department data and
higher quality and timely mortality data by rapidly integrating death
certificate and toxicology information.
Q & A / Discussion
David K. Mineta
Deputy Director, Demand Reduction
Office of National Drug Control Policy (ONDCP)
dmineta@ondcp.eop.gov