Testimony of Vaira Harik, Barnstable County Department of Human Services on HB3898 2/9/16

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1 Testimony of Vaira Harik, M.Sc. Barnstable County Department of Human Services To the MA Joint Committee on Mental Health and Substance Abuse Special Hearing: House Bill 3898 Establishing a Commission on Behavioral Health Promotion and Upstream Prevention Tuesday, February 9, 2016 Good morning Chairwomen Flanagan and Malia, and members of the Committee: My name is Vaira Harik. I am here representing the Barnstable County Department of Human Services to offer our unqualified support of House Bill 3898, Establishing a Commission on Behavioral Health Promotion and Upstream Prevention. I would like to convey greetings from our Director, Beth Albert. She sends her regrets that she cannot be here today. Thank you for this opportunity to present a few elements of our work on substance use on Cape Cod that have direct bearing on the pervasive problem of behavioral health disorders. My testimony is divided into three related parts: 1. I will describe the regional work of our substance use council, which will address component 3.b. of the PromotePrevent Plan 1 which reads Assess strategies to improve our system of behavioral health, including improving local and state collaboration across public health, mental health, public safety, and education; 1 The Commission has distributed a document which introduces the proposed PromotePrevent Plan. The PromotePrevent Plan Summary and Factsheet is appended to this testimony. 1

2 2. I will provide an estimate of substance use and addiction costs associated with mental health issues. This will address components 6 and 9 of the PromotePrevent Plan which read: Assess the costs to behavioral issues, like addiction, incarceration, homelessness, and academic failure and (a)nalyze the costs and benefits of implementing the PromotePrevent Plan ); and 3. I will briefly describe the findings of a focus group on addiction that we held with behavioral health providers on Cape Cod in May Barnstable County Regional Substance Abuse Council (RSAC) As you know Barnstable County is Cape Cod. A population of 215,000 people lives in 15 towns year-round. Fortunately, our county is one of a few that have retained a regional government model. I say fortunately because this model of government greatly facilitates public health and human service planning at a regional level. The Barnstable County Department of Human Services takes maximum advantage of this opportunity. In January of 2014, responding to increasing evidence of acceleration in drug overdoses and deaths, the Department convened the Barnstable County Regional Substance Abuse Council (RSAC). The Council s goal is to create a coordinated and comprehensive regional approach to substance use across the continuum of prevention, harm reduction, treatment, and recovery. We took action at the right time. Three months later Gov. Duval Patrick, with then-dph Commissioner Cheryl Bartlett, declared a public health emergency to respond to the State s opioid crisis. The RSAC brings together a diverse group of 40 stakeholders representing local government, elected officials (local, state, and federal), state agencies, law enforcement, courts, schools, healthcare and behavioral health providers, youth, and community coalitions. The Council s co- Chairs are Beth Albert (our Director), Ray Tamasi (CEO of Gosnold on Cape Cod), and Cheryl Bartlett (the immediate past Commissioner of the MA Department of Public Health). In essence, Barnstable County is fortunate to have its own blue ribbon panel of human service, substance use treatment, and public health experts leading our work. 2

3 In response to an identified need for an assessment of the substance use problem and its associated costs and a need for a regional plan of action, the RSAC has issued an Analysis of Substance Use on Cape Cod: A Baseline Assessment (March 2015) 2 and Addressing Substance Use on Cape Cod: Action Plan, (August 2015) 3, both of which now inform and direct the Council s work. The Baseline Assessment includes an epidemiologic analysis of substance use on Cape Cod, an environmental scan which identifies the substance use-related service delivery system, and a cost analysis of substance use on Cape Cod, which I will discuss next. Estimated Cost of Substance Use on Cape Cod Our costing work revealed an allocated expenditure of approximately $512 per resident per year due to substance use and addiction in 2013, for a total cost of over $110 million on Cape Cod. This analysis took into account the estimated costs of substance use to the sectors of law enforcement, incarceration, treatment, recovery, harm reduction, and prevention. Table 1 summarizes these findings. Table 1. Summary of Costs of Substance Abuse-Related Activities in Barnstable County, 2013 SUMMARY OF COSTS SUBSTANCE ABUSE- RELATED ACTIVITIES IN BARNSTABLE COUNTY DOMAIN Total by Domain Percent of Total DIRECT COSTS Sub-Total Alcohol Sub-Total Heroin/Opiates Sub-Total Marijuana Sub-Total Other Drug HARMS REDUCTION $ 707, % $79,000 $615,000 $13,000 Pending PREVENTION $1,010, % $566,000 $303,000 $141,000 Pending LAW ENFORCEMENT $56,900, % $23,500,000 $33,400,000 Pending Pending TREATMENT & RECOVERY $51,467, % $23,030,000 $23,596,000 $751,000 $4,090,000 Total Estimated Cost of Substance Abuse on Cape Cod $110,084, % $47,175,000 $57,914,000 $905,000 $4,090,000 Percent of Total 43% 53% 1% 4%

4 2. Estimated Cost of Co-Occurring Mental Health and Substance Use Disorders To estimate the subset of those costs related to co-occurrence and/or interaction with mental health problems we use the following rules of thumb which describe the relationship between substance use and mental illness: According to that National Association of Mental Illness (NAMI), citing Regier et al. 4, Roughly 50 percent of individuals with severe mental disorders are affected by substance abuse. 37 percent of alcohol abusers and 53 percent of drug abusers also have at least one serious mental illness (SMI). Of all people diagnosed as mentally ill, 29 percent abuse either alcohol or drugs. The above information, combined with our costing work on substance use, suggests a population per capita cost of co-occurring addiction and serious mental illness of $236 on Cape Cod (2013), or $50.8 million of the estimated total cost of substance use of $110 million (as reported above). Note that this likely underestimates this cost, since the percentages applied are those associated with serious mental illness (SMI), a diagnosis that omits less acute although impactful and debilitating mental illness. This per capita cost, when applied to the Massachusetts population allows for an estimate of the cost of co-occurring SMI and substance use-addiction of $1.6 billion per year (estimated for 2013). Studies show that at least 70% of such costs are typically paid with public funds (federal, state, and 4 Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. Jama. 1990;264(19):

5 local) 5. Thus in Massachusetts we estimate that over $1.1 billion of public funds are expended as a consequence of the interaction between mental health problems and substance use-addiction. This estimated expenditure, when compared to the entire Massachusetts state budget for SFY (nearly $32.5 billion, table 2) allows an understanding of the financial burden of this problem upon state coffers. Based upon the analysis above we estimate that over 3% of the total state budget was spent on mental health-related substance use problems by various state agencies. Table 2. State of Massachusetts Fiscal Year 2013 Budget Summary State of Massachusetts Fiscal Year 2013 Budget Summary ($000) FY2013 GOVERNMENT AREA GAA Judiciary 750,280 Independents 3,087,112 Administration and Finance 3,943,878 Energy & Environmental Affairs 206,090 Health and Human Services 16,469,000 Transportation 353,790 Housing & Economic Development 426,889 Labor & Workforce Development 35,149 Education 6,177,236 Public Safety 966,266 Legislature 61,328 TOTAL 32,477,017 By contrast, the $1.1 billion expended as a consequence of the interaction between mental health problems and substance use-addiction greatly exceeds the line item amounts budgeted for the Judiciary ($750,280,000) and for Public Safety ($966,266,000) and exceeds the combined budgets of the Energy & Environmental Affairs, Transportation, Housing & Economic Development, and Labor & Workforce Development ($1,021,918). This is a remarkable allocation of public resources, 5 Levit K, Kassed C, Coffey R, et al. Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, SAMHSA Publication No. SMA Rockville, MD: Substance Abuse and Mental Health Services Administration;

6 by fiat because it is a necessary and minimum response to the problem. The expenditures are made in response to the acknowledged addiction crisis and its interaction with the heretofore unheralded mental health crisis. 3. Focus Group on Addiction Held with Behavioral Health Providers As part Council s substance use Baseline Assessment on Cape Cod we conducted a series of 15 focus groups with a variety of constituencies. In May of 2015 a focus group with behavioral health providers from across the treatment spectrum yielded the following observations about the confluence of mental health problems and addiction: a. School children and parents should receive more education to understand the impact of their substance use choices on themselves and others, b. Treatment for addiction must address the patients underlying mental health issues. Focus group members estimated that 80% of addicted persons have dual diagnoses (mental illness and addiction); c. Treatment must encompass the entire family; d. Substance use treatment services for adolescents are severely lacking on Cape Cod; e. Proactive discharge planning from any medical facility, treatment facility, and correctional setting must be provided to avoid returning to using and recidivism to those institutions; f. Establishment of a sub-acute treatment unit to provide training in life skills is recommended; g. Law enforcement officers should be able to take drug users into protective custody when the circumstances warrant it. The hours for seeking a Section 35 commitment should be expanded; h. There should be a central website with listings of treatment and recovery resources, with referral assistance; i. It is a serious problem that many social service programs (such as housing programs) often exclude active users from accessing these services. Focus group members believed that this policy was counter-productive because it denied needed support services to this population, thereby reducing their chances of successful treatment and recovery. 6

7 Lastly, I would like to read into the record the following quotation from one of the focus group participants, a psychiatrist: There is an epidemic of trauma underlying the dysfunctional families and substance use that we see. If we truly wish to address the pervasive behavioral health problems in our society we must acknowledge and address the association between trauma and using drugs to self-medicate the effects of trauma. Thank you for this opportunity to comment on your work. As this Commission notes in its Factsheet, (b)ehavioral health disorders including mental, emotional, and substance use disorders exact heavy costs on our communities. The Barnstable County Department of Human Services welcomes opportunities to work with our colleagues at all levels of government to seek solutions to this problem and to plan for their implementation. Bibliography 1. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. Jama. 1990;264(19): Levit K, Kassed C, Coffey R, et al. Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, SAMHSA Publication No. SMA Rockville, MD: Substance Abuse and Mental Health Services Administration;

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COMMUNITY ASSESSMENT OF THE OPIOID CRISIS IN LORAIN COUNTY, OHIO EXECUTIVE SUMMARY

COMMUNITY ASSESSMENT OF THE OPIOID CRISIS IN LORAIN COUNTY, OHIO Prepared for The Nord Family Foundation December 20, 2017 Background The impact of the opioid crisis in Lorain County, Ohio is far-reaching