ISSUE BRIEF Embargoed until Tuesday, December 17 at 10:00 AM ET Pain in the Nation: Healthcare Systems Brief HOW HEALTHCARE SYSTEMS CAN HELP ADDRESS THE DRUG, ALCOHOL AND CRISES

Hospitals and health systems are on the front line addressing alcohol and drug misuse, providing or linking patients to health services and integrating behavioral health services across systems. As such, it’s critical healthcare system efforts are supported so they can optimize prevention and build a “whole health” approach.

This approach requires a careful, encompassing This brief focuses on how to support this systems method—creating new programs approach by focusing on prevention and without intentionally integrating them with collaborations and partnerships that will and connecting them to other parts of the result in enhanced behavioral health services. same system continuum cannot bring about as Systems can and should be advocates robust a change as necessary. Additionally, in for patients and ensure the resources some cases, without taking this comprehensive commensurate with the challenge are method, a solution could increase quickly identified—and accessed. fragmentation and create more problems. MAY 2018 The Rising Problem of Deaths of Despair

In 2016, 142,000 Americans died were disproportionately large increases from alcohol-induced fatalities, drug in drug deaths among racial/ethnic overdoses and suicide—one every four minority groups, particularly among minutes.1 These “ of despair” Black Americans. In the previous have become a full-blown public decade, Blacks had relatively low drug health crisis and contributed to the overdose rates — averaging 35 percent unprecedented fall in in lower than Whites between 2006 and the in 2015 and 2016.2,3 2015. However, between 2015 and 2016, Blacks experienced an alarming Unfortunately, the problem is not increase — of 39 percent — in drug- getting better. Alcohol, drug and related deaths.5 suicide deaths increased 11 percent between 2015 and 2016, and the The United States has also seen a nation is now on a trajectory to lose steady rise in alcohol-related and more than two million people to these suicide deaths over the past few causes by 2025.4 decades — with increases in death rates of 55 and 54 percent between And the data indicates alarming 1999 and 2016, respectively.6,7 trends: while drug overdoses were still highest among Whites in 2016, there

Annual Deaths from Alcohol, Drugs and Suicide, 1999-2016

141,963 150,000 140,000 127,524 130,000 120,000 110,000 91,349 100,000 90,000 80,000 64,591 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 11 14 16 10 07 01 13 12 05 06 02 08 03 04 09 015 999 000 20 20 20 20 2 20 20 20 20 1 20 20 20 20 20 20 2 20

Total Deaths Drug Deaths Suicide Deaths Alcohol Deaths

Source: CDC WONDER

2 TFAH • WBT • PaininTheNation.org Deaths of Despair & the Healthcare Sector

The deaths of despair dramatically impact stays for opioids.12 These increases our nation’s healthcare system. Overdose are reflected in community health patients are inundating hospitals and needs assessments, with communities overwhelming first responders. One-third consistently ranking behavioral health of adult hospital stays and one-fourth of and substance use as two of their top teenage hospital stays in 2012 included a three health concerns.13,14,15,16,17 mental or substance use diagnosis.8,9 The increases in these expensive In fact, hospital stays for mental health/ conditions are also driving up our nation’s substance use was the only category of healthcare costs. Healthcare spending on hospitalizations that increased from patients with substance use disorders or 2005 to 2014 and, between 2009 and at risk for suicide in 2014 were 2.5 times 2014, opioid-related inpatient stays higher than average at $20,113 per patient increased 64 percent and emergency per year.18 Accordingly, these patients department visits doubled.10,11 account for a disproportionate share of total healthcare spending, with roughly 9.5 During a similar period, drug-use percent of total health costs spent on the related hospital stays for mothers and 3.8 percent of the population with drug, newborns also rose, including a 135 alcohol or suicide-related diagnoses.19 percent increase in maternal hospital

For the purposes of this brief, behavioral health involves substance use, mental health and other psychological conditions.

Percentage of hospital stays in 2012 that included a mental or substance-use diagnosis.

32% 28%

Adults Teenagers

TFAH • WBT • PaininTheNation.org 3 How Healthcare Systems Can Help Recognizing that deaths of despair are caused by a confluence of factors that contribute to adverse health and underlying pain, the Trust for America’s Health (TFAH) and Well Being Trust (WBT) have called for a national strategy to improve resilience.20

As hospitals and health systems work with healthcare providers (referred to in patients, providers and communities to this brief collectively as “healthcare address alcohol, drug and behavioral systems”)—have efforts underway to health conditions, it is critical to support modernize behavioral health services, healthcare system efforts to prioritize improve pain treatment and management prevention and adopt a “whole health” practices, limit the supply of opioids, raise approach. Organizations that provide awareness of the risk of addiction, reduce healthcare—including hospitals, stigma, and partner with the broader outpatient and long-term care facilities, community on improving the health and community health centers, and other well-being of Americans.

Prioritizing Prevention Investing in efforts to prevent patients practices include: screening for mental from misusing substances or attempting health or substance misuse risks, suicide can be cost-effective and save counseling patients and families to lives.21,22,23 Healthcare systems that more safely store lethal means, implementing fully integrate prevention efforts into take back days, and expanding the their organizations can help stem the availability and use of naloxone. increase in despair deaths. Promising

1. Screening for substance misuse, suicide and mental health issues Regularly screening patients for substance l Screening patients on a regular use disorders and mental health issues is a basis using an age-appropriate critical step healthcare systems are taking. questionnaire; Routine screening for substance misuse l Briefly interveningwith patients who is one of the National Principles of Care present risk factors by providing for Substance Use Disorder Treatment feedback about unhealthy behaviors issued by the Substance Use Treatment and educating them about the risks Task Force (see box on page 13). The involved with substance misuse; and Substance Abuse and Mental Health Services Administration (SAMHSA) l Referring for treatment those recommends the Screening, Brief patients who need further Intervention, and Referral to Treatment assessment and services.24 (SBIRT) method, which involves:

4 TFAH • WBT • PaininTheNation.org AMERICAN HOSPITAL ASSOCIATION’S (AHA) STEM THE TIDE TOOLKIT

Health care systems can help to opioid toolkit includes resources to reduce the stigma associated with help providers better understand and alcohol, drug and behavioral health address stigma in patients with opioid conditions, both within healthcare use disorders and describes how systems and the broader community. many hospitals and health systems This will help foster an environment implement programs like Mental Health in which individuals are willing to First Aid to combat stigma.25 seek treatment. AHA’s Stem the Tide

Studies show that even a single instance to engage in substance misuse and have of SBIRT or another brief discussion higher academic outcomes.31 Studies show that even a about a patient’s behavioral health can single instance of SBIRT or To support these programs, systems help lower healthcare costs, lessen rates can use a mix of funding sources. another brief discussion about of drug and alcohol misuse and reduce For instance, nonprofit hospitals can the risk of trauma.26,27,28,29,30 For example, a patient’s behavioral health use their community benefit dollars: suicide screening is a central aspect of can help lower healthcare Nationwide Children’s Hospital uses the successful Zero Suicide initiative community benefit dollars to place costs, lessen rates of drug and discussed below (see box on page 6). licensed behavioral health clinicians alcohol misuse and reduce the Additionally, healthcare systems are into first and second grade classrooms in risk of trauma. coordinating with schools and other Columbus, Ohio schools to help teachers community partners to implement administer the evidence-based PAX Good screening and provide access to Behavior Game and Signs of Suicide treatment for individuals identified as SOS program with their students.32 at risk for substance misuse, suicide or Using another strategy, through a $1.33 other mental health concerns. Systems member per month investment, Trillium also play a role in supporting evidence- Community Health Plan Coordinated based primary prevention efforts in Care Organization supports teacher their community—including social- training and implementation of the PAX emotional learning programs. People, Good Behavior Game in Lane County, particularly students, who are socially Oregon schools.33 and emotionally healthy are less likely

TFAH • WBT • PaininTheNation.org 5 THE ZERO SUICIDE MODEL

The Zero Suicide Model is a l Developing firearm removal policies comprehensive suicide prevention with patients and their families to approach that rests on the foundational help reduce access to means of belief that all are preventable.34 suicide; and Launched by the National Action Alliance l Assuming every patient with a for Suicide Prevention and supported by history of behavioral health needs is SAMHSA, the model uses a framework a suicide risk.38 of screening, treatment and support to integrate suicide prevention into primary and behavioral healthcare. The Zero Suicide initiative was modeled on The program has achieved practices utilized by several healthcare dramatic results—an 80 systems that showed significant percent reduction in suicides reductions in suicides for patients in among Henry Ford’s HMO their care, including the Henry Ford Health System in Detroit.35,36 members. This reduction has

At Henry Ford, primary care doctors been maintained for over a screen every patient during every visit decade, even as the overall U.S. with two questions: suicide rate has increased.39 1. How often have you felt down in the past two weeks?

2. How often have you felt little Implementation of this approach has pleasure in doing things? had no negative impact on the division’s financial health. In fact, the Zero Suicide Patients with high scores are asked approach can even save health systems additional questions about sleep money. Nashville-based Centerstone, a disturbances, changes in appetite and behavioral healthcare organization that thoughts of hurting oneself. Patients implemented the model, has reaped who indicate a problem are assigned annual cost savings of more than to appropriate care, which may include $400,000 from the program.40 cognitive behavioral therapy, medication, group counseling or, if necessary, SAMHSA is now providing federal hospitalization.37 The Zero Suicide funding to organizations—including protocol includes other practices, such as: community-based primary care and behavioral health organizations and l Testing new behavioral health models, emergency rooms—to implement the such as drop-in group therapy and Zero Suicide model in health systems.41 same-day psychiatric visits;

6 TFAH • WBT • PaininTheNation.org 2. Reduce access to lethal suicide means

As a suicide prevention measure, pass such a law in 2011.43 However, a healthcare systems can also encourage federal court in 2017 struck down the their providers to counsel patients bulk of the Florida law as a violation to safely store both firearms and of the First Amendment.44 While three medications. A proven successful other states—Minnesota, Missouri and method is the Counseling on Access to Montana—have legal restrictions related Lethal Means (CALM) approach. One to health providers collecting firearm study of this intervention at Children’s information, none of them explicitly Hospital Colorado found that parents of prevent clinicians from counseling children being treated for suicide risk patients about safe gun storage.45 who were educated about safe storage of Medication “take back” programs can medications and guns made significant help prevent drug misuse by reducing changes in their behavior. In follow-up the number of unused medications interviews, 76 percent of parents who available in homes and institutions. had been counseled about safe storage Given that a majority (53 percent) of reported that all medications were now people who misuse prescription drugs locked up (compared to 10 percent get them from friends and family,46 before counseling) and 100 percent these can serve as important prevention of those with guns reported their guns efforts. Some healthcare systems have were now locked up (an increase from installed drop boxes in hospitals and 67 percent).42 pharmacies where patients can deposit In recent years, there have been efforts medication. Another strategy is to in a number of states to pass legislation supply patients with safety bags along prohibiting doctors from counseling with their medications where they can their patients about safe gun storage, seal unused medicines and dispose of and Florida became the first state to them in the regular garbage.47

Reported effectiveness of counseling regarding the safe storage of medications and guns on parents.

All Medications are Locked up All Guns are Locked up

10% 76% 67% 100%

Before Counseling After Counseling Before Counseling After Counseling

TFAH • WBT • PaininTheNation.org 7 Community Partnerships Prevention efforts are most effective when all sectors in a community—healthcare systems, schools, law enforcement, government agencies, businesses, community organizations and faith-based groups—work together to invest in upstream prevention and identify at-risk community members to ensure they receive the support and services they need.

The Institute for Healthcare Improvement has identified a community-wide, system-level approach as a meaningful Create opioid-informed strategy to combat the .48,49 Healthcare and prepared systems have an important role in spearheading and communities

participating in such community-wide efforts. c

Many healthcare systems are participating in and providing Improve appropriate support for community coalitions to prevent substance use of opioids for misuse, prevent suicide and improve mental health. Hospitals nonmalignant pain

can be key leaders in such community coalitions. ide on the T Healthcare systems can also work to educate their communities about pain, anxiety, addiction and trauma, Reduce harm for those including the potential dangers of opioids and viability of addicted to opioids alternative pain management methods. For example, hospitals rn the

are providing training for first responders, law enforcement Opioid Epidemi officers and other community workers about overdoses and Improve management Tu use of the drug naloxone.50 of opioid addiction as a

And another way healthcare systems are partnering with the chronic community is through take back programs and expanding Source: 100 Million Healthier Lives availability and use of naloxone, a medication that rapidly reverses opioid overdose. A recent advisory from the Surgeon General calls on physicians and other prescribers, substance a community health worker model, and worked with the use disorder treatment providers and pharmacists to prescribe Charlestown Drug Court to help individuals on probation or dispense naloxone to those at elevated risk for opioid who are suffering from chronic substance use disorders. overdose and to their friends and family.51 The Charlestown Coalition, formed in 2004, has had some One example of this type of successful community effort notable successes: was spearheaded by the Massachusetts General Hospital l Emergency Medical Services responses for heroin overdoses (MGH) Center for Community Health Improvement. decreased 62 percent from 2003 to 2010; The Center created four coalitions focused on preventing substance use disorders, including take back programs, l Drug-related deaths decreased 78 percent between 2003 naloxone distribution, emphasizing connections to and 2008; and treatment through recovery coaches, and screening all l A preliminary evaluation suggests youth are more likely patients for substance misuse.52 to think through the consequences before deciding about Specifically, the MGH Coalition in the Charlestown substance use and more likely to say no to tobacco, alcohol, neighborhood partnered with community residents who or another drug.53 teach science at elementary and middle schools, utilized

8 TFAH • WBT • PaininTheNation.org Improving Behavioral Health Services 1. Better training and care integration and coordination Health systems are educating their medical and behavioral healthcare clinicians about both substance misuse services and systems, including: and suicide prevention. Unfortunately, l Co-locating and integrating physical many healthcare providers have never and behavioral healthcare services; been trained in suicide prevention and lack the confidence to effectively l Assigning patients case managers to help deal with a suicidal patient.54 The them navigate the healthcare system; National Action Alliance for Suicide l Implementing Accountable Prevention has proposed suicide Communities for Health (ACH) models, training guidelines for clinicians a cross-sector approach to improving and suggested they be required by health and health equity by enhancing state licensing entities, educational the clinical-community link;56, 57 and institutions and accreditation programs.55 Healthcare systems can l Supporting a “no wrong door” approach, use these recommendations to develop which allows patients to quickly access their own training requirements or an entire range of healthcare and social programs for their providers. service benefits regardless of where they enter a health system. This philosophy In addition, while behavioral health requires coordination among multiple services have long operated in their own sectors, so that healthcare providers silo and have not traditionally been part can refer patients to other entities for of the medical care systems, systems and services needed to improve their health providers are increasingly employing and well-being, such as for housing or strategies to shift towards a “whole nutritional assistance.58, 59, 60, 61, 62 health” mentality to ensure coordinated

TFAH • WBT • PaininTheNation.org 9 2. Boosting medication-assisted treatment

Enhancing behavioral health services discrimination against MAT patients, These medications are clinically requires ensuring providers are lack of physician training, and negative effective; reduce or prevent employing up-to-date treatments that views about MAT in the healthcare field.67 withdrawal symptoms; relieve have been proven clinically effective, Another complicating factor is the fact notably medication-assisted treatment that both methadone and buprenorphine cravings; block the reward (MAT)—the use of FDA-approved are controlled substances that are subject sensations from substance use; medications in combination with therapy to additional restrictions when used to and sustain recovery. to treat substance use disorders. The treat an opioid use disorder, including FDA has approved three medications to limits on the number of patients that one help treat opioid disorder: methadone, practitioner can treat.68 buprenorphine and naltrexone. The In addition to being clinically effective, FDA has also approved naltrexone, MAT also makes fiscal sense. A 2015 acamprosate and disulfiram to treat study found that treatment of opioid alcohol use disorders. These drugs are dependence with methadone and clinically effective; reduce or prevent buprenorphine was associated with withdrawal symptoms; relieve cravings; $153 to $223 lower total healthcare block the reward sensations from expenditures per month than substance use; and sustain recovery.63,64 behavioral health treatment without MAT is one of the National Principles of MAT, and that patients were 50 Care for Substance Abuse and endorsed percent less likely to relapse when by all major government health agencies treatment involved MAT.69 A systematic and experts in the field. Nevertheless, review of the literature has found SAMHSA has found that MAT is that pharmacotherapy treatment of underused.65 Indeed, a Blue Cross Blue alcohol dependence produced marked Shield study of its member plans found economic benefits.70 Unfortunately, that the number of patients diagnosed despite research to the contrary, many with an opioid use disorder between physicians do not believe that MAT is 2010 and 2016 exceeded the increase more effective than abstinence-based in those receiving MAT by eight-fold.66 treatment, according to a 2016 GAO They attributed this discrepancy to the review.71 Healthcare systems are working misperception that MAT simply replaces to educate their clinicians about the one illicit substance with another, effectiveness of MAT.72

Monthly healthcare expenditure savings asscociated with treating opioid dependence using behavioral health treatment and MAT

Patients whose treatment $153 to involved MAT are $223 50% less likely to relapse

10 TFAH • WBT • PaininTheNation.org 55% 77%

Percent of U.S. counties that do not have Percent of U.S. counties that report any practicing behavioral health workers unmet behavioral health needs

3. Increasing the number of behavioral health providers

A successful behavioral healthcare l Training other providers—such as system also requires sufficient providers peer counselors, community health to care for the growing number of workers and paramedics—to serve as patients who need treatment. Currently, behavioral health workers; there are not enough: 55 percent l Shifting towards providing care of U.S. counties do not have any in teams that include physicians, practicing behavioral health workers counselors and recovery specialists to and 77 percent report unmet behavioral maximize the use of providers’ time health needs.73 In 2011, 43 percent of and expertise;76 counties in the United States did not have a doctor licensed to prescribe l Implementing innovative approaches buprenorphine.74 Reasons for these such as telehealth that ease geographic shortages include high turnover rates, an and logistically difficulties; and aging workforce, stigma and low pay.75 l Encouraging nurse practitioners Increasing the workforce intentionally and physician assistants to train and is incredibly important. obtain certification to prescribe buprenorphine in office settings, Healthcare systems are working to which is permitted under the address these shortages by: Comprehensive Addiction and l Offering recruitment incentives to Recovery Act (CARA) through behavioral health providers; October 1, 2021.77,78

TFAH • WBT • PaininTheNation.org 11 Pain Treatment & Management Practices The Journal of the American Medical Association published Patients should not suffer in pain. At 8. Use risk reduction strategies, such as the same time, healthcare providers naloxone; new research in March 2017 have a responsibility to ensure they are 9. Review PDMP data; that found that ibuprofen, relieving their patients’ pain in ways that acetaminophen and other do not leave their patients vulnerable 10. Drug test patients prior to starting to substance addiction and misuse. opioid therapy and at least annually; nonsteroidal anti-inflammatory Healthcare systems must develop pain 11. Avoid prescribing opioid and drugs reduced pain more than treatment and management practices benzodiazepine concurrently; and opioids in patients with chronic that require their physicians to treat back, knee and hip pain.80 pain responsibly, including clear 12. Offer treatment, including MAT, for guidelines on opioid prescribing, patients with opioid use disorder.79 educating patients and prescribers Alternative therapies to opioids on opioid risks; training healthcare include physical therapy, cognitive providers to identify early signs of an behavioral therapy, localized nerve opioid use disorder; and expanding blocking and non-opioid medications, prescription drug monitoring programs such as acetaminophen or ibuprofen. (PDMP) and other tools to detect Many of these treatments can be as or misuse and diversion. more effective than opioids. In fact, The U.S. Centers for Disease Control the Journal of the American Medical and Prevention’s (CDC) Guideline for Association published new research in Prescribing Opioids for Chronic Pain March 2018 that found that ibuprofen, can serve as a resource in this process. acetaminophen and other nonsteroidal The Guideline recommends that, when anti-inflammatory drugs reduced pain not treating active , palliative or more than opioids in patients with end-of-life care, healthcare providers: chronic back, knee and hip pain.80

1. Not use opioids as a first-line treatment; PDMPs, recommended in CDC’s Guideline, are an important tool 2. Establish goals for pain reduction and for healthcare systems working to function and continue opioid use establish responsible opioid prescribing only if the benefits of opioids towards practices. These electronic databases meeting these goals outweigh the risk; allow healthcare professionals to access 3. Inform patients of the benefits and information about the dispensing of risks of opioid use; controlled substances statewide and the data can help physicians avoid 4. Begin opioid treatment with dangerous drug interactions and identify immediate-release versions; “doctor shopping” patients seeking 5. Use the lowest effective dose when multiple opioid prescriptions. PDMPs prescribing opioids; also allow healthcare systems to identify possible provider overprescribing, both 6. Prescribe opioids in short duration intentional and unintentional. for acute pain; The Partnership for Drug-Free Kids’ 7. Frequently reevaluate the harms and prescriber education initiative, Search benefits of continued use of opioids;

12 TFAH • WBT • PaininTheNation.org and Rescue,81 is a tool that can assist Healthcare systems are also healthcare systems with opioid misuse implementing risk-reduction practices prevention. Search and Rescue provides such as requiring patients to show a one-minute opioid risk assessment, identification prior to dispensing continuing education courses on opioid opioids, prohibiting dispensing of prescribing and helps providers find certain medication in the office local opioid treatment programs where setting (i.e., requiring pick up at a they can refer patients. Other resources separate pharmacy), and requiring include the AHA, Catholic Health patients with high patterns of receiving Association and America’s Essential prescriptions from multiple providers Hospitals, which have all issued guidance to be “locked-in” to using a single to help hospitals and emergency pharmacy to monitor and coordinate departments respond to the opioid the safety of their prescriptions. To crisis and integrate and support mental prevent the diversion of opioids for health.82,83,84 CDC and AHA have also illicit use, healthcare systems are developed a prescription opioid handout also working to ensure that onsite or to facilitate communication between partner pharmacies have appropriate providers and patients about the risks and control processes in place to ensure all side effects of opioids, and what patients medications are secure.86 should do when prescribed opioids.85

NATIONAL PRINCIPLES OF CARE FOR SUBSTANCE USE

In 2017, the public-private Substance Use 5. Coordinated care for every illness Treatment Task Force, which was created 6. Behavioral health care from by the organization Shatterproof to ensure legitimate providers all Americans with a substance use disorder have access to treatment based 7. Medication-assisted treatment on proven research, issued National 8. Support for recovery outside the Principles of Care for Substance Use.87 doctor’s office88 Based on core concepts from the Surgeon General’s Report on Alcohol, Drugs, and These principles have been endorsed Health, the task force advocates for: by more than 300 experts in the field, as well as by the federal agencies with 1. Routine screening in every medical primary responsibility for addiction policy: setting SAMHSA, the National Institute on Drug 2. A personal plan for every patient Abuse (NIDA), the National Institute on Alcohol Abuse and (NIAAA), 3. Fast access to treatment CDC, FDA, and the Centers for Medicare 4. Disease management that includes and Medicaid Services (CMS).89 long-term outpatient care

TFAH • WBT • PaininTheNation.org 13 Conclusion

Unless action is taken, the country will continue to be on the worst possible case scenario track for alcohol, drug and suicide deaths. TFAH and WBT strongly recommend that the resources and expertise needed to prevent more deaths be provided as soon as possible—and the nation come together to support a National Resilience Strategy.

Prioritizing prevention, working together, improving behavioral health services and engaging in responsible pain treatment and management practices, healthcare systems can help mitigate the devastating epidemic of drug overdoses, alcohol-related fatalities and suicides among the next generation of Americans.

When implementing these action steps, it is essential that healthcare systems take a careful, system-wide approach to maximize impact and minimize fragmentation. The integration of new and existing programs alike can boost community capabilities and ensure community members have access to all available resources (i.e. connecting a patient across the healthcare system, the private sector and safety net programs). Simply creating new programs in communities, hospitals or schools without connecting them to other systems pieces will not bring about as robust a change as possible.

Additionally, healthcare systems can and should advocate for the policies and resources necessary—both within and beyond the clinical setting—to reduce alcohol, drug and suicide deaths among their patients.

14 TFAH • WBT • PaininTheNation.org Endnotes 1 Unless otherwise noted, all of the despair 9 Heslin KC, Elixhauser A. Mental and Substance 18 Trust for America’s Health. Pain in the na- death data is from the CDC WONDER Use Disorders Among Hospitalized Teenagers, 2012. tion: the drug, alcohol and suicide epidemics database. United States Department of HCUP Statistical Brief #202. March 2016. and the need for a national resilience strategy. Health and Human Services (US DHHS), Agency for Healthcare Research and Quality, http://www.healthyamericans.org/assets/ Centers for Disease Control and Prevention Rockville, MD. http://www.hcup-us.ahrq.gov/ files/TFAH-2017-PainNationRpt-FINAL. (CDC), National Center for Health Statistics reports/statbriefs/sb202-Mental-Substance- pdf. Published November 2017. Accessed (NCHS). Multiple Cause of Death 1999- Use-Teenagers.pdf. Accessed April 7, 2018. February 27, 2018. 2016 on CDC WONDER Online Database, 10 McDermott KW, Elixhauser A, Sun R. Trends 19 Ibid released December 2017. Data are from the in Hospital Inpatient Stays in the United States, Multiple Cause of Death Files, 1999-2016, as 20 Ibid 2005–2014. HCUP Statistical Brief #225. June compiled from data provided by the 57 vital 2017. Agency for Healthcare Research and statistics jurisdictions through the Vital Sta- 21 Miller T, Hendrie, D. Substance abuse Quality, Rockville, MD. www.hcup-us.ahrq. tistics Cooperative Program. http://wonder. prevention dollars and cents: a cost-benefit gov/reports/statbriefs/sb225-Inpatient-US- cdc.gov/mcd-icd10.html. analysis, DHHS Pub. No. (SMA) 07-4298. StaysTrends.jsp. Accessed April 7, 2018. Rockville, MD: Center for Substance Abuse 2 Kochanek KD, Murphy SL, Xu JQ, Arias E. Prevention, Substance Abuse and Mental 11 Weiss AJ, Elixhauser A, Barrett ML, Steiner Mortality in the United States, 2016. NCHS Health Services Administration, 2008. CA, Bailey MK, O’Malley L. Opioid-Related Data Brief, no 293. Hyattsville, MD: National Inpatient Stays and Emergency Department Visits Center for Health Statistics. 2017. 22 Vasiliadis HM, Lesage A, Latimer E, Se- by State, 2009–2014. HCUP Statistical Brief guin M. Implementing suicide prevention 3 National Center for Health Statistics. Health, #219. December 2016. Agency for Health- programs: costs and potential life years United States, 2016: With Chartbook on care Research and Quality, Rockville, MD. saved in Canada. J Ment Health Policy Econ. Long-term Trends in Health. Hyattsville, http://www.hcup-us.ahrq.gov/reports/ 2015;18(3):147-55. Maryland. 2017. https://www.cdc.gov/nchs/ statbriefs/sb219-Opioid-Hospital-Stays-ED- data/hus/hus16.pdf. Published May 2017. Visits-by-State.pdf. Accessed March 14, 2018. 23 Washington State Institute for Public Policy. Accessed March 13, 2018. Good behavior game. Benefit-Cost Esti- 12 Agency for Healthcare Research and Qual- mates Updated June 2016. Olympia, WA: 4 Pain in the Nation Update: Deaths from Alcohol, ity (July 28, 2015). Increased Newborn Washington State Institute for Public Policy. Drugs, and Suicide Reach the Highest Level Ever and Mother Hospital Stays Related to Sub- http://www.wsipp.wa.gov/BenefitCost/Pro- Recorded. Trust for America’s Health website. stance Use. https://www.ahrq.gov/sites/ gramPdf/82/Good-Behavior-Game. Updated http://healthyamericans.org/assets/files/ default/files/wysiwyg/research/data/data- December 2017. Accessed March 12, 2018. TFAH-2018-PainNationUpdateBrief-FINAL. infographics/pdf/neonatal-maternity.pdf. pdf. February 22, 2018. Accessed February Accessed April 7, 2018. 24 About Screening, Brief Intervention, and 26, 2018. Referral to Treatment (SBIRT). Substance 13 Trust for America’s Health. Blueprint for a Abuse and Mental Health Services Admin- 5 CDC Multiple Cause of Death data show that, Healthier America 2016. Policy Priorities for the istration website. https://www.samhsa.gov/ between 2006 and 2016, Blacks averaged 10.0 Next Administration and Congress. http:// sbirt. Updated September 2017. Accessed drug deaths per 100,000 and Whites aver- healthyamericans.org/health-issues/ February 28, 2018. aged 15.5 drug death per 100,000. wp-content/uploads/2017/02/TFAH- 2016-Blueprint-Fnl.pdf. Published October 25 American Hospital Association. Stem the 6 Ingraham C. Americans are drinking them- 2016. Accessed April 8, 2018. Tide: Addressing the Opioid Epidemic. Chi- selves to death at record rates. Washington Post. cago, IL. https://www.aha.org/system/ December 22, 2015. https://www.washing- 14 Alberti PM, Sutton K, Baer I, et al. Commu- files/2018-02/stem-tide-addressing-opioid- tonpost.com/news/wonk/wp/2015/12/22/ nity Health Needs Assessments: Engaging epidemic-toolkit.pdf. Published 2017. 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