Harm Reduction in U.S. Substance Use Disorder Efforts: Top Official Explains How It Works

Tom Coderre

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Marianne O’Hare : Welcome to Conversations on Health Care . This week we welcome
Tom Coderre, Deputy Assistant Secretary for Mental Health and
Substance Use at SAMHSA on the rising mental health and substance
use crisis in this country.

Tom Coderre: People talk about there being no options . That is not what we want to
say to somebody who’s suffering from mental illness. There are
always options. There’s always hope.

Marianne O’Hare : Lori Robertson joins us from F act C heck.org and we end with a bright
i dea improving health and well being in everyday lives. Now, here are
your hosts Mark Masselli and Margaret Flinter.

[ Music ]

Mar k Masselli: May is National Mental Health Month and this year it is particularly
meaningful as new data emerges about the effect of the pandem ic on
our collective wellbeing.

Margaret Flinter: Tom Coderre is at the center of the U . S . efforts to recognize and to
deal with these issues. He's the Acting Deputy Assistant Secretary for
the Mental Health and Substance Use also known as SAM H SA, the
Substance Abuse and Mental Health Services Admin istration of the
United States.

Mark Masselli: Tom, welcome to Conversations on Health Care .

Tom Coderre: Thank you, Mark and thank you, Margaret. It's great to be with you.

Mark Masselli: Yeah, you know, we start with grim numbers. The National Center for
Health Statistics recently reported that the U . S . had a record 100,000
drug overdoses in 2021 a 16% increase from previous year, and the
excess of alcohol drinking increased by 21% d uring the pandem ic . The
Biden administration is implementing a national drug control strategy.
And this is the first time the government is prioritizing harm
reduction . If we can ask you to set the record straight on wh at harm
reduction is all about?

Tom Coderre: Sure Mar k, and thanks so much for the question. And first of all, let
me begin by acknowledging how tragic those overdose deaths that
you talked about are . Those are not just statistics, as we know, those
are real people. Those are mothers and fathers and brothers and
sisters, who have been taken from us way too soon. And the overdose
crisis in America is doing that month after month. And it's not just a
crisis of one substance. And it's really an addiction crisis in our
country, as you pointed out. There are far t oo many people who turn
to substances to change the way they feel, because they've lost hope
or they are self medicating for some underlyin g condition that they

Tom Coderre

may have.

Let's just talk a little bit about harm reduction, because really, that
approach is really all about saving lives. Harm reduction is proactive,
and its evidence based. It's to reduce the negative personal and public
health impacts of any behaviors that are associated with alcohol and
other substance use. It works at both the individual le vel and the
community level. And it's, as you pointed out a v ery important part of
the Biden - Harris administration's comprehensive approach to
addressing the crisis that we're in the middle of through bringing
prevention, treatment, and recovery services t o individuals, where
they are, to help them work through their own goals, to help bring
them across the stages of change . Harm reduction incorporates a
whole spectrum of strategies, again, to meet people where they are
on their own terms and it serves as a pathway to a dditional
prevention, treatment, and recovery services through really
something that I think is important. It's engagement , right?

That's the thing. That's one of the missing pieces, often to the puzzle
is that you don't just set up treatment and everybody shows up in
treatment and gets well . It’s a process of engagement for new people
across stages of change, and helping them try to find out what their
goals are in life, addressing the broader health and social issues
through improved policie s, progr ams, and practices.

Margaret Flinter: Tom, thank you for that. And this is kind of a technical question,
maybe, but I think it gets to the importance of the program SAM H SA
funds . We’d like you to explain to our listeners, the government and
P erform ance R esults A ct T ool - [ Crosstalk - Overlap 00:04:08] - but
good to understand. I know it’s required of all programs at SAM H SA
funds, we've read that it's used to assess addiction program
performance, but it's got some critics that say it's overbearing and the
questions it asks people, we always worry about things that might be,
you know, disincentives to people to participate. What is this A ct and
the T ool an d what's your thoughts on this?

Tom Coderre: Well, thanks for asking Margaret. It's, you know, it's a law that was
enacted a long time ago back in 1993. And it's one of a series of laws
that's really to improve governance, performance management. Of
course, the taxpayers are investing lots of money into these
government programs and they want to make sur e that they're
working. So GPRA requires agencies to engage in performance
management tasks, such as setting goals , measuring results, and
reporting progress, and to comply with GPRA , agencies produce
str ategic plans, performance plans, and conduct gap ana lysis. And as
part of this F ederal mandate, all of our SAM H SA g rantees are required
to collect and report performance data using approved measurement
tools. And many of these tools as you pointed out and we heard this

Tom Coderre

from our stakeholders that they needed some relief from some of
these tools. So how can we meet them where they are, because
they're doing important work in the community , t hey're saving lives ,
t hey're offering effective prevention, treatment, and recovery
services, we have the ability every f ew years to update those
questions and that's exact ly what we did.

So we have a new revised GPRA tool that's going into effect on
st
October 1 , and the revised updated questions, people were able to
make public comments and we heard from, you know, active
additions, we heard from treatment professionals, harm reduction
specialists, tribal communities, and lots of other stakeholders and the
public comments review. And we have the new tool as a result of new
questions as a result of that. So hopefully, that w ill reduce some of
the burden that folks felt in the past.

Mark Masselli: Tom, what a great approach that you have at SAM H SA as part of the
U . S . Department of Health and Human Services, which enga ges with
community partnerships, connects people to innovati ve and evidence
based practices. I'm wondering what you could share with us about
the excitement that's going out in the field, some of the best practices
that you're seeing around the country .

Tom Coderre: SAM H SA has, as you all know, an evidence based pr actice resource
center . We have it on our website, it's available to all. And we have a
way to share and lift up some of the most significant evidence based
practices that are happening around the country. So we have things
like tools for prescribing b upre norphine in primary care settings, we
have information about prescription stimulant mixed u se among
youth and young adults, guide book on preventing marijuana,
Telehealth , which has obviously been a big deal during the pandemic
when everyone had to move to virtual platforms, even things like
reducing vaping among and young adults. So we've seen lots of these
evidence based practices being employed around the country, and
we're hap py to be able to lift those up.

We also have seen practices like you know, ar ound b uprenorphine
training requirements, that at the start of the COVID pandemic, we
had to relax the training requirements from practitioners who wanted
to treat people who had an opioid use disorder, removing that barrier
that existed. As a result, we 'v e seen more eligible practitioners sign up
to be able to prescribe b uprenorphine which is an urgently needed
medication to help people on their treatment pathway. Equally
important are peer recovery aids, people who share their own
journeys and strategies with others who are grappling with their own
cycles of substance use and peer supports play a really important role
in work of rec overy. So we also just embark on a listening session . Our
Center for Substance Abuse Prevention had a series of listening

Tom Coderre

sess ions last year. And we learned that for some organizations, the
pandemic was an opportunity to be innova tive in their use of
technology, to go b eyond their existing practices.

One organization, for example, developed a mobile A pp through
which individuals could connect with a confidential crisis phone line ,
chat with professionals in the crisis intervention unit. So that was an
important tool. And we're transitioning our National Suicide
Prevention Lifeline to a new three digit number 988. And so as we do
that transition, we see that as the first step toward a transformed
crisis system in America, where we're making $282 million investment
to the transition to the lifeline. But the implementation is going to
depend significantly on our partners and our stak eholders at the state
level and local levels as we seek to help transform what historically
has been an underfunded and fragmented system. So we value the
support and contributions of our partners at the community level
when we're making these innovations.

Margaret Flinter: Well, just want to emphasize how appreciated and valuable the
changes to the training requirements were. And that at the
community level, everyone's certainly focused on getting the
information about the crisis number out to the public. So thank you so
much for [ Crosstalk - Overlap 00:09:39 ]

Tom Coderre: Thank you Margaret. Thank you for pointing that out.

Margaret Flinter: And I want to get back to data in the interest of the most critical issue
which is preventing these fatal overdoses. W e know that the best
predict or, perhaps the best predictor of a fatal overdose is a prior
non - fatal overdose that's why we so prioritize anyone seen In the ER
brought in by the EMS folks, but there isn't a way to measure non -
fatal overdoses overall. Do you have any initiatives in the work for
that so that we can do a better job of preventing the fatal overdoses?

Tom Coderre: Yeah, this is a really difficult question. And of course, there are non -
fatal overdoses that happen that we know about, because law
en forcement responds or somebody ends up in emergency room. But
then there are a lot of non - fatal overdoses that we don't know
anything about b ecause we have deployed so much Naloxone into
communities that it's really hard to track w hen somebody has a non -
fa tal overdose so that data becomes really difficult to collect. We're
lucky that we have things like ODMAP , which first responders use to
enter the data in real time into a system so that law enforcement can
help track across counties, states, where there a re hotspots so that
they know if something's happening, and the n they can respond
immediately.

SAMHSA has our system called DAWN, our Drug Abuse Warning
Network because we agree that non - fatal overdose data holds value

Tom Coderre

in providing public health surveillan ce. So, our DAWN involves a
network of hospitals providing us data about patients who present to
their emergency departments with conditions related to substance
use.

So because other surveillance tools that we have, like our flagship
NSDUH, o ur National S urvey on Drug Use and Health , that data lags
behind by the time we get that data, it's not really helpful in real time
to help us respond. You know, one of the things that I think we really
have to do here is work with state and county level, folks, becaus e a
lot of these systems have to be employed there. We have state laws,
and we have County Coroners and, and we even have municipal rules
that are in place , that these partnerships have to be developed. And
perhaps SAMHSA has a role in helping to provide r esources to get
these data systems up and running around the country so that we can
get a better sense of when these non - fatal overdoses happen so we
can respond more quickly.

Mark Masselli: Tom, we see the Biden administration stresses the word unity and
highlights bipartisanship in this effort, but there are disagreements ,
Republicans in states such as West Virginia and Indiana have shut
down needle exchange programs. Donald Trump's Surgeon General
recently said Republicans are more likely to believe addi ction is a
moral failing than a treatable disease. How do you balance all these?
And what do you say when you hear people express these views or
take these actions?

Tom Coderre : I'm not a political appointee anymore, Mark. So you know, we are in a
polarize d moment in our history. So we have to be careful that that
doesn't seep into this space and get in the way of us helping in
behavioral health and save lives. But what I do know is that for mental
illness and substance use disorder, it's probably the one i ssue on
Capitol Hill and in S tate H ouses where there's the most bipartisan
support, mental illness and substance use disorders don't
discriminate. They don't have party labels, and Congress is working
together to provide resources that are so desperately n eeded. So
there will always be disagreements on the margins. But on the big
things, there's a lot of agreement, and there's a lot of people working
together. Of course, SAMHSA’s priority is connecting people to
effective treatments and supports, because we know that recovery is
real and it ’ s possible for everyone .

Margaret Flinter: Well, Tom, I think it's safe to say that none of us believe you could
really put a dollar figure on the total cost of the opioid crisis to the
United States and think it's incalc ulable. But the experts say maybe a
trillion dollars each year. And there's a recent financial settlement
with the Sackler family, which controls Purdue Pharma, the maker of
OxyContin . And now settlement, I believe, is $6 billion, which is

Tom Coderre

supposed to be d evoted to addressing the epidemic. We all
remember the tobacco settlement money and certainly some
criticisms that there was too much lost opportunity to really curb
smoking with those funds. How do we do our best to ensure that the
money funds what we hav e evidence really works to reduce overdose
from opiates?

Tom Coderre : That's a great question. And it's on the minds of so many Americans,
especially people who were harmed by companies who had, you
know, who had a moral obligation to be good stewards of t hese
products , an d so that will get decided in courts. And there are plenty
of outside groups who are looking at this and they’re making
recommendations.

Georgetown University recently held a roundtable with people from
all parts of the field about how the se resources should be spent, and
that the settlement monies go to things that really help mitigate the
ongoing crisis. But what I can say about SAMHSA is that we have a
budget request into Congress of more than $10 billion with this
urgent need being face d throughout the country and throughout our
communities, we need that money more than ever. Programs funded
by SAMHSA , which prioritize connecting people to treatment for
substance use disorders and mental health conditions have never
been as crucial as th ey are now.

Especially given the toll that the COVID 19 pandemic has had an
illness. But we've seen an exacerbation right of people who had mild
anxiety and depression now it's moderate or severe. We've seen
substance use continue to rise and so these reso urces really will help
us connect people to the health that they need.

Mark Masselli: Well, both of them are very important for the settlement that that
will be good news, and but there is hope. And you've testified before
the Senate that there are at leas t 22 million Americans who've
resolved their issues with addiction, but there are so many ro o ts as
well to that recovery. What does the research tell us about what
works right now?

Tom Coderre : Well, there's a -- there's a lot of evidence about what works. And I
was really proud to be involved back in the Obama administration on
a 2016 Surgeon General's report on alcohol, drugs and health. And for
those of you who are familiar with the Surgeon General's reports,
they review the current evidence. And that re port had several
chapters, one on neurobiology , one on prevention, one on treatment,
o ne on recovery support, and one on health systems that really
walked through. And even though it's a couple of years old, it's pretty
timely, there's no cookie cutter app roaches treating substance use
disorder, it's very individualized and SAMHSA’s role is to make sure
that there are multiple entry points to effective evidence based

Tom Coderre

treatments and recovery supports.

The re are also, as you pointed out many pathways, a lot of times
people conflate a 12 - S tep group with clinical treatment, and the two
are very, very different. There's a big difference between the two.
One really is about managing one's symptoms of their substance use
disorder. And the other one is a peer suppo rt that extends beyond
those acute symptoms, right ? When we talk about addiction being a
chronic condition that needs to be managed over someone's lifetime ,
that’s really where a 12 - Step groups and other peer support related
activities, which I have been t he beneficiary of myself, where they
come in, and then they can help that person sustain their recovery for
the long term. And I think that's really important.

Margaret Flinter: Well, Tom, many of us have read the sad story over recent days in the
media ab out the suicide of country singer, Naomi Judd, and she spoke
very publicly for years about her struggle with depression, and she
referred to it as in her family. Did I believe is treatment resistant ,
depression? I wonder, are you worried that this leaves p eople
thinking that that means there are no options if they have this
diagnosis? And I'll add that Dr. Tom Insel just told us there are still
options even if someone carries this label of treatment resistant
depression, what's your thoughts on that? How do es that land with
the public?

Tom Coderre : First of all, about Naomi Judd, that's -- her story is heartbreaking to
me, and many, many Americans, that one day before she was about
to be inducted into the Hall of Fame, that she succumbed to her
illness. And that was tragic. And at SAMHSA , it's really our role to
promote options as broadly as we can and to seize every opportunity
to make sure that people know where to look and to get connected to
treatments and supports. We know recovery is possible. It's real . It's
for everyone , and so my message would be not to lose hope. I think
you know, when people talk about there being no options, that is not
what you want to say to somebody who's suffering from mental
illness, there are always options, there's always ho pe. There's always
support, there's always something else to try , and so we cannot give
up on any individual. And we can't be sending the message to any
individual that we don't have the support that they need.

Mark Masselli: Tom, you talked a few minutes ago about your own journey. And
you've been very open about sharing that and it's very inspiring to
those of us who have heard it, but I'm wondering if you -- if we could
ask you to share what you'd like , so others can learn and better
understand the journ ey that people go t hrough to get on the other
side?

Tom Coderre : Oh, sure. I mean, thanks so much for asking that. You know, we're
th th
taping this on May 16 th and yesterday, May 15 was my 19 recovery

Tom Coderre

anniversary, believe it or not , just yesterday. So, for me, this is
personal. I'm passionate about it and say, recovery has saved my life
and actually given me a life that beyond my wildest dreams that I
could never have imagined. I went through a very public battle with
addiction. I was a S tate S enator from Rh ode Island . I served eight
years in the State Senate . I developed a issue with alcohol and other
drugs and it ended up costing me everything I ended up losing my
position in the S enate, I lost my job, as a nonprofit executive, I, you
know, my family and fr iends tried to help , I resisted their help . I
pushed them away that caused me to lose them, and eventually, you
know, I that hope I spoke about earlier, I lost that hope. But
fortunately, I was able to get the help that I needed , and today, I'm a
person in long term recovery, which for me means I haven't used
alcohol or drugs since May 15 , 2003 , and I've been able to not just
create a better life for myself , but I've been able to create a better life
for my family, and ultimately, my entire community becaus e that's
what happens when people find it to sustain their recovery . I had
access to a long term residential treatment program, psychiatric
services, which I needed, and then what SAMHSA likes to call the four
dimensions of recovery, health, home , purpose and community.

That's how we build the life and the community for everyone, by
making sure that the social determinants of health are not ignored,
that people have access, I was able to go back to school and finish a
B achelor's degree. I was able to get employment, eventually
reemployed , get my family back in my life, that family, I said, I pushed
away and resisted their help . They came back into my life. My mom,
my dad, my brother, my sister, my nieces and nephews, got to have
their family member back, an d that was critically important for me as
well. So I've been really fortunate to be able to get into this space,
and match my love for politics and public policy with my passion for
recovery, and being able to help other people find what I've found. So
it' s been a truly a blessing and something that I'm so excited about.

Margaret Flinter: Well, Tom, thank you for sharing your story. Thank you for your
service to the country and for your leadership in this most critical area
that our country faces. Lots to do, and we join you in your fight. Thank
you also to our audience for joining us today and you can learn more
about Conversations on Health Care, and sign up to our email updates
at www.chcradio.com . Tom, thank you so much again for joining us
today.

Tom Coderre: Thanks for having me.

[Music]

Mark Masselli: At Conversations on Health Care, we want our audience to be truly in
the know when it comes to the facts about health care reform and
policy. Lori Robertson is an award winning journalist and Managing

Tom Coderre

Editor of FactCheck.org, a nonpartisan, nonprofit consumer advocate
for voters that aim to reduce the level of deception in U.S. politics.
Lori, what have you got for us this week?

Lori Robertson: Paxlovid is an antivir al pill that is the preferred treatment for non -
hospitalized high risk COVID - 19 patients. While it was tough to find
after being authorized by the Food and Drug Administration at the
end of 2021, it's no longer in such short supply. Paxlovid is the brand
n ame of Pfizer's oral antiviral treatment for COVID 19. It consists of
two sets of pills that are taken together, the primary pill prevents
replication of SARS - CoV - 2 the virus that causes COVID 19. The second
pill slows the breakdown of the primary drug and liver to boost levels
of that drug in the blood. The standard course is to take a total of 30
pills over the course of five days. As an antiviral, Paxlovid should be
taken as soon as possible after someone gets sick and it is not meant
for people who are alr eady hospitalized for COVID - 19.

A Randomized Controlled Trial found the drug was about 88%
effective in preventing hospitalization and death in unvaccinated high
risk adults with COVID 19. The trial included about 2 , 200 non -
hospitalized participants wi th symptomatic COVID - 19 who were
neither vaccinated nor previously infected. All were either 60 years
old or older or had at least one chronic medical condition that put
them at higher risk of developing severe COVID - 19. There were no
major safety concerns in the trial. Possible side effects include a
temporary altered sense of taste, diarrhea and vomiting. The drug
does pose risks to some people with liver or kidney disease . Multiple
experts told us its likely Paxlovid has at least some benefits in
vaccina ted people.

The full results of the Pfizer trial likely to be released later this year, or
from the University of Oxford Clinical Trial that is now studying
Paxlovid and is open to participants regardless of vaccination status.
That's my FatCheck for this week. I'm Lori Robertson, Managing Editor
of FactCheck.org.

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Marianne O’Hare: FactCheck.org is committed to factual accuracy from the country’s
major political players and is a project of the Annenberg Public Policy
Center at the University of Penn sylvania. If you have a fact that you’d
like check, email us at www.chc.radio.com . We’ll have FactCheck.org’s
Lori Robertson check it out for you here on Conversations on Health Care.

[Music]

Mark Masselli: Each wee k Conversations highlights a bright idea about how to make
wellness a part of our communities and everyday lives. One in five

Tom Coderre

Americans will suffer a diagnosable mental health condition in a given
year. For those with serious mental health conditions , the
consequences can be devastating , loss of job or home or even early
death. Seeing a rise in mobile apps aimed at behavioral health
entering the marketplace , University of Washington Researcher, Dror
Ben - Zeev thought a comparative effective analysis stu dy wo uld be a
good idea.

Dror Ben - Zeev: My team and I conducted a three - year comparative effectiveness trial
having a head to head comparison between a mobile health
intervention for people with serious mental illness called Focus, and
more traditional clinic b ased group intervention. So the study really
gets at some of the core differences between mobile health and clinic
based care. Is there something about the mobile health approach that
would make it more accessib le or less accessible over time?

Mark Massell i: More than 90% of the mobile A pp group engaged in the online
program along with weekly call - ins wit h a behavioral health clinician.

Dror Ben - Zeev: The second thing we wanted to see was after people complete care,
what are their subjective ratings of thei r experience in treatment? Are
they satisfied with both intervention? And probably the most
important piece of the study are the clinical outcomes. So we
measure to see whether involvement in both interventions for 12
week period would that create some sor t of difference in psychiatric
symptom, severity and quality of life , and 90% of the individuals who
were randomized into the mobile health arm actually went on to
meet a mobile health specialist and use the intervention A pp that's
assigned to them at leas t once. Whereas in the clinic based arm, we
saw that only 58% of the participants assigned to that clinic based
intervention ever made it in for a single session.

Mark Masselli: Both groups of patients saw roughly equal results from their
completed treatme nt. But the mobile group was m ore likely to
engage in therapy.

Dror Ben - Zeev: The group dynamic a sense of shared experience, and perhaps even
normalization of some of the experience that on its own is quite
potent for people, right , and so we know that th e very existence of a
group can be quite helpful. But for others, the interaction is anxiety
provoking .

Mark Masselli: A targeted mobile A pp aimed at facilitating access to clinical care for
those experiencing serious mental illness symptoms, proving equal ly
effective in managing the condition improving access to intervention
for behavioral health needs. Now that's a bright idea.

[Music]

Mark Masselli: You've been listening to Conversations on Health Care. I'm Mark

Tom Coderre
Masselli.
Margaret Flinter: And I'm Margaret Flinter.
Mark Masselli: Peace and Health .
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Marianne O’Hare : Conversations on Health Care is recorded at WESU at Wesleyan
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