WA HCA - DBHR Listening Session
(November 28, 2023) - Five-Year Strategic Plan

2023-11-28 - WA HCA - DBHR Listening Session - Five-Year Strategic Plan - Takeaways
[ Event Details ]

WA HCA staff presented the newest strategic plan for substance use disorder prevention and mental health promotion, touching on the history, goals, and groups that created the plan.

Here are some observations from the Tuesday November 28th Washington State Health Care Authority Division of Behavioral Health and Recovery (WA HCA DBHR) Listening Session.

My top 3 takeaways:

  • Substance Use Disorder (SUD) Prevention and Mental Health Promotion Section Manager Sarah Mariani laid out the history of the most recently released “Substance Use Disorder Prevention and Mental Health Promotion Five-Year Strategic Plan.”
    • The strategic plan has been developed by the State Prevention Enhancement Policy Consortium, where WA HCA DBHR was part of the State-level public health interests funding programs geared towards substance use disorder (SUD) prevention and mental health promotion. The consortium partners included other state agencies, including the Washington State Liquor and Cannabis Board (WSLCB), local public health officials, as well as prevention organizations.
    • During the listening session, Behavioral Health Communications Manager Melissa Thoemke welcomed Mariani, the consortium co-chair, and Prevention Supervisor Alicia Hughes (audio - <1m).
    • Mariani explained that they’d been “working across the different agencies” on the 2023-2027 Strategic Plan, which was finalized and posted on the consortium webpage at the Athena Forum (audio - 1m).
    • She then elaborated on the history and “what the framework for the plan is.” The strategic plan “focused on the prevention and promotion work that's happening across different agencies,” and in particular we look at that around here at the Health Care Authority, the very specific goals around building health and wellness of individuals, families, and communities.” This included an emphasis on youth substance avoidance, SUD prevention, “as well as promoting mental health and well-being,” said Mariani (audio - 3m).
      • She described how WA HCA DBHR officials partnered with other state agencies and institutions, such as tribal governments and “local partners, school districts, local nonprofits, counties, educational service districts, and more” with a focus on serving “areas that have the greatest risk and the highest need in our state.” Mariani talked about how staff used research and “evidence-based practices to make sure that we're using the limited resources we have most effectively while also taking into consideration local culture and equity that needs to be addressed in doing this work, and tracking for outcomes.”
      • An approach to prevention Mariani shared considered “how do we prevent problems from boiling over,” endeavoring to “turn down the heat on the environment and the experiences, and really support individuals and communities to build that health and wellness.” This could mean going “way upstream" to help people continue “making healthy choices,” she remarked, plus “preventative stuff that adds protection in people's lives and reduces the risk.”
    • Mariani referred to the consortium as representatives of state agencies trying to “think about how we can support one another's specific roles and authorities within our state agencies and organizations, as well as what collaborative work we can do to create synergy and efficiency and supporting communities in health.” A “coordination piece” Mariani noted was informing “partners/funders/leaders” in finding “supportive environments across the work through our work groups and our partnerships.” The strategic plan, she said, was the central way they were “clear about what it is we're going to do” (audio - 3m).
  • Mariani reviewed the principles and framework for the strategic plan, then Prevention Supervisor Alicia Hughes went over the action plan, work group contributions, and how officials would be evaluating effectiveness.
    • Mariani detailed the consortium mission and vision, commenting “it really pulls forward those pieces around how we can, through partnerships and collaborations, strengthen and support an integrated statewide system of community-driven substance use disorder prevention behavioral mental health promotion.” She viewed the plan as “pull[ing] together the connection points, but also [was] intended to support the dispersed, related components that come along with behavioral health.” Mariani remarked the “key values” of the consortium included (audio - 2m, presentation):
      • “Working collaboratively for collective impact”
      • “Addressing disparities and promoting Health Equity”
      • “Using data to inform our decisions”
      • “Clearly recognizing the Centennial Accord in the relationship that we have with tribes that are within Washington State”
      • “Thinking about how we can build overall community wellness and support community-level initiatives”
      • “Considering the lifespan of individuals”
      • “Continuing the ever effort forward. When we originally wrote this plan, health care reform and the Indian Health Care Improvement Act were newer…we do continue to have that be some of the underlying framework that we want to make sure to keep that in mind”
    • There were also “key principles” in the plan Mariani identified:
      • “Looking at how we can work to prevent youth access to alcohol and other drugs”
      • “How we can educate the broader community about this work and about prevention and promotion efforts”
      • “Looking at how we can promote inclusion and education of research into policymaking and what ways we can help be prepared and help do some education that way”
      • “Thinking about what programs can further develop positive youth development”
      • “Looking at supporting public policies that improve overall public behavioral health and safety,” specifically:
        • “Reduced or limited availability of products”
        • “Limiting the density of purchase locations…as we know that that has an impact on use rates”
        • “Reducing and limiting product types”
        • “Reduce and limit the promotion and advertising”
        • “Very clear labeling”
        • “Ensuring that there’s equitable practices in legal markets for different products and substances”
        • “Looking across these different pieces of public policies that can have positive and/or negative impacts,” in particular “research that's been shown to make a difference, when we do have less marketing happening, when we don't have products that are appealing to youth, youth use less. But when we do have lots of appealing products that we find that youth use more. So how do we continue to educate around those?”
        • In 2022, WA HCA DBHR published Location Matters: Access, Availability, and Density of Substance Retailers after some researchers expressed concern that individuals’ proximity to cannabis retailers could be associated with use. Authority materials on Balancing commerce and public health in disadvantaged communities were published September 8th. A third installment of required reporting on cannabis legalization by analysts at the Washington State Institute for Public Policy (WSIPP) also emphasized access near residential areas as a factor to consider in retail licensing. Additionally, SB 5080, passed into law earlier in 2023, required local retail density ordinances to be a factor WSLCB Licensing Division personnel considered before approving future licenses, which staff last publicly discussed on November 8th.
    • Hughes then briefed on the Strategic Prevention Framework Model developed by the US Substance Abuse and Mental Health Services Administration (US SAMHSA) which was followed in developing the Washington State strategic plan and when performing needs assessment. She said the model helped them “to assess what our highest priority needs [were], what the resources we currently have in the state” were, and “where are those gaps really in substance abuse and mental health resources in Washington State?” (audio - 8m)
      • The needs assessment was based on both national and state-level datasets like the Healthy Youth Survey (HYS), Hughes explained. Priorities included “preventing underage drinking and cannabis misuse among youth and young adults,” she said, along with reducing opioid, Fentanyl, and prescription drug misuse; vaping and tobacco use by youth; “working on mental health indicators around depression, anxiety, suicide ideation; and problem gambling and working to reduce those rates.”
      • “We're very cautious about how we interpret our data that we did receive during the COVID-19 pandemic,” Hughes said, because “the pandemic led to lots of changes in our behavioral health data collection and different data trends and, and mostly because the pandemic had different changes that youth were experiencing as a result of that.” 2021 HYS results suggested that the pandemic “may have had youth with less opportunities to socialize with peers, and so some of the typical response rates may have looked different in the 2021 survey,” she noted. Similarly, Hughes highlighted a “gap in the trend data between 2018 and 2021 just to make sure that we're showing that there may have been some changes within the data and all of that data should be interpreted with caution.” The 2023 HYS “was just administered in October and that will help us determine which, if any, of the impacts may remain from the pandemic,” she added.
        • The implications of the COVID-19 pandemic on substance use has been confounding researchers for years, leading to gaps in prior data sets and experts qualifying their comments to hedge against drawing conclusions about changes in behavior patterns.
          • During a Northwest Prevention Technology Transfer Center webinar in October 2020, UW professor Ron Jackson pointed to “an uptick” in SUD due to the pandemic, but warned he couldn’t “tell a person why they have a cannabis use disorder" as it was generally too “complex.” That December, WSLCB staff discussed the pandemic’s implications for substance use trends, and a policy tracking spreadsheet from the agency COVID - Legal/Policy/Rules team showed a staffer, along with others at the DOH and WA HCA inquired about “data on alcohol and marijuana sales to use as an indicator of use, and to forecast the adverse behavioral health effects due to the COVID-19 pandemic.” The document noted the request was “resolved quickly.” During another NW PTTC webinar in December 2020, prevention advocates raised concerns around temporary allowances for alcohol and cannabis.
          • In May 2022, WSLCB leaders talked about delays in conducting the HYS which had been scheduled for 2020, sharing that the pandemic led to a gap between 2018 and 2021 which broke “our trends analysis” for the intervening years, so officials couldn’t “directly compare” survey results as they had in in the past. WA HCA Prevention Research and Evaluation Manager Tyler Watson offered numerous “caveats,” some due to the pandemic, but observed how students “across the board” were reporting “low levels of substance use.” There had been a “much larger decrease” from 2018 responses, and “polydrug” use was lower. Additionally, negative perceptions of cannabis and other drugs “slightly increased as well.”
            • While datasets from the pandemic merit thoughtful interpretation, the data may reinforce the concept that substance use is predominantly socially driven amongst a substantial cohort of youth who may have abstained simply because they were presented with fewer opportunities to obtain and consume substances.
          • Separate data in a Washington-specific report on cannabis market trends reviewed by WSLCB in November 2022 suggested that among teens and adults “modest increases [in overall use were] fairly stable over the past four years,” and most respondents stated it hadn’t impacted their cannabis use. Another researcher argued for caution when looking at declines in reported cannabis use, arguing changes “may be related to…post-pandemic school context effects, and to the change in the survey administration.”
          • On June 1st, WSIPP staff released the report, A 10-Year Review of Non-Medical Cannabis Policy, Revenues, and Expenditures, that would “not detail the impact of the COVID-19 pandemic on the cannabis industry, regulatory policy, or costs to governments and businesses.”
      • Hughes went over some of the findings of their needs assessment:
        • “Based on prevalence, the misuse of alcohol remains the most concerning substance issue among our youth” and among adult populations.
        • “We have cannabis ranked second in terms of the most concerning substance misuse for youth. What we can see is that in 2021, the prevalence of cannabis use among 10th grade students with 7.2%”
        • “Commercial tobacco use by high school youth ranks third as a substance of concern.”
        • “We have seen a lot of mental health concerns that we want to prioritize, and have prioritized in our strategic plan.”
      • According to Hughes, 2021 HYS survey responses showed “some student populations are more heavily affected than others, and some of those populations include students who identify as female, students who identify as LGBTQ+, those with disabilities, and students from lower income households.” Data had indicated ”where there might be a statistically significant difference among these youths who are experiencing these different behavioral health challenges,” she argued, quickly mentioning other concerning statistics.
        • “In 2021, while we see that 8.4% of 10th grade students reported drinking alcohol in the past 30 days, we do see that that rate is higher among students who identify as LGBTQ+, those with disabilities, and those from lower-income households.”
        • “We see that female 10th graders are more likely to report seriously considering attempting suicide when compared to their male counterparts.”
        • “We see that almost two in five 10th graders reported feeling so sad or hopeless for two weeks or more during the past year that they stopped doing their usual activities. But that rate goes much higher, so it goes from 38% to over 50% for females, over 50% for American Indian/Alaska Natives who have these higher reported rates of feeling sad.”
        • “And then those who are identified as having a disability and/or are unhoused may be more than twice as likely to have attempted suicide.”
        • Hughes said these were “really important things that we're considering as we're looking at this data in figuring out where are our priority populations and marginalized communities and those who are most vulnerable, and how can we prioritize prevention services for those with the highest?”
      • She also called attention to “data indicators that we monitor over time related to our outcomes” which consortium members used in assessing the impact of the strategic plan. In considering the 2023-2025 indicators, Hughes stipulated that “it may look like it increased from 2021. A little bit of that is we're expecting some numbers to bounce back, for lack of a better term, based on the interesting data we saw during the COVID-19 pandemic, so the targets for ‘23 and ‘25 are really based off 2018 Healthy Youth Survey” results.
    • The next stage had been using the needs assessment to craft a statewide action plan, Hughes explained. She said this would “drive our strategic plan for Washington State around the prevention and promotion services that we have.” She continued by telling the group “we created these five strategic objectives as a policy consortium that are all centered around health equity” (audio - 4m).
      • First, “strengthening our state collaboration to prevent initiation of substance use and promoting mental health and…working to increase that collaboration and connection with all of our state agencies and partners, and tribal partners” in order “to improve our agency representation and diversity in voices at the consortium membership” including through an “equity ad hoc work group” and at “our monthly meetings and during legislative session.”
      • “Our second strategic objective [was], utilizing the needs assessment data in Washington State, creating and disseminating communication plans, campaigns, public education, trainings and other resources…to look at what…the data [was] saying, how can we make data-driven informed decisions around our policy and programming?”
      • The third “objective [was] to implement environmental strategies, which are policy strategies to reduce access and availability of substances, change community and social norms with substance use, and reduce stigma in accessing behavioral health services.” Since they were “frequently reviewing statewide policies within different agencies and work groups regarding substance use or suicide prevention or mental health supports,” they planned to look at “what consequences or supports that different bills and legislation has on youth in Washington State and other vulnerable populations.”
      • “Our fourth objective of the consortium [was] to commit and dedicate efforts to implementing substance use disorder prevention and mental health promotion programs… to strengthen protective factors while reducing risk factors.” This included a “shared definition of prevention” among state agencies and a “continuum of care” with prevention programs able to help people throughout their lives.
      • “And then our last objective [was] to strengthen the long-term sustainability of the behavioral health promotion and substance use disorder prevention workforce” by being “advocates for training and credentialing the prevention and promotion workforce around Washington State” and administering the certified prevention professional credential “to professionalize the field and really enhance their skills,” as well as seeking “ways that we can activate prevention providers in our different programs and strategies and different recruitment and retention needs.”
    • Hughes indicated that there were six work groups within the consortium dedicated to topics of concern. She mentioned being a co-lead on the opioid prevention work group, and that there was a “young adult cannabis and alcohol prevention work group” focused on an “18 to 25 year old range.” Hughes then expounded on the role of each work group in studying a topic and reporting back to the wider consortium, but emphasized “some of these groups also work independently” on mandated tasks, notably the “opioid prevention work group is part of the state Opioid Response Plan” (audio - 2m).
      • “Washington Healthy Youth” (WHY) Coalition focused “on reducing and preventing underage drinking and youth cannabis youth statewide.” They used HYS data on substance use as their primary indicator for tracking progress, “and they have some different strategies related to educational tools, public education campaigns, and a lot of education and resource sharing” (audio - 1m).
      • “Washington Breathes” was the “commercial tobacco and vapor product one and they work on both prevention and treatment” of underage tobacco or vapor product use, plus “how can we improve tobacco cessation treatments and…how can we end commercial tobacco sales.” They had their own strategic planning “and they really look to see how resources can be leveraged between prevention and treatment services” (audio - 1m).
      • “The Opioid Prevention work group [was] really focused on preventing the misuse of opioids, fentanyl, and other substances within communities” along with “strategies related to prescriber education and using the prescription drug monitoring program, a lot of campaign work and public education about the risks of opioid use and overdose prevention,” and safe storage/disposal, plus treatment programs (audio - 1m).
      • A “Mental Health Promotion and Suicide Prevention work group” was in a “capacity building phase,” to identify state and local resources on those topics (audio - <1m).
      • “The Young Adult work group” dealt with cannabis and alcohol misuse among those 18 to 25. Having “really great collaboration partnerships across the state with our college coalition, with our university…they do a lot of public education to enhance young adults’ knowledge” of “how evidence-based screening and intervention tools and resources can be implemented statewide to support this young adult age group” (audio - 1m).
      • “Most recently we have the Problem Gambling Prevention work group that was formed in 2023…that delegated some more resources to problem gambling.” They were “kicking off some prevention work in this space and should have a…strategic plan created by the end of next year” (audio - <1m).
    • Hughes mentioned that evaluation of the strategic plan was conducted every other year, meaning “the consortium ha[d] a pretty robust way to collect and report data” and “really look at what outcomes we're having within the State, and…are we reaching our targets that we identified for 2023 and 2025” (audio - 1m).
    • WA HCA DBHR Deputy Director Michael Langer pushed for feedback from attendees in treatment and recovery fields: “if you have…an opinion about where you think there may be some intersect or…collaboration locally with the prevention providers and the treatment or recovery providers, it'd be interesting to have that conversation” (audio - 1m).
    • Mariani concluded the presentation with a remark welcoming “any specific way you think this might apply to some of your work, or like [Langer] said if there's an intersection between the work” or how participants “might take and use some of this information.” The consortium wanted to “make sure now that we've put the time and effort into developing the plan…that people know about plans” and used them “as a working, actionable document, not just something that we did and then we put it on a shelf” (audio - 1m).
  • Attendees put forward questions around vapor products and specific populations identified in the plan.
    • Brenda B. asked about vapor products and “wet lungs,” also known as acute respiratory distress syndrome (ARDS), wondering if that was a medical condition being seen in treatment centers, or communicated as part of preventative education. Mariani offered general information and alleged that the situation was complicated because of a lack of regulation around vapor products. She acknowledged that youth vaping had been an increasing trend and WA HCA had been working to communicate the risks with DOH counterparts. Brenda claimed, “where I used to live, my neighbor's son, he was 17. He was able to go into a vape store and get a cannabis vape refill.” She’d felt the distinction between cannabis and nicotine products was tough to differentiate, “it's really hard to tell unless you've been around them for some time and you can see the reaction.” Any vapor store selling products with cannabinoid content should be reported to WSLCB Enforcement Officers, added Mariani (audio - 6m).
    • Angie Silva, Courage to Change Founder, asked “what about our senior citizens, our elderly, focusing on them as well in this five-year plan?” She brought up “some changes in Medicare that are coming up that are very exciting,” but “I just wanted to say that, and I'm excited to hear you say that you're not going to just put this on the shelf…I just want to throw it out there for, for elderly population, too.” Hughes agreed, “we really do want to engage adults and older adults in our conversations” on SUD prevention, though she believed there was less research on prevention education for this cohort. She called out topics like safe drug disposal and “co-occurring use” of multiple substances as areas worth engaging older communities on. Langer confirmed that retirement or losing a “loved one or partner” were life events where SUD risks increased, but there wasn’t “robust” funding of research in that area, though US SAMHSA had some resources. He felt WA HCA staff had worked “episodically over the years” with other health officials on information for older populations (audio - 4m).
    • Brenda followed up to ask about people transitioning genders, and whether prescribed hormones and other “transitional medications” placed them at a higher risk for SUD. Mariani wasn’t aware of dedicated legislation on the topic, but knew “in data, that we often find that youth that are gender diverse, or have sexual, sexual orientation other than heterosexual tend to…also have higher risk in terms of a number of behavioral health components and health components in general.” She relayed that WA HCA staff recognized “this is a population that we need to make sure that we're focused on directing resources for” (audio - 2m).
    • Betty Jensen stated via chat that “part of prevention should be encouraging those that are not using,” and Mariani completely agreed: “we definitely do look to support and encourage and continue non-use among youth and young adults” (audio - <1m).
    • Langer thanked participants, and considered the release of the strategic plan as something that “spurs on the conversation” (audio - 1m).

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