People use prevention strategies throughout their lives. Many who live with risk for heart attack or stroke due to family history or other factors watch their blood pressure and cholesterol levels and might also take medication. Women undergo mammograms to identify breast cancer disease as early as possible. Dentists seal children’s teeth with a fluoride treatment to prevent tooth decay and its health consequences.
Prevention is also a scientific solution to the opioid and overdose crisis. In keeping with its focus on health equity and whole-person research, the Helping to End Addiction Long-term® Initiative, or NIH HEAL Initiative® funds prevention research within a range of community systems and involving several populations with increased risk. This research aims to enhance safe housing for homeless youth, help individuals in juvenile detention centers deal with past trauma, guide children in after-school programs to learn to avoid risky behaviors, and more.
Helping Families in Need
The conditions in which people live, learn, work, and play – social determinants of health – affect people’s lives in many ways, both good and bad. Preventing harmful outcomes, such as risky substance use, is simple in principle but can be very difficult in real life, where many children and adults live with numerous social and structural risk factors.
The child welfare system is one place HEAL-funded scientists are looking for prevention opportunities. Research has shown that parental use of substances is a risk factor for children being referred for social services. Since these children are at risk for ongoing child abuse or neglect, HEAL researchers hope to learn if offering services to parents can ultimately protect children. Prior prevention programs have focused on parental substance use alone without considering life stressors that can lead to it as well as harmful consequences such as child abuse and neglect.
To address this gap, clinical psychologist and implementation scientist Lisa Saldana, Ph.D., of the Oregon Social Learning Center, developed the NIH-funded Families Actively Improving Relationships (FAIR) program. It addresses the multiple needs of families referred to the child welfare system for severe substance use (methamphetamine or opioids) and child neglect. In addition to treatment for substance use disorders, this program delivers parental skills training, mental health treatment, and helps with ancillary services such as housing and employment. The goal is not only to prevent further substance use among parents but also to prevent harm to their children by stabilizing the family unit.
The FAIR prevention program is a health approach that recognizes a health problem (in this case, substance use and/or child neglect) but aims to keep the problem from getting worse. Saldana is currently using HEAL funding to adapt the FAIR program to reach young parents earlier – before they misuse opioids or methamphetamine. This new approach is called Pre-FAIR.
To develop effective programs that will work in the child welfare system and in other community settings, scientists like Saldana need extensive input from everyone involved. To develop FAIR and Pre-FAIR, she and her team met with judges, social workers, parents, caseworkers, and others to identify the biggest challenges facing the child welfare system and the families it serves.
They learned that every community is unique, but that some things remain constant.
“Laws and policies can’t be changed,” she explains, “but what you can change is the way systems work with families to access the services they need – treating substance use and mental illness in the same place.”
Yet patient-centered treatment that offers services together can be hard to find, especially in lower-resourced areas like rural America. One reason is that the worlds of mental health and substance use have traditionally been separate: different providers and different treatments in different locations. Difficulty accessing services contributes to the fact that only 10% of people with a substance use disorder and less than half of those with mental illness get the care they need.
Another problem is lack of people to help. There are currently not enough providers across the nation to meet this urgent need. Although federal agencies including NIH, the Health Resources and Services Administration, and others are supporting training programs to fill this gap, expanding the behavioral health provider workforce takes time. Another HEAL partner, the Substance Abuse and Mental Health Services Administration, is dedicated to integrating substance use and mental health services through funding to states and communities in need. HEAL is also funding research on ways to combine and package treatments and interventions, toward increasing access to treatment for opioid addiction, mental illness, and management of chronic pain that also goes hand in hand with these other issues.
Medicaid, the federal system that provides healthcare to people who can’t afford it, is required by law to offer services for mental health and substance use, but the national provider shortage makes this tough. To make her research feasible, Saldana and her team devised a workaround, teaming with Medicaid to set up community health centers in Oregon that provide treatment for both substance use and mental illness in the same place. This involved lots of groundwork to recruit people for the task and in some cases cross-training them.
“There is one clinic in an area that's straddling two different rural counties, and there were no services available,” Saldana says, explaining that in one case the team worked with a mental health provider to start an integrated clinic by helping this individual get a license to treat substance use disorders.
Her HEAL research team continues to work closely with communities to build more community health centers, one by one. The centers have become so popular that the Pre-FAIR research project has had to shift course temporarily to expand access to integrated services alongside the delivery of Pre-FAIR for the prevention study.
“We've gone into these rural communities where there are no services and people are seeing friends and family dying right before their eyes,” she says. Building relationships with each of five Oregon counties in her HEAL study, she explains, is creating demand for earlier prevention targeted to at-risk parents in the child welfare system. Those programs provide hope for keeping families together and for helping children facing many obstacles have healthy futures.
In keeping with HEAL’s commitment to connecting with real-world use of scientific solutions to the opioid and overdose crisis, HEAL prevention research is embedded into systems where the results can be applied rapidly and employ existing funding streams so it can thrive long-term after the research is done. This approach recognizes, and confronts, the everyday challenges of keeping people out of harm’s way, offering hope to children and families who need it now.
To read other Research Spotlights on HEAL prevention research, see “Prevention Is Treatment at a Different Time” and “HEALing in Advance: About the HEAL Preventing Opioid Use Disorder Research Program.”
National Institute on Drug Abuse (NIDA)
Read about NIDA's role on the NIH HEAL Initiative.
Read about the Preventing Parental Opioid and/or Methamphetamine Addiction within DHS-Involved Families program on NIH RePORTER.