(1-11-21) I asked Dr. Elinore McCance-Katz to review her four years as the first-ever Assistant Secretary For Mental Health and Substance Use now that she has resigned. Her response follows:
Dear Pete,
I can’t imagine that anyone was more surprised than me when I was nominated to the political appointment of the first Assistant Secretary for Mental Health and Substance Use.
I have never been active in any political party although I have worked in government for many years—for both Republicans and Democrats. 
I have done this because I believe it is imperative that healthcare practitioners have a real ‘place at the table’ and provide subject matter expertise and experience working with those who suffer from illnesses to the government which regulates the delivery of healthcare services in this nation. I have three major tenets that influence my approach and decisions in behavioral health.
Health Care Is A Right, It’s Cruel To Not Help SMI, And Families Matter
The first is that healthcare is a right—that people have a right to treatment of mental and substance use disorders. The second is that it is not honoring a person’s civil rights to allow them to suffer from brain diseases such as schizophrenia, schizoaffective disorder, bipolar disorder, and drug and alcohol addiction because they are too ill to realize they need medical care—rather it is cruel. That approach condemns affected people too often to live unsheltered, without adequate food, isolated and alone, at risk for violence, abuse, injury and sometimes death. For far too many it results in imprisonment for minor infractions of the law further stigmatizing and isolating them. I believe that a society is judged by how it treats its most vulnerable and, from my perspective, there are none more vulnerable than those who are terribly impaired by severe mental and substance use disorders. I believe families are the real backbone of the safety net system for those living with these serious mental illnesses and that they should be communicated with by healthcare providers when someone too ill to know to contact family members is admitted to a hospital—to not do so is callous. For the great majority of those with serious mental illness family members are the consistent caregivers and as such, should be included in care plans developed by clinicians unless there is evidence for mistreatment or abuse. In my experience, that is rarely the situation.
These principles have guided me through these last four years in federal service.
I very much appreciate the opportunity to highlight what I consider to be the major accomplishments of my time in this role. I was fortunate to have historic legislation pass in the form of the 21st Century Cures Act which provided support and an outline of areas to focus on at the Substance Abuse and Mental Health Services Administration (SAMHSA). One of the first things I did was to develop a new strategic plan with five areas I thought to be of greatest importance to making a federal agency designated to address the task of reducing the impact of mental and substance use disorders on American communities to be able to actually do so.
The areas included addressing the opioids crisis, addressing serious mental illness, expanding substance abuse prevention programs, improving data collection and analysis to best assure that federal grant programs were meeting their intended goals, and expanding healthcare practitioner education related to training on mental and substance use disorders.
The Opioid Crisis – Meds, Peers, Technical Assistance
The opioids crisis is one of the worst public health crises to face the American people. Individuals, families and communities have been ravaged by addiction and death from these substances for over more than 20 years. One of the first actions I took was to require the use of evidence-based treatments for opioid use disorder (OUD) including use of FDA-approved medications to treat this life-threatening condition. Over the course of my tenure as Assistant Secretary, the nation went from under 1 million receiving these medications to over 1.45 million receiving opioid pharmacotherapy for OUD.
SAMHSA, working with states and communities across the nation, focused on prevention, treatment and community recovery service provision and we encouraged the partnering of treatment services with community supports. We emphasized the importance of peers in working with those affected and helping to be a link to both clinical services and community supports. SAMHSA provided extensive technical assistance and training to states and communities with a doubling of practitioners able to provide buprenorphine treatment of OUD through the DATA waiver training which was provided in a variety of iterations to better meet clinician needs.
These technical assistance resources provided training at no cost to participants and helped to expand service delivery in a time of great need. Further, we modified the substance use disorder confidentiality regulations known as 42CFR Part 2 to make it easier for healthcare practitioners to share information about a person’s treatment for substance use disorders with consent. The knowledge of a person’s vulnerability to substance use disorder and details of treatment is essential to providing safe, effective, and individualized healthcare. It is also important to reducing stigma regarding substance use problems a person may face and makes it easier for treatment to occur. During the SARS-Cov-2 pandemic, I moved quickly to assure that access to treatment for OUD would remain by making telehealth services including by use of telephone available for those with SAMHSA grant funding. This was then determined by CMS to be allowable as well greatly expanding access to care for Americans living with OUD and other mental and substance use disorders.
SMI Relegated To Criminal Justice System – A Violation of Rights
It is my opinion that addressing serious mental illness has, to a great extent in our country, been relegated to the criminal justice system. There are numerous reasons for this, but one of the main contributors is the lack of a crisis care safety net in this country. Emergency departments continue to be the primary destination for those with serious mental illness in crisis in many parts of the country. Emergency departments are not equipped to address the needs of those in mental health crisis resulting in extensive boarding of individuals with no treatment during that time or, simply, release to the street with no help having been given. This can lead to infractions of the law resulting in incarceration.
For police bringing people in such crisis to an emergency department, it can mean extensive waits with the person because no treatment services are readily available. The reality is that it is just easier to take such individuals to jail. From my perspective, this is a true violation of the individual’s rights and one I have worked hard to remedy.
I have advocated for crisis care services including mobile crisis services and have expanded these services through expansion of the Certified Community Behavioral Health Clinic grant program which provides integrated mental, substance use disorder and physical healthcare services. Since my time at SAMHSA, we have also required that grantees provide crisis services designed to keep people out of the ED and jail and to connect them to integrated, easy to access healthcare services. I have supported the establishment of the 988 mental health crisis/suicide prevention national hotline—and I have advocated for full funding of this system.
I have promoted the use of psychiatric advance directives that make it possible for an individual who may be too impaired by their mental illness to make their wishes known to have those aspects of their care honored. Joint Commission has now made this an area that they are working to assist facilities in implementing and SAMHSA has funded development of a no-cost phone app for personalized directives to be easily accessed in time of emergency. Several additional important changes occurred during my time in office.
Assisted Outpatient Treatment Increased Funding
SAMHSA had initiated a small Assisted Outpatient Treatment (AOT) program prior to my arrival, but funding for this program increased during my tenure. SAMHSA also evaluated this program and was able to show clear and strong positive results including reduced emergency department visits, reduced hospitalizations, and reductions in justice system interactions. However, one of my own personal goals was to provide comprehensive community-based resources delivered by a team of qualified behavioral health providers in an evidence-based approach called Assertive Community Treatment (ACT) to the seriously mentally ill prior to interactions with the justice system.
SAMHSA received funding for this program in 2018 and grantees continue to demonstrate the importance of this approach in a variety of community settings. One issue that I had never understood was why mental health block grant funds could not be used to provide treatment for serious mental illness to those who were incarcerated. SAMHSA is now able to allow the use of mental health block grant funds to be used to treat those with serious mental illness in jails and prisons when this treatment is delivered by community mental health providers. I believe this will be key to reducing impact of serious mental illness, improve outcomes for some of our most seriously mentally ill and will, over time with widespread adoption, reduce costs related to serious mental illness.
I also advocated for and received support by this administration for lifting the Institutions of Mental Disease (IMD) exclusion making it possible for inpatient care in facilities focused on providing services for mental disorders to be able to bill Medicaid for those resources. I believe these measures will change the way we address serious mental illness in this country and will improve the lives of those living with these serious and often, life-threatening conditions.
Increased Service Delivery To Children and Adolescents Needed
It is also imperative that there be increased recognition and service delivery to children and adolescents who live with serious emotional disturbance or serious mental illness. Project AWARE is a multi-faceted program put in place following the Sandy Hook School tragedy that took the lives of 20 young children and 6 adults before the shooter took his own life by suicide. This program provides funding for infrastructure to address the mental health needs of children including training of school staff and community members on signs and symptoms of mental illness and how to help someone who may be experiencing a mental health crisis, as well as the implementation of positive school environments. During my time at SAMHSA we expanded this program to include direct funding of school mental health staff and the establishment of innovative programs based in schools and which provide mental health services.
SAMHSA worked with CMS to publish a guidance on how school systems could provide services that could be billed to Medicaid in order to better assure that schools would consider establishing such services for students and their families. I am unable to say whether serious mental illness can be prevented, but I do believe I can say with certainty that early intervention, the provision of psychological supports and where needed, treatment services early in the course of a mental illness is key to mitigating the adverse effects of a mental disorder on a person’s life. Schools are where our children spend a major portion of their lives and schools are familiar to parents and caregivers. Making use of schools to help to lessen the impact of mental illness on an individual will also increase safety and improve the learning environment for all.
Substance Abuse Prevention Key To Preventing Future Addiction Epidemics
I believe that substance abuse prevention is key to addressing current substance misuse in our nation and to preventing future addiction epidemics. I also believe that prevention activities need to be expanded to serve adults. We have had areas of significant success in substance abuse prevention in adolescents and young adults—particularly in alcohol and more recently in opioid misuse so we know prevention works. Adults need the same interventions—they need information and education so that they also can make informed choices. I have supported the widespread education of the American people on the risks associated with marijuana use. There are now reams of data showing the risks of marijuana use to the unborn and, particularly, to adolescents and young adults. The high THC content of marijuana products have now made marijuana a substance that not only will result in addiction in up to 20% of users, but may have lifelong consequences in the form of serious mental illness and cognitive deficits in chronic users. I have prohibited use of SAMHSA grant funds to treat mental and/or substance use disorders with marijuana. Why? Because, contrary to what has been committed to statute in some areas, marijuana is not a treatment for mental illness or substance use disorders—it is a risk factor for those conditions.
I strongly believe that no one should be subject to criminal charges because of marijuana use—or any illicit drug use for that matter.
Rather, I believe treatment should be available to anyone needing or wanting it. I also believe that Americans need to have the relevant information needed to make their own decisions about drug use and their health. The federal government has an obligation to do this in my opinion. We have done this while I have been at SAMHSA and I believe it is a service to the American people.
Speedy Data Important
Those of us in government also have an obligation to assure to the greatest extent possible that taxpayer funds used to implement programs aimed at meeting healthcare needs of our people actually do meet those needs. It is our obligation in government to monitor for developing problems. It is our obligation to determine what the needs related to mental and substance use disorders are and to address those. At SAMHSA, we have updated our data collection systems and continue to produce real-time reports on grant-funded services. We have updated the National Survey on Drug Use and Health to use current diagnostic criteria and we have added diagnosis to the data collected on program participants so that we know who SAMHSA grant dollars are serving.
I thought it very important to reconstitute the Drug Abuse Warning Network as this sentinel system can provide information on developing problems with drug and alcohol misuse, injuries and toxicities by region and can help to more effectively channel funding to needed areas. I have also funded a pilot study to determine prevalence of serious mental illness in the nation using a paradigm that captures those we know have high rates of such disorders, but who too often are in the shadows and not reflected in household surveys—the homeless, the incarcerated, those in institutions. This is very important to accurately assessing needs of the seriously mentally ill population. Similarly, we need to know about gaps in the behavioral health workforce. I believe that one of the most important contributions of my time here was to use an easy to understand model employing evidence-based treatment approaches to estimate behavioral health workforce needs. This approach was reviewed and endorsed by stakeholders who also provided their insights and input. We identified a staggering greater than 4 million practitioner gap that can be a guide for addressing mental health and substance use disorder clinical need going forward.
Parity – A Major Priority For Me
SAMHSA has no statutory authorities in the area of mental health and substance use disorder clinical care parity. However, by expanding the knowledge base of the existing workforce, we can help to increase access to these services nationwide. This was a major priority for me coming into this position. By funding regional technical assistance and training centers for substance abuse prevention and mental health, SAMHSA was able to expand training to any practitioner with interest in the topics. We also increased resources to the Providers’ Clinical Support System for Medication Assisted Treatment (PCSS-MAT) which provides most of the DATA waiver trainings nationwide. In doing so, we have nearly doubled to over 94,000, the number of waived practitioners who can provide buprenorphine from office-based practices to treat OUD. We established the State Opioid Response Technical Assistance program which placed teams in every state consisting of local practitioners able to offer training, mentoring and implementation resources to address the opioid crisis. We added to SAMHSA’s already existing network of national training and technical assistance centers including addition of the Clinical Support System for Serious Mental Illness (also known as SMI Advisor) which includes training on evidence-based treatment of serious mental illnesses, a clozapine center of excellence, and a track on medications, side effects, and psychotropic medication monitoring best practices.
SAMHSA added new technical assistance centers for eating disorders, protected health information including resources for increasing understanding of HIPAA, 42CFR Part 2, FERPA and how these interact, a center for family behavioral health resources, a peer recovery support center, and technical assistance and training for behavioral health issues specific to the needs of Hispanic/Latino, Native American/Alaska Native, African-American, LGBTQ, and older Americans. To better address the needs of children and school-based mental health, we supplemented the regional mental health technical assistance centers. Because I have spent much of my career teaching, I thought it very important to bring additional resources to colleges and universities to address the opioids crisis by embedding the DATA waiver into undergraduate education and to focus resources on training in substance use disorders in as many healthcare training programs as possible. As a result, in 2020 the DATA waiver training has been added to all physician assistant programs as one example, reducing the training burden on practitioners who want to treat those with OUD in their practices. SAMHSA has now funded substance use disorder screening, treatment and recovery resource utilization in programs of family practice medicine, emergency medicine, nursing, social work, psychology, toxicology, and pharmacy. In doing so, we mainstream the care and treatment of these disorders, reduce stigma and make it easier for Americans to get appropriate, evidence-based care for these illnesses. One of the major advantages of this approach is the investment in continuing medical education (CME) and continuing education units (CEU) for participants. By making training available at no cost to practitioners that also provides CME/CEUs, we hope to incentivize the pursuit of knowledge and skills in mental healthcare and substance use issues.
Much Has Been Accomplished – Right Person For This Time
Much has been accomplished over these last 4 years to improve resources to Americans to meet their mental health and substance use disorder needs. However, much remains to be done. We need only look at the devastation of SARS-Cov-2—the increased risk of infection for those with mental and substance use disorders, the mental health consequences for those recovering from viral infection, and the unintended consequences of COVID-19 in the form of increased alcohol and illicit drug use, drug overdose deaths, mental illness and suicide related to extended restrictions aimed at controlling viral spread to underscore the ongoing and even increased needs of Americans in these areas. During the pandemic, I took numerous actions quickly to preserve as best I could access to treatment for OUD and other substance use disorders and to address mental health needs including the needs of healthcare practitioners experiencing burnout and mental illness related to the severe stresses of working during this time with so many critically ill patients. Resources to address mental health and substance use issues will need to be increased substantially to meet the needs of so many affected by these conditions.
I attribute my selection as Assistant Secretary for Mental Health and Substance Use, to a large degree, to stakeholders and advocates who thought I was the right person for this time. As I go home to my family and resume my personal life, I look to these same groups to keep the momentum going—and I hope to help to continue that positive direction as well. What has been accomplished under my watch is a product of a collective vision I have shared with stakeholders and have worked with them to accomplish. The progress made could only happen with the support I have received from SAMHSA staff who are so dedicated to meeting the needs of Americans living with serious mental illness and substance use disorders.
I feel proud of these accomplishments and I look forward to seeing SAMHSA move forward with continuing gains in behavioral healthcare for the American people.
Dr. Elinore McCance-Katz
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