Alignment for Progress: 
A National Strategy for Mental Health and Substance Use Disorders

Americans in mental health crisis are more likely to encounter law enforcement and become incarcerated than receive the medical care and treatment they need.[4][5] All levels of the criminal legal system – from the Department of Justice to local law enforcement agencies - should take steps to establish policies and support programs that divert individuals living with mental health and substance use disorders (MH/SUD) away from the criminal legal system and into treatment.[5][6] Evidence-based model programs that provide training and support to law enforcement officers and non-sworn personnel to help them more appropriately identify, triage, and respond to individuals experiencing MH/SUD crises are critical to helping to decriminalize MH/SUDs in America. [1][2][3]

Every year, almost 2 million people living with a mental health condition enter into jails or prisons. Once in jail, they are two times more likely to remain confined than others facing the same conviction.[2]

To reduce the number of people with mental health and substance use disorders in the criminal legal system, Congress should provide funding and support to drug court programs that offer substance use treatment and services, including relapse prevention, health care, education, vocational training, job placement, housing placement, and child care.[3][4] Congress should also provide appropriations for mental health courts that train law enforcement and others in the criminal legal system to assess the needs of individuals with mental illness, and connect them with treatment plans and social services, including skills training.[5][6] To ensure proper funding and support for these mental health courts, Congress should eliminate the current restrictions on Department of Justice grant funding, which is currently capped at 100 programs.[5]

In 2021, nearly 80 percent of overdose deaths were caused by opioids, many of which could have been prevented if Naloxone was readily available and used to reverse the overdose.[3][4] In early 2023, the Food and Drug Administration (FDA) approved the over-the-counter Naloxone nose spray, Narcan.[5] The Biden Administration has launched a campaign to raise awareness of the benefits of this life-saving drug.[3] However, cost can be a barrier to access, as it can vary based on the facility or geographical location where an individual obtains Naloxone.[4] The Administration and Congress should work together to ensure the widespread availability of low-cost (or even free) naloxone. One model that has been scaled successfully are AEDs, devices that can deliver life-saving interventions for individuals experiencing cardiac arrest and are now widely distributed across a range of public and private settings. Federal agencies, including the Department of Health and Human Services, Department of Education, Department of Housing and Urban Development, the Federal Emergency Management Agency (FEMA), and the Bureau of Indian Affairs, should take action to ensure that a variety of funding streams can be used to distribute naloxone and promote such use of funds.[1][2][6]

Contingency Management is a highly effective approach to treat individuals with substance use disorders (SUDs). It provides small tangible reinforcements such as prizes, vouchers, or small amounts of money to motivate and sustain objectively measured positive changes in behavior (e.g., abstinence or decreased drug use). In addition, it takes advantage of the brain’s reward response – the same response that fuels substance use. While Contingency Management treats many SUDs, there is a particularly urgent need to increase its use to treat stimulant use disorder, which lacks other proven effective treatments. One meta-analysis[1][2] found that Contingency Management “has an extraordinarily strong evidence base and is a demonstrably cost-effective technique that has been used for decades to promote abstinence from benzodiazepines, cocaine, tobacco, opiates, alcohol, marijuana, and methamphetamine.” Yet, adoption has been limited due to concerns that laws meant to prohibit kickbacks might inadvertently snare providers and payers utilizing this evidence-based treatment.[3]

Thankfully, the Office of the Inspector General of the U.S. Department of Health and Human Services (HHS) issued an opinion[4] in 2022 that allayed these concerns and has also approved raising the $75 limit per patient per year for Contingency Management. Unfortunately, the Substance Abuse and Mental Health Services Administration (SAMHSA), which must approve any increase, has not yet done so. As a result, Contingency Management continues to be underutilized despite the availability of flexible State Opioid Response Grants to help fight the opioid and stimulant epidemics. States that use these funds for Contingency Management are forced to do so at a level far below what the evidence suggests is effective.

Under current law, any student convicted of possessing or selling a controlled substance becomes ineligible to receive federal student loans, grants, or work assistance for a period of time.[2] This policy disproportionately impacts students of color, who are more likely to be convicted of disqualifying drug offenses.[3] According to the U.S. Department of Education, 86 percent of Black students take out student loan debt compared to 68 percent of white students.[4] As a result, the current law marginalizes those who need aid the most and deprives them of access to the educational opportunities needed to improve their lives.[5] Legislation introduced in the House and Senate during previous Congresses would have repealed the provision of the Higher Education Act that makes students convicted of drug-related offenses ineligible for federal student aid.[6][7]

During Spring 2023, after the COVID-19 public health emergency ended, the Biden Administration released proposed rules that would have returned to restrictive telehealth prescribing rules for buprenorphine, the critical medication for opioid use disorder, and important mental health medications. To receive a prescription for these medications by imposing an in-person medical evaluation requirement following an initial 30-day supply prescribed via telehealth.[1] Such restrictions would significantly decrease access to needed MH/SUD treatments.

For individuals with opioid use disorder, such a requirement would disrupt care for tens of thousands who cannot access an in-person appointment and would make it impossible for countless others to initiate and sustain treatment. This is especially true for rural Americans and those without access to transportation. Recent research demonstrates the effectiveness of prescribing buprenorphine through telehealth.[2]

The Kennedy Forum and Legal Action Center led a letter to HHS and the DEA opposing these harmful rules, which was signed by over 50 other groups.[3] If the Administration believes statutory changes are needed to fully allow for appropriate telehealth prescribing, it should work with Congress without delay to ensure that these medications can be prescribed via telehealth.