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

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.

Individuals with untreated MH/SUDs, but particularly untreated psychosis, are at very high risk of homelessness, incarceration, and early mortality.[1] Yet, too often, our system fails to help individuals get the help they need. Such help is especially important when the person’s illness results in agnosia, a symptom of their condition that impairs their ability to understand and perceive their own illness. Through a compassionate civil court process, states can help individuals with untreated serious mental illnesses (SMI) – particularly schizophrenia spectrum disorders and other conditions with psychosis – access clinically appropriate, community-based services.

This new approach is currently being implemented in California, which enacted the CARE Act in 2022. California’s CARE Court process allows family members, close friends, first responders, and MH/SUD providers to petition the CARE Court on behalf of an individual with untreated SMI and co-occurring SUDs.[2] The individual is provided legal counsel and is able to choose a voluntary supporter who can help the individual understand and communicate decisions. If the petition meets established criteria designed to protect the rights of individuals and ensure system accountability, the CARE Court can create a 12-month CARE plan (which can be extended to 24 months) to provide the individual with a broad range of services, including medications, recovery supports, and social services such as housing. Counties are mandated to provide these services. While medications can be ordered as part of a CARE plan, the administration of medications can never be forced.[3]

By moving upstream, California’s CARE Court is designed to prevent individuals with the most complex MH/SUD needs, who are frequently living on the streets, from much more restrictive conservatorships or incarceration.[2] Congress should support such efforts, while ensuring that states are protecting individuals’ legal and constitutional rights and building in accountability to prevent abuses.

Untreated psychiatric disorders in adolescents can lead to major lifelong problems for adults. It is particularly urgent for adolescents to receive treatment since about 14 percent of adolescents experience some type of mental health condition[1], and half of all mental illnesses begin by the age of fourteen.[2] However, medications to treat mental health and substance use disorders (MH/SUDs) have often not been approved for children and adolescents. For many health conditions, there can be a long lag between when the FDA approves a medication for adults to when (if ever) a medication is approved for children and adolescents.[3]

While it is critical to recognize differences between adults, children, and adolescents – and not to assume similarities – the fact that clinical trials are more expensive and burdensome for children and adolescents means that prescribers frequently prescribe FDA-approved medications “off-label” for youth.[3] A more rigorous approach is needed to help guide safe and effective treatments for adolescents, particularly those experiencing MH/SUD.

In early 2023, FDA staff presented to ISCTM (International Society of CNS Clinical Trials and Methodology) on potential opportunities to improve the availability of mental health medications for adolescents, particularly for schizophrenia, bipolar disorder, and major depressive disorder.[4] Large databases exist for all three diagnoses that contain thousands of adults and pediatrics. These databases could potentially be used to extrapolate the efficacy of medications for children and adolescents. There was “substantial evidence to support the full extrapolation of efficacy from adults to adolescents” where the disease is similar, the pharmacokinetics (medication levels in the blood/body) are similar, and the method of action and patient response are similar.[4]

The FDA should continue to explore avenues to increase the availability of key MH/SUD medications for adolescents when significant mental health conditions often first present. One option could be to allow a bioequivalence study and an open-label safety study to be done post-approval. Doing this could accelerate approvals to increase adolescents’ access to the best MH/SUD medications (which often have fewer side effects), encourage additional research, and leave in place incentives to study diseases in children and adolescents.

Childhood trauma, especially since the emergence of COVID-19, continues to have devastating effects on children and adults across the nation. Nearly half of children have been exposed to significant adverse childhood experiences (ACEs).[1] As children experience more ACEs, their risk for future mental health and substance use disorders (MH/SUDs) increases in adulthood. By preventing ACEs, the United States could reduce the adult incidence of depression by an estimated 44 percent (the highest of any health condition) and heavy drinking by 24 percent.[2] Despite the widespread occurrence of childhood trauma, only a very small fraction of the children who need care receive it because of socioeconomic barriers, including racism, poverty, and access to services.[3]

Congress should address this critical issue by passing comprehensive legislation like the RISE from Trauma Act. This bill would help to train frontline service providers and community members about trauma, toxic stress, and resilience, would require the Department of Justice (DOJ) to create a national center to disseminate best practices to law enforcement agencies to improve interactions, and establish grant programs improve prevent and reduce trauma across a variety of settings.[3][4]