Prevention Profiles: Take Five - Dr. Miriam Delphin-Rittmon (SAMHSA)

RICHARD LUCEY: Hi, everyone and welcome to this episode of Prevention Profiles, Take Five. I'm Rich Lucey in the Drug Enforcement Administration's Community Outreach and Prevention support section.  

Glad to have you with us for this episode is going to be an exciting one. And I am very pleased to have as our guest today Dr. Miriam Delphin-Rittmon. Let me tell you a little bit about her and then we'll get into our interview.  

Dr. Miriam Delphin-Rittmon is currently assistant secretary for mental health and substance use in the US Department of Health and Human Services and the administrator of the Substance Abuse and Mental Health Services Administration.  

She previously served as commissioner of the Connecticut Department of Mental Health and Addiction Services, and served in this role for six years. Prior to her current appointment, Dr. Delphin-Rittmon was an adjunct associate professor at Yale University, where she served on faculty for the past 20 years.  

While at Yale, Dr. Delphin-Rittmon served as the director of cultural competence and research consultation with the Yale University program for recovery and community health.  

Throughout her 20-year career in the behavioral health field, Dr. Delphin-Rittmon has extensive experience in the design, evaluation, and administration of mental health, substance use, and prevention services and systems. And has received several awards for advancing policy in these areas.  

Most recently, she received the 2019 State Service Award from the National Association of State Alcohol and Drug Abuse directors and the 2016 Mental Health Award for Excellence from the United Nations committee on mental health. With that, Dr. Delphin-Rittmon welcome to the podcast.  

MIRIAM DELPHIN-RITTMON: Oh, thank you so much, Rich. Thank you for having me on, it's a pleasure.  

RICHARD LUCEY, JR: And of course, I said it's a pleasure to have you here because this is the first time that we've had an administrator of SAMHSA as a guest on the podcast. And so breaking ground, if you will, a little bit there on that. So happy to set that precedent with you.  

So first, let me congratulate you on your Senate confirmation this past June, which was on the same date as DEA administrator Milgram's confirmation, so you have that in common.  

So it's been six months, and I know that it seems like probably just yesterday, that six months prior flew right by. But with that, what is your vision for SAMHSA as a whole and in particular its efforts to prevent substance misuse?  

MIRIAM DELPHIN-RITTMON: Yeah. Now, thank you so much for that question. I mean, it's something that I've been working on since my confirmation. SAMHSA's mission really is to mitigate the impact of mental health and substance use challenges across the country. I would say now as a function of COVID that mission is more important than ever.  

And so really my work is focused really just there. Working to ensure that Americans across the country have access to critical behavioral health services and supports.  

I have outlined five priority areas and four cross-cutting areas. And I'll go through those real quickly. So for example, preventing overdose is a key part of our work right now. Enhancing access to suicide prevention and crisis care, promoting children and youth behavioral health, integrating primary care and behavioral health. And then using our data, using performance measure data and evaluation. All of those areas are critical.  

And then real quick in terms of cross-cutting recovery, workforce, financing, thinking about sustainable financing mechanisms and equity are cross-cutting issues.  

RICHARD LUCEY, JR: Well, happy to hear you list those five areas because at least three of them fit squarely in work that we do, namely, preventing overdose, working with children and youth. And in fact, you mentioned preventing overdose and using data. I know those are two of Administrator Milgram's priorities right now.  

And so I think that opens up the opportunity for continued collaboration between our two agencies which we've enjoyed both when I was at SAMHSA. You and I shared a little bit of time together there when I was at CSAP, but now also my time here at DEA, we've had a great partnership with CSAP and SAMHSA at large. So happy to continue that.  

MIRIAM DELPHIN-RITTMON: Yeah. And I have to say, I'm absolutely happy to continue that as well. And such a critical partnership it is really between the work that SAMHSA does and DEA does. And I'm pleased to hear that you have that priority and interested in prevention as well. Because as you know that's a key area of our work at SAMHSA and so important right now as we're seeing young people struggle.  

RICHARD LUCEY, JR: Absolutely. You made reference also to COVID and the pandemic, and I'll get into that in just a little bit. But before we do, I'll move on to our second question, which I'd like to talk about data for a bit, as you mentioned that.  

So SAMHSA oversees administration of the National Survey on Drug Use and Health, as we like to use our alphabet soup in the federal area. Means that many stakeholders in prevention including DEA look at NSDUH to see the current rates and trends related to drug use among various age groups. What are some of the latest key findings from the survey? I know you just announced these actually just in the last couple of three weeks. But it may be, especially related to drug misuse among young adults.  

MIRIAM DELPHIN-RITTMON: Yeah. So we did announce and released the news the 2020 about two weeks ago now. And we did see some troubling trends in terms of substance use related to young adults, particularly transition age youth, so young people between the ages of 18 to 25.  

And some of what we found there is that young folks 18 to 25 they were more likely than other groups to use marijuana and also less likely to perceive the risk of harm in using marijuana.  

So in particular some of that data showed us that about 34% of individuals in the sample 18 to 25 use marijuana. And that was much higher than other age groupings.  

But we also found individuals in that age group were more likely to use other substances as well compared to other age groupings. Were more likely to use hallucinogens and also more likely to use other illicit drugs.  

So definitely an area that we need to pay attention to in terms of working to link young folks to services and supports to be able to prevent substance use, but for those that may be struggling ensure that they get connected to the care that they need.  

RICHARD LUCEY, JR: And it's nice when the National surveys seem to align with each other in terms of the findings. Because we also know the Monitoring the Future study which came out with its latest findings around college students, for instance, which fits squarely in that 18 to 25 age group, back in August, we saw now historic highs in daily use of marijuana among college students.  

And from my opinion, what seems seemingly out of the blue in the last four decades, the highest rates of hallucinogens. You just mentioned it among this age group. That seems to have come a little bit from out in left field quite honestly with this age group. So again, their findings are seeming to align pretty well with what you're seeing in the NSDUH.  

MIRIAM DELPHIN-RITTMON: Yeah. I mean, and the alignment just lets us know that increasingly this is an age group where the prevention programming really makes a difference. And that is an area where we've made some investments certainly across the states.  

The states implement the substance abuse treatment and prevention block grant. There's a 20% set aside for prevention with that block grant. And the states are doing really innovative work, and at the community level. Because really the states will often disseminate those resources to communities. And it's really innovative work happening at the community level around addressing underage substance use.  

RICHARD LUCEY, JR: Absolutely. You also mentioned the perception of harm of using marijuana has gone down, and the same was true in the other survey that I mentioned. We know perception of harm goes down, typically we see rates going up.  

MIRIAM DELPHIN-RITTMON: Yes. Yeah, absolutely. And so an important piece of the prevention work is raising awareness. Raising awareness, that in fact, many of these substances do cause and contribute to negative health outcomes.  

And so doing those also awareness campaigns with young people are really critical. Letting you know that marijuana can impact mood and other substances can impact energy level or brain development and/or contribute to anxiety and depression.  

And so arming young folks with information about the dangers of substance use can be really important as a strategy as well  

RICHARD LUCEY, JR: And you mentioned 18 to 25 age group. And of course, it's a big segment of that group I've focused my entire career on, which are college students. But we certainly know there are people in that age group who go into the workforce, they're not going on to college, we have certainly military young people, unfortunately, we have homeless young adults in that age group.  

And one of the critiques, I guess I'll call it, that I've often heard in my career is that by that age it's too late for prevention. And I say there's nothing further from the truth. I mean, prevention can really start at any age. Have you experience that also?  

MIRIAM DELPHIN-RITTMON: Absolutely. Prevention can happen across the lifespan. And the SAMHSA prevention programs really are lifespan focused. I mean, so certainly we have programs targeted to young adults. In terms of our programs are geared towards college campuses or even some of the community programs that are geared towards elementary schools.  

I remember one program where it was a program actually developed by the students around reducing vaping and tobacco use. Students came up with it themselves and they called it Blow Bubbles, Not Smoke. And so at the end of the day, they handed out bubbles to the other students. And it was a whole campaign around just the dangers of tobacco.  

And so I really love hearing about some of the creative work that the students are doing. But you're right. Across the lifespan prevention can and does have an impact.  

And so some of our work within the harm reduction space certainly I think is impacting and reaching individuals who are older than students or not in elementary school or in high school or college.  

And some of those harm reduction strategies, for example, the use of fentanyl test strips. Our federal funds can now be used to purchase federal fentanyl test strips, to be able to test substances for fentanyl.  

RICHARD LUCEY, JR: Yeah. That's a pretty seismic shift too I think in the federal strategy with harm reduction, since you've mentioned it. I know you have some grant opportunities coming out around this area. It's always been a bit of a-- my entire career has been in government, both state government in New York and now in my third federal agency in my career with the FEDS.  

I've always said, first and foremost, the message has to be one of non-use, if you're underage. That has got to be the primary message. But for those students who choose to ignore the law, I think that's when the harm reduction message does start to creep in. If you will, because we can't ignore the fact is happening.  

So I think as someone who works in a federal agency were anxious in a way to see what is the concrete messaging that's going to be coming out around this definition, services type. Because like I said, it is a change.  

MIRIAM DELPHIN-RITTMON: Yeah. Absolutely. And as you know the secretary released the overdose prevention strategy and that was cross HHS. And even other agencies outside of HHS, certainly I think can lean on that strategy.  

But it is a way to-- harm reduction can help to move people along in terms of stages it changed. It can be a valuable strategy for planting seeds. As with our State Opioid Response Grant, one of the strategies is to widely disseminate naloxone. And naloxone saves lives as in overdose reversing medication.  

And so disseminating that far and wide to include on college campuses. Because we know that college campuses have been impacted there as well. But a real valuable harm reduction strategy that also creates opportunities for planting seeds to the extent that information about services and supports are also shared with individuals who we disseminate the naloxone or other harm reduction materials to.  

RICHARD LUCEY, JR: Absolutely. A segue now to-- with this question and then a third question in the whole context to the pandemic. Obviously, we're now a year and a half into this, I don't think anybody thought we'd be this long into this pandemic.  

But let me ask you first about, has it related to the data. And NSDUH, I know it's affected in some respects other data collection, but were there any qualifiers about the data given limitations on data collection during the pandemic, did that have any kind of an impact?  

MIRIAM DELPHIN-RITTMON: Yeah. Great question. It did. It did impact, the pandemic impacted the way in which data was collected for the NSDUH. Typically, NSDUH is done all year round as a household survey.  

But we did have to stop data collection March through September in this 2020, so March through September 2020 because of the pandemic. But then in October we switched to an online version. So a web based version of the NSDUH to be able to continue collecting data.  

So the overall sample size was smaller. Usually, we have around 67,000, for this NSDUH we had about 37,000 participants, which is still a robust sample. It's robust and still allows us to be able to interpret the data but it did impact our overall sample.  

Another critical change in this NSDUH is that DSM-5 was used instead of the DSM-IV. So the diagnostic manual, we use the more updated manual. And so the criteria for diagnosing substance use disorders was different.  

And in fact, the numbers show this year higher numbers of individuals, about 40 million individuals with substance use disorder as opposed to 20 million in 2019. And we believe a lot of that is because of the changing criteria across DSM-IV versus DSM-5. It's easier to get a diagnosis or to meet the criteria using the DSM-5 as opposed to DSM-IV.  

RICHARD LUCEY, JR: And I was so glad that you provided that context. Because I think as we've looked at other surveys collected during the pandemic, I think it's also important to reassure our listeners that despite the much smaller sample size it's still reliable and valid data. I mean, that's really important.  

I think it was brought up during your recent announcement of the data, the gentleman, remember his name from CBHSQ. I'll use the acronym again because I'm familiar with it but the Center for Behavioral Health Research. It is data that we can rely on and it is valid.  

MIRIAM DELPHIN-RITTMON: Yeah, it is. It's still a robust sample. I mean, 37,000 data points is a really robust sample that allows us to still do the analysis that we typically do with the NSDUH and to do the extrapolations as well so to interpret that data.  

Where we might have some challenges as we're now going to begin to do a series of other NSDUH reports where we disaggregate the findings by race and ethnicity or by state or by region, and that with a smaller sample, we might run into some analysis where the numbers are just too small to be able to interpret them, particularly when we start breaking the data down by different racial and ethnic or gender groups.  

But we're working on that and we'll take a look at what the findings show. And we'll qualify or communicate any limitations of what the overall findings are when we do those follow up reports.  

RICHARD LUCEY, JR: I'm glad you mentioned that. Because I do recall from the stakeholder briefing that was done a couple of weeks ago, whenever data sets are released people are really interested. As you mentioned, for example, how it relates to a particular racial group, ethnic group, a student subpopulation, what have you. But you start to slice the data a little too thin, as you say, then it starts to-- we don't want it to break. I guess that's the way to look at it, that then it becomes a little bit more unwieldy and less than reliable.  

MIRIAM DELPHIN-RITTMON: Yeah. It does. And so what we plan to do moving forward is to-- so that the NSDUHs so NSDUH 21 and 22 and moving forward, likely we'll be able to do comparisons across those NSDUHs but then also group the data. Group the data so that we have a greater number of individuals within cells to be able to do those more disaggregated analysis by race and ethnicity, if you will.  

So sometimes in order to look across either by region or race and ethnicity or by state, you need much larger numbers. And so to summarize across a number of years, we would be able to do that.  

So with the current 2020 NSDUH, because of the various methodological differences we can't compare with previous years. So can't compare with the 2019 or 18 or any of the previous year. So it's really a point in time analysis as opposed to a trend analysis.  

RICHARD LUCEY, JR: It almost becomes its own baseline. If I will, in some respect.  

MIRIAM DELPHIN-RITTMON: Yeah. That's exactly right. In many ways, it becomes a new baseline. [CLEARS THROAT] Excuse me. A new baseline because it's a point in time now. Point in time survey.  

RICHARD LUCEY, JR: So let me now segue on to my third question, which is now really the context of the pandemic. So many students were experiencing unhealthy levels of stress and pressure and low levels of engagement before the pandemic.  

And we also know that drug use tends to increase during stressful times and following a traumatic event. And I have said, not so kiddingly, I don't think there's a type size big enough for the as to risk that we put next to 2020 defined as a stressful and year of anxiety. Not just about the pandemic, I mean, obviously that drove a lot but certainly had the civil unrest due to social injustice and racial injustice issues. Perhaps, the most contentious presidential election in our history.  

So what are some of the key concerns SAMHSA has or is focusing on with regard to behavioral health services for youth and young adults with all of that contextual stuff that's happened over the last-- since May 16, if you will, of 2020?  

MIRIAM DELPHIN-RITTMON: Yeah. It's a great question. And as I mentioned, this is one of our priority areas. Because we know youth have had a tough-- I mean, the country, the world has had a tough year and a half. And our data does show that-- even the NSDUH shows that young people in particular also have had a really hard time there. Some of the NSDUH data, in fact, show that young people are reporting that the pandemic did negatively impact their mental health.  

And that substances were used to cope across the board, not just for young people but for individuals 18 or older. Substances were used as one coping strategy to get through the pandemic.  

And so in terms of our programming and what we're thinking about that, I mean, again, the goal is to just increase access to services. So one grant that we have project AWARE, it's a school based initiative and it is focused on working with schools around increasing awareness and resiliency in education, that's what the AWARE stands for, the acronym.  

And the goal is to increase awareness of being able to identify when young people may be struggling. So there's training for school personnel and staff and also students. Helping students to recognize when they may be struggling and maybe having experiencing distress. But then also connecting students to services and supports as necessary.  

So that's one grant that we've disseminated across the country to include additional awards that were made as a function of some American Rescue Plan resources. So that's one area of real focus.  

Another area is through our crisis services and support. So in June 20-- or July 2022 the 988 crisis line will be going live. And that is an expansion of the current Suicide Prevention Lifeline.  

Essentially what that line will be is it will be just a three digit number that young people or family members or people can call when they're in distress or in crisis or having suicidal thoughts. They'll be able to speak to somebody, if necessary a crisis worker, will be deployed. And the goal, ultimately, there is also to connect people to needed services and supports.  

So those are just two strategies that we have in place. But some of the thinking is we want to be able to meet people's needs and meet them when they're struggling and where they're struggling, whether it be in school or whether it be in the community. And so each of those projects is geared towards that.  

RICHARD LUCEY, JR: Happy to hear you mentioned 988, I actually was just looking into it just within the last couple of weeks. If I read correctly, I think it's going to be available either to call that number and text that number, is that correct?  

MIRIAM DELPHIN-RITTMON: Yeah. That's absolutely right. So it'll be-- there'll be a call line, so the 988, but then there's also a text and a chat feature as well.  

And that's specifically geared towards some of our research. We know that young people, for example, prefer the text or the chat functions. And so we wanted to be able to put multiple options or ways that people could connect if they're struggling. So in addition to the speaking over the phone there's the text and chat option as well.  

RICHARD LUCEY, JR: Right.  

MIRIAM DELPHIN-RITTMON: Yeah.  

RICHARD LUCEY, JR: I want to switch back to-- we were talking about youth and young adults in dealing with the effects of the pandemic and everything else from the last year and a half.  

So I like what you said at the outset, this affected everybody, first of all, we all know that. So workplaces were turned upside down as we were continuing to maximum telework for a lot of federal employees, for example.  

But for K-12 and college, their workplace is the school setting, if you will. And it's such a hybrid even now, I think in the fall. I think a lot-- I don't have kids personally but I've got nieces and nephews that are in college and in high school.  

I think there's even anxious, people are glad to be getting back to what the familiar is. But there is also some stress with that, reintegrating, relearning how to socialize in-person. I think we're all happy to get back to it but it feels like we have to learn how to do that all over again.  

MIRIAM DELPHIN-RITTMON: Yeah. It's something there's-- we're hearing that a lot. There's questions like you're shaking hands, you're not shaking hands or I've heard people say, oh, well, I'm a hugger, and hugs seemed to really be out. And so there's truth to that. There is a needing to readjust to the new reality.  

Many college campuses do have mask rules or classrooms have mask rules. So there are adjustments that have to be made. And so from a behavioral health perspective, one of the things that we're working on is certainly working with college campuses around ensuring that there are-- services and supports are available.  

So for example, we have a Garrett Lee Smith Award that is a grant available again across the country that is geared towards suicide prevention, but also connecting people with needed services and supports. There's education training components to that grant. And so the goal ultimately is to ensure that people are able to connect when needed.  

RICHARD LUCEY, JR: I'm really happy to hear you mention the GLS grants. I know that from my time at SAMHSA, when working with our colleagues in the Center for Mental Health Services, we used to say that preventing alcohol and other drug misuse also is preventing suicide. We know of that alignment that connection between the two.  

For our listeners, if you know of a school that's working on-- has this grant or working toward this grant, there are ways to connect the alcohol and other drug misuse issue to it, definitely.  

MIRIAM DELPHIN-RITTMON: Yeah. Absolutely. And you're right. We know there's co-occurrence that some individuals struggle with mental health and substance use challenges. So Garrett Lee Smith, it can help to address individuals that may be struggling with substances, as well as you mentioned.  

There may be some individuals that are using substances to medicate or self-medicate for depression or anxiety or other behavioral health challenges they're experiencing. So this certainly could be an entryway into services and supports for individuals if they have this grant on campus.  

And then many college campuses also have counseling centers. Counseling centers where students can connect or their residence hall counselors are often trained to be able to connect people to services and supports as well.  

RICHARD LUCEY, JR: I think this is a really nice segue into my fourth question, which really has to do with some of SAMHSA's more high profile campaigns. And there are a number of them to raise awareness about the importance of preventing alcohol and other drug misuse.  

So for our listeners, I'm talking about, for example, National Prevention Week, the Communities Talk initiative, National Recovery Month. We know that community engagement is absolutely important and it's fundamentally important in these efforts. How is SAMHSA helping to facilitate this collaboration between colleges and universities and their surrounding communities?  

MIRIAM DELPHIN-RITTMON: Yeah. Great question. And again, this is an area where we're seeing real creative innovation as well. So we have this one grant, we call it the Strengthening Opioid Misuse Prevention Act program.  

And there's one grantee that they've put together a radio show, an hour long radio show. They call it Youth Speak Out. And the youth, they designed, the show, they write the show they do the interviews. And it's a great way for them to get engaged around behavioral health issues by actually doing a show. And it helps to benefit both the campus, but then the surrounding community. Because a show, hour-long show is broadcast throughout that community.  

So that's just one creative example of what's happening at a local level at a college, university level. But then also that has ripple effects in the surrounding community. So really excited about that initiative.  

We have other initiatives so for example, minority aids program. Same thing there is work that's done there on college campuses but then also within the surrounding community as well.  

The goal of that is to engage either community level or public or private or nonprofit partners to help raise awareness about risk behaviors and also to provide information about connecting to services. Whether it be substance use services or in some instances, it may be harm reduction services as well or supports as well. So that's another initiative that we have.  

And then recently we announced that-- this is one, I mean, I think it can impact communities as well. It's the Talk. They Hear You app. And so now we have an app that can be put on phones for family members to talk with there-- it just has tips around starting conversations with young people around substances.  

And so that's one that's getting quite a bit of-- we're excited to see that it's getting quite a bit of reach. And so that's one that's available as well.  

RICHARD LUCEY, JR: Really glad to hear you mentioned the app with Talk. They Hear You, which is the whole basis of that campaign. I know parents influence their kids decision-making primarily around underage drinking but also other drug use.  

And with college students, oftentimes, there's the misperception that the parents work is done, so to speak. And I know SAMHSA also has the sound of your voice campaign, which is the college bound, high school seniors. Parents, your job isn't done yet, you still have a role to play.  

MIRIAM DELPHIN-RITTMON: Yes.  

RICHARD LUCEY, JR: So that's really important, we continue to emphasize that.  

MIRIAM DELPHIN-RITTMON: Yeah. Absolutely. And the app, it certainly can be-- some of the tips there could apply for having conversations with college age or high school age kids. And so really valuable information there.  

But I think that point is right on, the parents work it's-- we often hear that parenting work is lifetime work. And so it often includes having some of these difficult conversations.  

And it takes a village. I mean, I think aunts and uncles and friends and family members, I think we can all play a role. If we know of a young person that's struggling or looks like they may be having emotional challenges.  

And I think we can all play a role, in terms of just checking in to see how they're doing or letting them know about resources that may be available, sharing our own stories of the ways that we may have worked with challenging situations. And so I think we can all play a role there.  

RICHARD LUCEY, JR: Definitely. Well, as we wind up the interview I now move to the same question I ask of all of the guests on the podcast, which is more or less your carte blanche, if you will, the advice or the words of encouragement. What do you have for the professionals who are working to prevent drug misuse among college students, that's our primary audience here, and the students themselves who listen to the podcast?  

MIRIAM DELPHIN-RITTMON: Yeah. Great question. It's such an important question. And what I would say is first and foremost, I would just want to say just thank them. Just thank you so much for the really important work they do to help prevent drug use among college students.  

And then the other thing I would want them to know that they're not alone. SAMHSA, we are here to partner. We see the important work they do, we hear their concerns. We want them to know that they are our resources that we're committing to be able to continue to address prevention needs, and we're here to engage into partner. And so that's what I would say to prevention specialists and other individuals working to prevent drug use.  

RICHARD LUCEY, JR: Absolutely. This is just a great advice. And as we wrap up, I am thrilled with this interview I just really thank you so much. I love the way you present the data, the way you present the messaging.  

As we hope for these podcasts, for the matter of fact, it's based in a sense of genuineness and reality and very conversational. So Dr. Delphin-Rittmon, I really, really appreciate you being on today's episode with us.  

MIRIAM DELPHIN-RITTMON: Oh, thank you so much. Thank you for the invitation and for the great work that you're doing in the space as well. Thank you.  

RICHARD LUCEY, JR: Thank you. And I know I can speak for the agency, which I don't often get to do, but I know that we look forward to our continued partnership and collaboration with SAMHSA at large and specifically with CSAP. It's been grade up to this point, we look forward to great things in the future.  

MIRIAM DELPHIN-RITTMON: Thank you. And we are absolutely looking forward to that as well, to finding innovative ways to expand our partnership. I think there's so much alignment there, and I think we can only take it to a new level. So really excited about that as well.  

RICHARD LUCEY, JR: I totally agree. And to our listeners, I hope you've enjoyed listening to this episode of the podcast as much as I've enjoyed doing the interview. Take a listen to our previous episodes on campusdrugprevention.gog. And with that, I'm going to say thanks for listening and have a great day.