It’s not a pretty picture, but this agency snaps the same frame every year

It’s impossible to have a cogent health policy without data. For mental health and use of addictive or illegal substances, that’s where the Substance Abuse and Mental Health Services Administration (SAMHSA) comes in. Its annual survey of Americans’ use of alcohol, tobacco and drugs makes for a sometimes grim, but useful picture. For more on the survey, Federal Drive with Tom Temin spoke with Jennifer Hoenig, SAMHSA’s national study director.

Interview transcript:

Jennifer Hoenig
Thank you. I’m pleased to join you today to talk about the National Survey on Drug Use and Health, or NSDUH, as we call it. And NSDUH is designed to provide nationally representative data on the use of tobacco, alcohol, illicit drugs or other substances, substance use disorders, receipt of substance use treatment, mental health issues and use of mental health services, among a civilian, non institutionalized population, [age] 12 or over in the U.S. And we employ a probability sample designed to be representative of the nation as a whole, but also for all of the 50 states and the District of Columbia. And the 2021 NSDUH used multimode data collection throughout the year. Prior to quarter four 2020, all interviewing in NSDUH was done entirely in person. But the COVID-19 pandemic necessitated methodological changes to our survey. We now collect data via in person interviews, and also via web surveys. And in 2021, eligibility of areas for in person data collection commenced in areas that were deemed to be safe, based on state and county level COVID metrics.

Tom Temin
Let me ask you this, when you are interviewing people, by whatever means, how do you know that the sample is projectable? For example, just the first stat in here in the summary, 57.8% or 161.8 million people used tobacco, alcohol or an illicit drug in the past month, therefore current use. How do you avoid self selection? Or making sure that the numbers, if you’ve interviewed 20 people to project over 1,000, that those are projectable, that sample?

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Jennifer Hoenig
That’s a great question. So it really has to do with the design of the survey and the actual sampling frame. And without getting too detailed into the exact specifics of it, we have things called state sampling regions which are divided, 750 across the country. And that really serves as one of our main sampling frames. And from that, we do go into smaller geographic units to make sure we’re really getting representative of all areas of the U.S. So we are in rural areas, we are in suburban areas, and we are in urban areas. And then all  through in person or web in 2021, depending on what the participant chooses.

Tom Temin
Right. You have to be careful not to go to Alcoholics Anonymous meetings to sample people or to bar rooms for example.

Jennifer Hoenig
Yes, it all comes to their home. So all participants are mailed what we call a “lead letter.” And in the lead letter, there is a link and a unique participant code to take the survey. Now from there, someone will go in and they’ll complete the screening, which is the first step. And if they are selected, they will take the interview via the web, but they can also say I’d rather an in person professional interviewer come to my home. And they can call that number on the lead letter to request that and then that person would go to their home and via a computer or laptop, using a system called CASSIE, they will take that survey.

Tom Temin
Interesting. All right. And I guess the question is now let’s talk about the results briefly. Any important trends that have emerged in the last couple of years in the survey, because of the pandemic, I guess, would be one of the driving factors in American behavior on many domains. How has it affected substance abuse and mental health?

Jennifer Hoenig
So that is a really great question. And unfortunately, in terms of trends for 2021, we cannot compare 2021 data to previous years of data because of methodological considerations that I spoke of earlier. So we found that through analyses conducted, in person samples do vary from multimode, web and in person. So we can really only speak to 2021 this year. But I can say that for 2021, we did find that many people who perceive that they ever had problems with their substance use or mental health did perceive themselves to currently be in recovery.

Tom Temin
Interesting. We’re speaking with Jennifer Hoenig. She’s national study director at the Substance Abuse and Mental Health Services Administration. So people saying they’re in recovery indicates they felt they had a problem prior to that statement.

Jennifer Hoenig
Yes. So it’s a two step question. We first asked people if they feel they’ve ever had a substance use problem, or did you ever feel you had issues with your mental health? And if they said yes to that, then we follow up and said, do you perceive yourself to be in recovery? And from that, that’s where we find that many people did report considering themselves to be in recovery. And for substance use, we found that to be 7 in 10 adults who ever had a substance use problem consider themselves to be recovering or in recovery. And two in three adults who ever had a mental health issue consider themselves to be recovering or in recovery.

Tom Temin
And is it possible to, say, look at 10 years or 25 years or the past — I don’t know how long this has been going on — maybe 50 years? Is the nation saner, or have greater mental health issues? Are we more sober or less sober, and so on?

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Jennifer Hoenig
And I understand the interest in that, but unfortunately, we can’t really speak for trends quite that long. I can say that a version of the survey has been in place since 1971. However, many changes have taken place over the years. And we really can’t talk about 50 year trends. The Substance Abuse and Mental Health Services Administration only began administering the survey in 1992. We went through some changes through the years, and in 2002 we added a participant incentive, literally a big break in comparability. In 2015, the survey was redesigned to feature an expanded section on prescription pain relievers. So again, there was a little bit breaking comparability, and then as I said, in 2021, we cannot compare it to any previous years. However, we do look forward to as we continue on with the survey, returning to comparability across years.

Tom Temin
Yes, because I think that would be one of the major values in having the whole survey program, wouldn’t it be to have that comparability?

Jennifer Hoenig
Absolutely. And we know that stakeholders do rely on these trends, and we are doing everything we can to return to that. Unfortunately, COVID disrupted a lot of our lives. And survey research was not immune to that, unfortunately. But we definitely plan to in the future, and we’re doing, like I said, everything we can to get these trends going in the future. Because we know that really important data from that really impacts programs and policies comes from this trend data.

Tom Temin
Right, let’s talk about that. You have a huge body of knowledge, whether comparable to last year or not even just for what’s going on today in the country, it’s really a great resource. What happens to it? Who else in the government uses it? And we’ll talk about federal and then maybe about state and local where a lot of programs actually are delivered?

Jennifer Hoenig
Absolutely. So one of SAMHSA’s four core principles is the commitment to data and evidence. So obviously, our annual NISDUH results help inform our internal SAMHSA efforts to expand access to treatment options, and recovery supports across the nation. Our data is definitely used by a variety of our federal partners: [Centers for Disease Control and Prevention, U.S. Food and Drug Administration]. We know that they’re using our data. Agency for Healthcare Research and Quality are also using our data. [National Insititutes of Health,] a number of offices in NIH as well. So we partner with them to make sure they’re getting our data and make sure they’re understanding our data. And then also partnering with them to really disseminate data using their data sources along with ours, to make sure that we’re giving a fuller picture. And certainly state and local health departments use our data as well. We get a lot of data requests from our state stakeholders. And we also through our regional administrators, are also in contact with state and regions to make sure that our data on state and regions is disseminated in those areas.

Tom Temin
Because no agency and no program probably has enough money to do everything it would like to. But if a state or local entity indicates or sees a shift, say, towards drug abuse and away from alcoholism, for example, just making that up. They might be able to reallocate their program dollars towards where the worst problem is or where the problem is worsening versus where it might be stable.

Jennifer Hoenig
Absolutely. Prior to this role, I was a senior researcher at the New York State Department of Health working in mental health and we certainly used the NSDUH mental health data to really gauge, “OK, at a national level, it’s at this level. How does that compare to our local data and how can we improve on this? And how do we compare to other jurisdictions?”

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