Brentin Mock is a staff writer at CityLab. He was previously the justice editor at Grist.
New York City First Lady Chirlane McCray has taken her city’s plan for addressing substance abuse and mental illness and expanded it to 185 cities.
In November 2015, New York City First Lady Chirlane McCray launched ThriveNYC, a comprehensive mental health prevention and treatment program funded by the city to the tune of nearly $850 million. This is the program responsible for the ads and billboards found around New York City displaying messages like “Anxiety doesn’t define me,” and for training 250,000 mental health “First Aid” responders, to help people with mental illness and substance abuse disorders. The plan has been working well enough that McCray has expanded this mission to 185 cities, which are working under the banner Cities Thrive Coalition.
McCray’s initiative unfolds right at a time when the White House and Congress have been pushing to dramatically scale back funding for mental health and substance abuse treatment as provided by the American Healthcare Act, Medicaid, and other federal programs. Which is to say, the Cities Thrive Coalition is congealing at a time when these 180-plus cities may only have each other to count on in the fight for mental wellness.
The project also launches during a time when police have been under intense scrutiny for responding violently to people with mental illness, and as opioid abuse and overdoses have become a national concern. The ThriveNYC plan has made progress on these issues despite flying into the federal headwinds of healthcare cuts. So far, the city has trained over 2,500 NYPD officers in Crisis Intervention Training, so they can deploy tools other than guns and handcuffs when encountering people who might be suffering mental or drug-induced breakdowns. And more than 2,300 New Yorkers have been trained to identify the signs and symptoms of someone who may be having an attack due to depression, psychosis, or substance misuse.
CityLab spoke with First Lady McCray in New Orleans, where she and Cities Thrive representatives spoke to the U.S. Conference of Mayors about the urgency of their work. This also happened to be the day that Trump finally relented in declaring the opioid crisis a national emergency after days of saying he wouldn’t. What this means has yet to be defined, and McCray says her neighbor New Jersey Governor Chris Christie, who headed Trump’s opioid commission, didn’t reach out to her, despite her work in this area. Here’s what the First Lady had to say about it:
Why is it important that cities pay special attention to mental health and substance abuse problems?
We're working hard to change how people talk and think about it. The whole substance misuse and addiction problem should be under the umbrella of mental health for political and funding reasons, but they are split. However, I'd say in at least half of the cases, mental illness and substance abuse go together because people often medicate to compensate for what's going on in the brain.
Thrive is about making change in those areas, but also, changing the way people access services, making it easier for people to get services where they live, where they learn, where they worship, where they work—because people don't want to go outside of their neighborhoods. They don't want to talk to someone they don't trust or don't know. And this is important background because people delay seeking help an average of ten years when they find themselves in mental distress. That's just the average. In poorer communities and communities of color, that can often be ten years or more.
Another thing that is not talked about enough is the fact that the signs and symptoms of mental illness in half of all cases emerge before the age of 14—in 75 percent of the cases, it’s before the age of 24. So we have an opportunity to prevent some cases [of mental illness], and certainly an opportunity to intervene before mental illness continues, and what that means is, we don't let people with diabetes or asthma wait ten years before they get help, or someone with heart disease wait ten years. What happens when you let diseases progress? You end up spending more money, and people get more ill.
How do you feel about the current Trump administration's response to the opioid crisis?
Well, his response has been law and order. They're talking about an epidemic and his first words are, ”We're gonna get tough.” I want to see this talked about primarily as a public health problem because we know that addiction is a disease that can be treated. Is there a role for law enforcement? Absolutely. We are working in New York City to prevent more opioids from coming into our city, but that's not the whole problem. We want to work on the root causes of addiction, which we know and we can address. We can't in the current structure, and we can't if we have a repeal of the ACA.
On the one hand I'm excited that Trump is declaring it a national emergency. On the other hand, I don't know what that means. Does that mean more funding? Does that mean more of the ability for people who are getting substance abuse treatment or are being treated for addiction, that they will be able to go to other places for treatment?
What would you like it to mean?
I would love for it to mean more funding, more flexibility so that people who have addictions can have more outpatient services, to get medication-assisted treatment. I would like more encouragement for physicians to be able to administer buprenorphine. I'd like to have them have more training and coaching because we know buprenorphine is a great medication. It stops the cravings and it allows someone to go to work or go to school and live their life, because addiction is a chronic disease, just like diabetes or asthma. There should not be a stigma about that.
This particular epidemic requires outpatient care. A lot of people are crying out for beds, but the reality is because addiction is a chronic disease you can't live in a bed. You can go and get your detox and rehab but at some point you have to come out. You have to live your life and that requires outpatient counseling, that requires medication-assisted treatment, which is the best evidence-based treatment we have. And we don't have the resources that we need to provide it properly. I'm hoping that this declaration of a national emergency is going to help provide more resources so that people can access medication-assisted treatment close to where they live.
I hope they can go to their primary care doctors who have been trained and coached to administer bupenorphine. I hope there are some kind of waivers so that people who are suffering from addiction can go some place other than a substance abuse clinic to get services because there's still such a stigma about these facilities and people need to feel free and unashamed to get healthcare where they feel comfortable.
The ACA seems to stand on fragile ground under the current Congress and White House. How might its repeal impact the way cities deal with these problems?
We worked very hard to make sure that it wasn't repealed because the ACA has given parity to mental health treatment, by including addiction and substance abuse in its coverage, which we never had before. Our insurance did not have to treat mental illness the same way it treated physical health [before ACA]. There's been an artificial separation in our healthcare system for way too long between physical health and mental health. It's an artificial disconnect because what can you do without your brain? There is no health without mental health. But, of course it's important that people be able to access their health plan so that we would be affected of course if the ACA were repealed.
What about non-opiate addiction problems, that affect more people of color?
I think our plan addresses them all. K2 was once a big problem, the synthetic drug that popped up in the bodegas and in the streets and that's something we had to deal with. I think we dealt with it pretty successfully. You don't hear much about it anymore. And then of course we have alcohol, a huge problem that nobody talks about. In fact it often works out that people have overdoses not just because they used opioids, but because they also were drinking. So it's a deadly combination.
We know this epidemic has been heavily focused on white working-class communities but the numbers in communities of color is rising, so we have to be attentive and be ready to respond to that. The faces [of drug addiction] have changed. When it was the crack epidemic, it was all brown and black people, but our faces have been erased this time around. You don’t even see [black and brown faces] on the nightly news or in the papers. There is no silver bullet to any of this. We have to take many paths to address all the different populations.
So how do you feel about the change in response based on race? Obviously when crack was pervasive, there was no national outcry of empathy, there was the opposite.
Right. On one hand, I'm glad there is this response because if any assistance is coming down the pike and it's universal then we will still benefit. But it's, of course, sad to see the disparity in terms of the inequities and attention that we received in the past. I think there is another factor though: I have to say that people are recognizing addiction as a disease much more than they did 10, 15, 20 years ago. But even now there is still this perception that [addiction is about] a lack of discipline or poor moral character, that it's anything but a disease. Ten, 15 years ago there was a lot more of that and connected with black, brown people and low-income people that just multiplied that perception. So we've come a long way now. There's no excuse.
Do you think the opioid crisis would be called a national emergency if the face of the crisis was black and brown faces?
To the extent that it is now? No, I don't think so. But if there were the same numbers of people dying, there would be some kind of outcry.
How have smaller cities in the Thrive coalition received these plans, especially in terms of coming up with funding to execute or even put together plans like this?
I'm pleased to say we have close to 200 mayors from around the country in our coalition from both big cities and small cities. This is a bipartisan effort and the reception has been fantastic. ThriveNYC is city-funded, but what we're doing with smaller cities and other cities in general is sharing our best practices, sharing the things that we are doing that they can also do. For example, we had our health commissioner write an executive order that would allow anyone to go into any of our chain pharmacies, like Duane Reed, CVS, and Walgreens, to buy naloxone without prescriptions.
That doesn't cost any money, but it's a change of policy. It’s very important though because usually family members and friends know if someone close to them is using, and so if they have naloxone they could save a life.
We are working on creating a hub so that we can share best practices and ideas, and we have monthly conference calls where we talk about what we're doing so that we can learn from one another. It's not happening on the federal level, so we have to do it ourselves.