Substance use continues to be identified as a top health priority in our community. Many individuals impacted by substance use disorders also struggle with mental health disorders, leading these health priorities to be combined.  Over 95% of key informants ranked substance use and over 66% ranked mental health as critical to address (2018 Haywood County Community Health Assessment).  Key informants included community or business leaders, physicians, other health providers, public health representatives, and social service providers.  Alcohol, tobacco and other drugs negatively impact all ages and ethnic groups in our community.  

Risk factors associated with substance use include several biological, social, environmental, psychological, and genetic factors; and, these factors can include gender, race and ethnicity, age, income level, educational attainment, and sexual orientation (Healthy People 2020). In 2016, the rate of smoking among pregnant women in Haywood County was 17.7 per 100,000 (State Center for Health Statistics). Individuals with mental health disorders also smoke at a higher rate than the general population (NAMI). Health indicators in our County show the following trends: .  

• In 2018, unintentional medication and other drug overdoses comprised 44% of all cases seen at the emergency department.  This is a slight decline from the 47% of cases in 2017 (NC DETECT, 2017-18*). 
• In 2018, over 17% of adults reported being current smokers.  This was a decrease from 2015, which showed a figure of over 24% (WNC Health Network-WNCHN, 2018).  
• Binge drinking was reported by six percent of survey respondents.  This was a dramatic improvement from 2015, in which 12.7% of adults reported binge drinking (WNC Health Network-WNCHN, 2018).  Binge drinking is defined as five or more drinks for a man and four or more for a woman on one occasion in the past month.       
• Over 17% of survey respondents experienced more than seven days of poor mental health in the past month.  This was an uptick from the 16% who reported this in 2015 (WNC Health Network-WNCHN, 2018).
• Over 3500 mental-health related visits were made to the emergency department by Haywood County residents (NC DETECT, 2018*).  This was a decrease from the previous year, which showed over 3800 visits.  
  • *NC DETECT is a statewide public health syndromic surveillance system, funded by the NC Division of Public Health (NC DPH) Federal Public Health Emergency Preparedness Grant and managed through collaboration between NC DPH and UNC-CH Department of Emergency Medicine's Carolina Center for Health Informatics.  The NC DETECT Data Oversight Committee does not take responsibility for the scientific validity or accuracy of methodology, results, statistical analyses, or conclusions presented.  
• Over nine percent of adults did not get needed mental health care or counseling in the last year, an increase from seven percent in 2015 (WNCHN-WNC Healthy Impact, 2018).  

Substance use and mental health and the related result ''advancing health and resilience by advocating for prevention, treatment, harm reduction and recovery'' are aligned with the following Healthy NC 2020 Focus Areas/Objectives:

Substance Abuse and Mental Health

• Reduce the percentage of high school students who had alcohol on one or more of the past 30 days.  
• Reduce the percentage of individuals aged 12 years and older reporting any illicit drug use in the past 30 days.  
• Reduce the rate of mental health-related visits to emergency departments (per 10,000 population).
• Decrease the average number of poor mental health days among adults in the past 30 days.  

How would we experience ''advancing health and resilience by advocating for prevention, treatment, harm reduction and recovery'' in our community?

Following the completion of the 2018 Haywood County Community Health Assessment (CHA), the Substance Use Prevention Alliance completed ''Getting to Strategies.''  This is a road map for health priority work groups.  The SUPA provided answers to the following questions:

• What are the overall quality of life conditions (results) we want for the people who live in our community?
• What would these conditions (results) look like if we could see them?
• How can we measure these conditions?
• How are we doing on the most important of these measures?
• Who are the partners with a role to play?
• What works to do better?
• What do we propose to do? 

Quality of Life Conditions (results): 

• A more caring, engaging and loving community 
• Everyone meets their full potential
• Institutions and the community are trauma-informed
• We are more empathetic and informed about addiction and mental health 
• Substance use is less romanticized among youth  
• There is more understanding, less stigma and increased community awareness
• There is increased cultural diversity and awareness
• We are more focused on wellness and less on sickness  

Health Behaviors:

• Reduced substance use and overdose
• Less pressure to make poor choices
• Reduced medication use
• Better stress management
• All individuals have Naloxone at home and in their possession at all times.  Provide Naloxone to people.  
• More physical activity
• Modeling healthy behaviors in order to help others (cooking/exercise/self care)
• Expanded messaging and campaigns about prevention, including more substance use education and prevention among youth and funding for school programs
• Invest in prevention staff 

Clinical Factors:

• Expanded Medicaid/access to more affordable health insurance 
• Available mental health and substance use treatment centers
• More hiring and reduced attrition among service providers
• Increased awareness of services and engagement in treatment and the continuum of care
• Better services

Social and Economic Factors: 

• Livable wages and more economic opportunity
• Individuals have work that is more fulfilling and supportive employers.  
• Students have better grades and are more successful (more educational attainment) 
• More community involvement and an increase in relationships across community
• A willingness to engage at all levels, with an increase in understanding and kinder people
• Be hands and feet in the community with an increased commitment to helping/serving.  Be more open to change and be part of it.  
• Reduced isolation, including more gatherings (block parties) and conversations
• Non-judgmental language; use person-first language with no labels.  Do not attach stigma to behavioral health issues.  Have the ability to openly discuss mental health and substance use concerns.  
• More educational events and opportunities exist and more people taking advantage of opportunities (e.g. poverty simulation) 
• A community that embraces harm reduction
• An increased awareness of reality with no blinders 
• Increased inclusivity, including caring for each other, being open, valuing all and seeing the whole person
• Recognize successes and areas to improve.  Have a commitment to improve.  
• Have more self-compassion with healthy boundaries and social support for self.  
• Provide increased support for parents (to enable them to better care for kids); fewer individuals are reporting Adverse Childhood Experiences.  
• Provide adequate support to address intergenerational poverty; no more denial of needs.  
• Improved targeting of law enforcement strategies; fewer arrests for unmet behavioral health needs.  
• Reduced trafficking of substances
• Invest in post-high school youth programs
• Increased awareness of supportive services, programs and agencies available.  Promote use of these resources for people who need them.  

Physical Environment: 

• Increased affordable housing with a reduction in or absence of homelessness
• Fulfilled housing and other needs
• Increased hiring and housing of people with behavioral health concerns

Health Outcomes: 

• Improved physical and mental health, with fewer people reporting poor mental health days and physical/emotional problems
• A reduced demand for services, including fewer overdoses and mental health crises
• Increased resilience and less stress
• Healthy youth and families
• Improved perception regarding the current climate
• Improved efficiency and funding with greater connectedness
• People are less busy, but more engaged in important things.  We establish healthy boundaries.  
• We experienced improved education and understanding about the issues.  This includes adopting healthy norms and standards.  

During both the 2018 CHA prioritization process and SUPA discussions, we discussed how we're doing on the most important of health measures:

• Substance use data from the emergency department (alcohol toxicity, all opioid overdose, heroin overdose, meth use, underage alcohol use)
• Adult tobacco use 
• Naloxone reversals
• Available prevention staff
• Uninsured adults
• Adults who have ongoing medical care
• The average weekly wage (lower than the state average)
• Educational attainment, including the high school graduate and drop-out rates
• Adults who think Haywood County is a poor or fair place to live
• Adults who always or usually get the support they need
• Adults who have an Adverse Childhood Experiences score of four or more
• The percentage of residents spending more than 30% on rent
• Adults reporting poor or fair health
• Adults limited in activities (primarily due to back/neck problems and mental health/depression)
• Adults who report being negatively affected by theirs or someone else's substance use

• Print and digital ad campaigns provided education about vaping and opioids.  The ads had several million reaches.  Partnering organizations were Haywood County Health and Human Services Agency (HHSA), The Mountaineer, and Smoky Mountain News (The Mountaineer, 2020 and Smoky Mountain News, 2020).  
• Vaya Health offered free virtual training sessions using the Question, Persuade, Refer curriculum.  This evidence-based suicide prevention program reached over 370 participants (Vaya Health, 2020). 
• Mountain Projects, Inc. created a resilience flyer in English and Spanish.  It includes items such as parent tips, substance use and mental health treatment options, and other simple strategies (Mountain Projects, Inc., 2020).  Partnering organizations included the 30th Judicial District Domestic Violence-Sexual Assault Alliance; HHSA; Mountain Projects, Inc.; Region A Partnership for Children; and Vaya Health.  
• Haywood County residents made over 50 calls to QuitlineNC, a free tobacco treatment service (QuitlineNC, 2020).  
• Over 1800 naloxone kits were distributed and over 180 overdose reversals were reported (North Carolina Harm Reduction Coalition, 2020).  
• A coordinator was hired for the Partnership for Success grant by Mountain Projects, Inc. in November 2019.  Since then, an assessment regarding underage drinking and vaping among youth has been completed, including key informant interviews with seven youth, and strategies for addressing these issues have been identified.  The grant is currently in the initial stages of implementation (Mountain Projects, Inc., 2020).