[00:00:00] Welcome to the Health Policy podcast. I'm Brian Hyde. Today I'm joined by Layal Bou Harfouch. She is a drug policy analyst at Reason Foundation, and also a, uh, student at, in evince- evidence-based healthcare at University of Oxford focused on harm reduction and addiction policy. You, uh, you stay busy, I take it. Oh, yeah, yeah, for sure. Hey, for, for- Sleep is not common. For the sake of folks who are meeting you for the first time, would you mind telling us just a little bit about your background? Sure, yeah. Uh, well, my background's kind of been a, a bit all over the place. I went to school, grew up in Michigan. I went to school at Central Michigan University. I, where I minored in substance use, but majored in kinesiology, so I thought I was gonna go to med school, but then got really interested in the substance use aspect of medicine and care. And so then I moved on to Johns Hopkins, where I got my master's in biotech and did some clinical research in addiction medicine there for, for quite a few years. And there I noticed a bunch of really systemic [00:01:00] issues that prevent addiction medicine from being optimized to its fullest, and getting patients the care that they need. And so when I realized that it was more of a systemic issue, I knew I wanted to take my work more broadly, and now I'm here at Reason in policy. And, uh, further pursuing my doctorate at Oxford in, uh, also my research is in drug policy, specifically around medication-assisted treatment for opioid use disorders. And so yeah, just continuing that theme. I fell in love with it, and, and, um, you know, and, and really delving in now on the policy side of things. And we have you here today to talk about a, a policy that I'm guessing is gonna be out of sight, out of mind for a lot of people, but nonetheless, it's something very important. Set the stage for us, if you would, um, and let's talk about SB 42 in New Mexico, the type of legislation it is, and then we're gonna delve into some of the rulemaking and how i- in some ways the, the cure is, is worse than the disease that it's trying to address. Sure, yeah. Uh, so SB 42, New Mexico's [00:02:00] Senate Bill 42, is the comprehensive addiction and recovery program bill, and basically the purpose of it was to uplift these things called plans of safe care. Plans of safe care in the child welfare w- welfare realm are, you know, basically a coordinated approach to putting together a plan of how we can keep families together safely in the context of any type of risk. But, you know, here in this case we're applying it to a mother who either has a substance use disorder or was exposed to a substance. And so in New Mexico, after legislation is passed, they go through this k- Code rulemaking process where they figure out how the bill is going to be implemented. And what's interesting about this is that under the proposed rules at the moment, any pregnant patient who admits to substance use, and this includes prescribed [00:03:00] medications or illegal substances like alcohol, tobacco, marijuana, can be required to comply with a plan of safe care, which includes mandatory substance use treatment, even in the absence of clinical assessment or diagnosis. So there's a bit of a contraindication there, and, uh, the, these implementation rules have really dangerous consequences because they're forcing this, everything into the kinda like this black and white frame of substance exposure equals automatic risk and, you know, that's just... The picture is way more complicated than that. And I don't know, I guess people who have, have, uh, been, you know, either have a family member who's dealt with substance abuse or, you know, child safety issues like this, once the state becomes involved, um, it's not your home anymore. Uh, you know, the arena has been declared theirs, and, uh, basically, it's, it seems like you are at, you know, their mercy or you're, you're beholden to them to [00:04:00] tell you how, when, and, and what, you know, your role is going to be as a parent. Yeah, and, you know, fundamentally here also, there's a bit of a knowledge problem. I- there's a, there's a f- a, a thought, thought leader that I, I really, I appreciate, uh, so much and, and reference him a lot, uh, Friedrich Hayek, who talks about, you know, this, this issue that n- one entity or one person cannot know everything in, in this life. And so when you look at government and the kinda y- the obsession of centralizing everything and centralizing decision-making, it's so... It's, it's really dangerous, especially in situations like this where, uh, there's no way that the government centralizing that decision-making can, can satisfy what is needed in that moment for these individual families. It's very... It, it should be personalized, and it should be something that relies on the people that are m- closer to the problem. But unfortunately here, we're also seeing a case where we want to centralize and k- standardize these [00:05:00] processes that are super complicated, uh, trying to apply a black and white framework to something that is very much gray. And so yeah, it's, it's, um, it's, it's- concerning to see, to see and to, to see also that the state is, uh, reporting how many newborns they've removed from homes as, as something of a success of the initiative. You know, this is, this has been a thing in New Mexico for, for a long time. Since last year, uh, Governor Grisham in, in New Mexico directed that all newborns exposed to drugs or alcohol be separated from their parents automatically for 72 hours. Wow. Uh, yeah. It's, a- and so, you know, that's, to, to this day the most recent number that was released that over 167 newborns have been taken into state custody. And, and that's a good thing- How many ... in the governor's estimation. Well, because there's this misconception that drug exposure is just risk, but again, these, [00:06:00] these measurements of drug exposure oftentimes come down to a single toxicology screen. And in hospital, in practice, a lot of that is a urine drug screen, and those, those are, those are wildly inaccurate and very sensitive to other types of medications as well, things that are very legal. And also foods. Uh, there is, you- if you eat a poppy seed ba- bagel in the morning, you can test positive for opioids on, on a urine drug screen. And so per this policy, if you are exposed to a substance per the toxicology screen, then you get your kid taken away. Imagine getting your kid taken away because of a poppy seed bagel. I mean- That is ... the, the phrase throwing the baby out with the bathwater comes to mind. Yeah. But, but when you're using a one-size-fits-all approach, um, it seems like that, that would invite more problems like that. This is not to say, and I don't think you're trying to make the case that, oh, you know, everything is fine, and sometimes there may be cases where a child does need to be [00:07:00] removed. But, uh, I agree, it's, it's, it just seems extreme to, to make that the, the default setting. Oh, absolutely. Nobody e- ever... No, there, there's no denial of complete risk. I mean, and across child welfare, even outside of the substance use context, there's always a risk, right? And so how do we reason with that more efficiently and effectively? Uh, I, I wouldn't say that the government has all my answers when it comes to that, and what, you know, what is the best way to handle that. The people who are interacting closely with the family and can see, you know, the people who are the specialists, the social workers who went to school for these things and, you know, are specialized, we should lean on the specialists for these things. And when we don't, we, and we try to rely on this kind of centralized black-and-white version of things, there's disastrous consequences. I mean, even in the essence of this, you are co-opting hospitals with law enforcement. That is incredibly dangerous in the, uh, [00:08:00] when you think about how many people are going to avoid care in general, uh, when it comes to this, 'cause then they're going to be afraid of getting their kid taken away, even if they're on treatment, even if they're on a very legal, medically managed substance, they are not going to, to come forward and be, be trusting in the healthcare system. And so it's, uh, you know, when you think about the down- downhill effects of this behavior, it's, it's, it's quite extreme. So let's talk about, uh, the possibility of either, uh, changing some of these rules or reforming some of these rules. Um, I have to believe somebody in New Mexico is saying, "Hold up. There's, there's gotta be a better way to do this." Uh, do we have some people leading out on that? Uh, yeah, there are, there are some people leading out on that, for sure. I've been in contact with quite a few. Uh, and I personally am on the steering committee for United Family Advocates, and am in a lot of connection with, uh, Richard Wexler over at the National Coalition for Child Protection Reform, who, you know, every time [00:09:00] we, we, I put together an op-ed or something, you know, is very, very happy to send it out to his advocates in New Mexico. So there are people who are on this wave as well, you know, understanding the, the risks that come with, with treating this, uh, problem so superficially. And so that's, that's a positive. Are, is anyone listening to it at this point? No, uh, because there are also people on the opposite end of the spectrum who say any drug use is, uh, unacceptable, and we need to, the state needs to handle that. And, um, so the, it's, it's quite a sensitive area in public policy right now. You know, and it, it seems, uh, I, I've only visited New Mexico a few times, but, um, New Mexico seems, uh, you know, a fairly permissive state in the sense that, um, recreational marijuana, totally legal there. Um, you know, alcohol, much more available there than in, in other states. I mean, it's, it, it just, it just seems like what a, what an interesting mixed message, considering that on the one hand you have this [00:10:00] legal blessing, but on the other hand, here's a very black-and-white approach to, you know- How, how it's used, I guess Yeah, it's, it's really interesting, uh, when you take a look at the broader scheme of, y- you know, just are- different areas of public policy because when you get to things like child welfare and drugs, uh, those things get quite sticky. And, you know, people often chase, especially government officials often chase headlines over actual evidence, and, you know, we see that, that in this case right here. You know, uh, it's, it's very, um... It's, again, not, not really based in the evidence because, you know, you have so many other options here that should come theoretically before removal. But in this implementation, uh, rule-making process, they're sort of streamlining the pr- the way to get to removal because, you know, if you apply this plan of safe care to someone who doesn't really need [00:11:00] it and they don't comply, then they're gonna get their kid taken away. And so there's, like... It's, it's almost making the process easier, which in a way is also scary. Uh, but yeah, it's, it's, it's all about doing something about the issue, doing something. And it, and what's dangerous here is nobody's having a think about what the something should actually be. It shouldn't be just a Band-Aid. It should be actually if we're gonna spend time and effort in creating this really comprehensive approach to addressing the issue, then we should take a look at what's underneath the Band-Aid a little bit more and try to solve it from, from the root of the problem and not just continue to perpetuate these cycles of trauma and harm. Is it out of bounds to ask who benefits from this hard-line approach? Um, I mean, I think reasonable people would not want a, a child, particularly a baby, to be in harm's way. Um, that's reasonable. Yes, if there's, if there's, you know, harm, the child should be, you know, removed from the situation. However, this doesn't sound reasonable to me, and so I have to ask, uh, you know, [00:12:00] if it's supposed to be for the benefit of the child, I'm not sure... I'm not sure- Sure ... that, uh, they're really coming out on the winning end there. Well, this is, this is the, another really interesting aspect to this because when you read about, you know, uh, people who are kind of talking about the opposite side of this, these things, they also claim it's for the safety of the children. And it's also backwards because removal in itself has a lot of disastrous consequences for children. In the United States, w- 80% of children in foster care have significant mental health needs compared to 20% of the general population. And so these, these comes in for- th- this comes in the form of attachment issues, uh, you know, other anxiety, depression, and- When you remove a child, these, these issues are, are long-term. These are things they deal with for their entire life. And not to mention the mother also, because in these conversations, I think we also forget about the mother, who [00:13:00] also should be a significant part of this, this equation as well, who, uh, may turn back to substance use and c- uh, have considerable amounts of relapse from the trauma of the removal. And so there are other ways and more comprehensive ways that can keep families together, and obviously with the asterisk, in, in situations where it is possible and where it is feasible. Um, so it's... There are other ways, and there should be definitely more than one step in between the inter- or the investigation and removal. There should be more than one in between there to try and keep families together, because ultimately, those longitudinal risks should, should be taken into more consideration. I keep coming back to, to the incentives that you mentioned before. Um, if you know that there is the risk that, uh, even, even one, you know, uh, hot urine test is going to risk your child being removed, that could, that could be very powerful incentive for people not to [00:14:00] come forward in situations where really they could use some help. But, but it's, it's like, you know, killing a fly with a sledgehammer. They, they don't want that much help. Uh, yeah. I- it's, it's also turning away people, not only just from their general healthcare. So when we're talking about just, like, prenatal healthcare is super important for the health of the baby, right? If we're doing things for the kids, the prenatal, prenatal healthcare is important so that the kid is birthed health- in a healthy condition, you know. So these things are, uh, for the kids, prenatal healthcare is important. There's also medication-assisted treatment for use disorders. And so that is being swept into this same framework of, of rules and implementation. So the, the, the implementation aspect of all of these legal and medically guided medications are, are being lumped in with this, these illicit substances are also... [00:15:00] It's also kind of counterintuitive, right? Because what do you... How, how is that, uh... How, how are we equating those two things? You know, it's, it's, uh, there's a clear information gap here in the people that are designing these, these implementation rules, because one does not equal the other in any type of way, even when we talk about risk. So is it a done deal? I know that, uh, the oversight transfers, um, as of what, July 1st of this year, it goes to the Health Care Authority. But is, is the rulemaking done, or is there still time to, um, you know, to address the process and, and maybe make some adjustments? So at the point right now from what I know of, it's still proposed rules, so it's still pro- in a proposed kind of state. Uh, with the direction that the administration is going in, I am not super confident that it will turn the other way. I think this is pretty intentional given the act from the previous year. You know, they're switching kinda the whole [00:16:00] direction of how they're taking substance use policy and child welfare together. And so, um, there is theoretically time. Uh, is there going to be a shift? I think that's gonna be dependent on whether or not the administration wants to be amendable to evidence instead of this kinda headline-chasing, weird, superficial Band-Aid solution that they have. Okay, so for, for people, first of all, for people who wanna become better informed, are there any information resources you would point them toward? Secondly, for citizens or residents of New Mexico, um, who would they be best suited to contact if this is something that they feel like needs to be addressed? Sure. Sure. I would, um, point to, for people who wanna know more about child welfare, the National Coalition for Child Protective Reform is, is amazing, and they bring light to so many different aspects of child welfare and, and can really kinda challenge thinking on different, different realms of that. And, and as far as, you know, who to contact in New Mexico, I would go s- [00:17:00] I would go straight to your, to your administration. I would, I would call, I would send letters, I would email. You know, uh, th- these, these things are... it's... there's a clear knowledge gap, and there's... if you're, if you're connecting with these ideas and, and you think there, that there's room for change, I would, I would connect with them and, you know, look around your, your area if there's grassroots organizing, uh, going on or, or, you know, other non-profit organizations who kinda take this stance and, and you wanna support. I would also encourage that as well. If there's a discussion, uh, you know, at least some verbiage, at least some discussion around this issue, uh, it, it... I think education does, does, does a lot and, and the more that people are informed on, on the evidence and what, what we should be considering in situations like this, then, uh, you know, these processes will move forward. My guest is Layal Boo Harfoush, and, uh, she is a drug policy analyst at the Reason Foundation. Uh, for those who wanna follow your work, tell them where they can find you. Sure, yeah. So I'm on X @LayalBooHarfou- so [00:18:00] without the C-H. My name was too long to put as an X, uh, username. And, uh, yeah, I'm also on LinkedIn. Uh, same thing, Layal Boo Harfoush, so, uh, if you're, if you're on that platform as well. Thank you so much for being our guest today on the Health Policy Podcast.