U.S. DEPARTMENT OF HEALTH and HUMAN SERVICES

SUBSTANCE ABUSE and MENTAL HEALTH SERVICES ADMINISTRATION

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Friday

February 3, 2006

VOLUME II

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1 Choke Cherry Road

1st Floor Conference Room

Rockville, Maryland

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PARTICIPANTS

**Chairperson**

**H. Westley Clark, M.D., J.D., M.P.H.**

Director, Center for Substance Abuse Treatment/SAMHSA

Chair, CSAT National Advisory Council

**CSAT Staff**

**Cynthia A. Graham, M.S.**

**George Gilbert, J.D.**

**Council Members**

**Anita Bertrand, M.S.**

**Kenneth A. DeCherchio, M.S.W.**

**Melody M. Heaps, M.A.**

**Valera Jackson, M.S.**

**Chilo L. Madrid, Ph.D.**

**Frank McCorry, Ph.D.**

**Gregory E. Skipper, M.D., FASAM**

**Eugene White-Fish**

**Ex-Officio Members**

**Charles G. Curie, M.A., A.C.S.W.**

Administrator, SAMHSA

**Richard T. Suchinsky, M.D.**

**Presenters**

**Brenda Bruun**

Special Assistant to the Director, Division

of Prevention, Traumatic Stress and Special Programs

Center for Mental Health Services, SAMHSA

**Daniel Dodgen, Ph.D.**

Emergency Management Coordinator, SAMHSA

**Cheryl J. Gallagher, M.A.**

Public Health Advisor, Systems Improvement Branch

Division of Services Improvement, CSAT

**David Gustafson, Ph.D.**

Director, Network for the Improvement of Addiction

Treatment (NIATx)

PARTICIPANTS *(continued)*

**Anne M. Herron, M.S., C.R.C., CASAC, NCACII**

Director, Division of State and Community Assistance

Center for Substance Abuse Treatment, SAMHSA

**Kirk E. James, M.D.**

HIV/AIDS Coordinator and CSAT Participant

Protection Officer

Systems Improvement Branch

Division of Services Improvement

Center for Substance Abuse Treatment, SAMHSA

C O N T E N T S

[Page No.]{.underline}

**Methamphetamine**

Cheryl Gallagher, M.A. \...\...\...\...\...\...\...\...\..... 5

**Question-and-Answer Session** \...\...\...\...\...\...\...\.... 18

**CSAT\'s Strengthening Treatment Access and**

**Retention Program / Network for the Improvement**

**of Addiction Treatment (NIATx)**

David Gustafson, Ph.D. \...\...\...\...\...\...\...\...\.... 27

**Question-and-Answer Session** \...\...\...\...\...\...\...\.... 46

**SAMHSA\'s Response to Hurricanes Katrina and Rita**

Anne Herron, M.S., Daniel Dodgen, Ph.D.,

and Brenda Bruun \...\...\...\...\...\...\...\...\...\...\.... 59

**Question-and-Answer Session** \...\...\...\...\...\...\...\... 101

**Public Comment Session** \...\...\...\...\...\...\...\..... \[None\]

**HIV Rapid Testing**

Kirk E. James, M.D. \...\...\...\...\...\...\...\...\...\... 115

**Council Roundtable** \...\...\...\...\...\...\...\...\...\...\... 143

**Future Meeting Dates** \...\...\...\...\...\...\...\...\...\.... 157

**Adjournment** \...\...\...\...\...\...\...\...\...\...\...\...\....
162

P R O C E E D I N G S

\[9:10 a.m.\]

DR. CLARK: Welcome to the second and final day of the 45th meeting of
the CSAT National Advisory Council. The spread of methamphetamine across
the country has alarmed officials at local, state, and federal levels,
individuals in tribes within the tribal community, both within
reservations and off reservations. The increase of methamphetamine
production, trafficking, and use has created pressures on the criminal
justice system, child welfare, and the treatment systems.

Cheryl Gallagher, public health advisor in CSAT\'s Division of Services
Improvement, Systems Improvement Branch, is our first presenter today.
Cheryl will discuss CSAT\'s response to the methamphetamine problem.

Cheryl.

**Methamphetamine**

**Cheryl Gallagher, M.A.**

\[PowerPoint presentation.\]

MS. GALLAGHER: Thank you, Dr. Clark.

Good morning. Today, I\'m going to talk to you about methamphetamine and
our efforts here at CSAT regarding treatment. First, I would like to
introduce my colleague at CRAFFT who is working on methamphetamine
activities with me. He will be available for questions, as well as I
will, anytime.

As you know, and Dr. Clark just said, meth has recently had a lot of
media coverage. It is a powerful stimulant, and it is highly addictive.
We have had questions from Congress regarding what we are doing here at
SAMHSA to address this problem. Mr. Curie and Dr. Clark have testified
before Congress and have briefed congressional staff on numerous
occasions. Fortunately, we have been doing quite a lot here at CSAT, so
we have plenty of information to share.

Our first major effort was in 1998. General McAfree \[ph\] was bringing
attention to meth at ONDCP, and here at CSAT we were hearing from the
field that meth was a major problem in our western states and was
spreading eastward. Our response was to design a cooperative agreement
that addressed dependence on methamphetamine.

NIDA had identified that the Matrix model was an evidence-based
treatment protocol that was effective in treating cocaine and
methamphetamine. Matrix is a manualized protocol, and we wanted to see
if it could successfully be transferred to community treatment
providers. We also wanted to look at the existing treatment available in
the community.

We released a request for applicants, and in 1999, we funded seven study
sites and one coordinating center. The coordinating center was UCLA, and
Drs. Doug England and Richard Rossin were the principal investigators.
The seven study sites were located in California, Hawaii, and Montana.
All of the sites had been treating adults dependent on meth for a
minimum of two years. That means they had been treating two years, but
the people had to have been dependent for the most part seven and a half
years before they came to treatment for meth dependence.

The sites offered us a variety of populations. The Billings site had
Native Americans from the Crow Reservation. The Hawaii site had Native
Hawaiians and Pacific Islanders, and it was an all-women\'s program. The
Hayward site was a drug court population. San Mateo had two locations.
One was serving an Asian population and the other, at Pyramid, was
serving a rural clientele.

The project was successful and produced a lot of lessons learned about
knowledge transfer and about meth clients. The collaboration produced
several publications. One of the ongoing things that we had was a
website, methamphetamine.org. That is still up, and it describes the
project, and it had a lot of literature on up-to-date information on
methamphetamine.

Then the Journal of Psychoactive Drugs published a description of the
study and the sites in a special April/June issue in 2000. Lastly, the
Journal of Addiction published our outcome paper in June of 2004.

The good news was that the treatments that were offered both at the
Matrix and the \"treatments as usual\" at the sites provided clients
with recovery at the same rates as recovery from other drug dependence.
The \"treatment as usual\" protocols had many of the same elements as
the Matrix model, such as cognitive behavioral therapy, psychosocial
approaches, and motivational enhancements. So we weren\'t surprised that
they both looked like they worked, but they did work very well.

We had 978 clients in this study, and the site with the very best
results was the drug court site. So we were happy to see that, too.

We also, at the same time, published our TIP #33 and the Companion
Products Treatment for Stimulant Use Disorders. We participated on the
Interagency Taskforce on Methamphetamine that was sponsored by the
Department of Justice and ONDCP, and they had their final report
published in June of 2000. It is available online, and I have copies if
you would like that, too.

We collaborated with the State Department to provide technical
assistance to the Ministry of Public Health in Thailand on a Matrix
model. This was a direct result of the Methamphetamine Treatment Project
and the website. It was a psychiatrist working for the State Department
in Thailand who was looking for some kinds of information on meth
because they were having such a huge problem with methamphetamine in
Thailand. So he contacted Dr. Clark, and then the State Department
requested that we provide some technical assistance there.

So our people from the Matrix Institute on Addictions, from the UCLA
Coordinating Center, Dr. Clark, myself, and John Campbell went to
Thailand and provided them with assistance.

In the beginning, the program was supposed to be just one pilot study at
Tanurak \[ph\] Hospital in Bangkok, but after we were there for only a
week, they decided to expand to seven treatment providers in different
sites around Thailand. The next time that there was a meeting with the
Matrix people, they had included 12 mental health hospitals. At this
time, they have included all their regional hospitals in all of
Thailand, so that is 800 sites. So they really have a very extensive
rollout of the Matrix model there.

We also had a Comprehensive Community Treatment Program on behavioral
therapies for gay male stimulant users and alcohol users at the same
time. Steve Shoptaw \[ph\] was the principal investigator on that
program, and he took the Matrix manual and adapted it for that specific
population. So we have some information about that, too.

We also sponsored conferences. The first one was in 1998 in St. Louis.
It was a collaboration with our Target Cities project there. Missouri
was already seeing problems with methamphetamine in 1998 and was looking
for information, so we had a two-day conference there.

Then we had a conference in Hawaii that was connected to a town hall
meeting that was sponsored by their state legislature. We heard from
over 50 recovering clients and family members and got a lot of
information about what an intergenerational problem methamphetamine use
is in Honolulu. Kids would talk about how they couldn\'t go home at
Christmas because their parents were using, so they had to stay in the
treatment site. So there are lots of problems there, and we have been
addressing that.

We had a one-day meeting in Hollywood, California, that did address
stimulant use and the gay population. Then, San Mateo and Portland both
had conferences with over 500 participants. Portland had 500 registered,
but other people showed up at the end because people were calling them
and saying, \"This is a really good conference. You have to come down
here.\" So they opened the doors to the rooms where we had our breakout
sessions, and people stood in the halls to hear the presenters because
the information was so necessary to their area. I mean, Oregon has had a
lot of problems with methamphetamine.

Then, Billings had a conference scheduled for right after 9/11, so a lot
of people could not get there because there were no flights, et cetera.
But they decided to go ahead with the conference, and they had over 200
people drive to the conference and attend the meetings there. So the
Billings site was very helpful in keeping that going since we weren\'t
there.

Then, in \'03, we funded two sole source programs through our Targeted
Capacity Expansion: the County of Hawaii, Office of the Mayor in Hilo on
the big island of Hawaii, and the Ohio Department of Public Health,
which really continued a program that they had begun in a competitive
grant with TCE and were having very good results with.

Then, in \'04, we funded six competitive grants, and they were in urban
areas in California, Washington, Oregon, and Texas. Then, this year, in
\'05, we funded 11 new meth grants in rural areas. The rural areas are
really being hit by methamphetamine primarily because the labs could be
in rural areas without being detected as easily. So they have had a big
influx of meth use and they had not experienced this kind of thing
before, so they really needed some help treatment capacity. So they are
in Texas, Georgia, Oregon, California, New Mexico, Tennessee, and
Montana.

We also have family and juvenile treatment drug courts. They, of course,
do see a great number of meth clients. We have 41 active drug courts
that were funded in 2004 and 14 new ones that were funded in \'05. We
are encouraging all of those grantees to establish partnerships with
their Drug Endangered Children Programs in their local areas to address
the needs of children living in environments where meth is manufactured.

As I said, we had our best results with the drug court population and
the meth treatment study, and we believe that is because it is such an
incentive for people to get into treatment and to stay in treatment. The
judges really provide a lot of positive feedback to the clients, and it
is very helpful for them in maintaining their sobriety.

As you heard yesterday, Access to Recovery is a very extensive program
here. We have two states that have identified methamphetamine as their
specific target area, Tennessee and Wyoming. So we will be hearing from
them later how that is going and what they are finding with
methamphetamine.

Tennessee did have a lot of problems with the labs which probably
encouraged them to apply with this specific area. A lot of their
hospitals were treating people with burns. It was costing a lot of money
because people didn\'t have insurance, of course, and we did have some
people travel there from ONDCP and see the burn units. Of the 14 beds,
they were almost all filled with people that were recovering from burns
with methamphetamine.

We are also engaged in an interagency agreement with the Drug
Enforcement Agency, DEA, to provide funding for summits for the
governors on methamphetamine. These summits provide a venue for
developing strategic plans to address the meth problem in the community.
So we have already funded three in 2005 that have taken place,
Wisconsin, Georgia, and West Virginia. The next one will be in New York
and we think in April. I don\'t have the specific date yet. After that,
we are going to be following up with Virginia.

One Sky is our Alaska Native and American Indian national resource
center. They held a summit in 2005 to develop a strategy to address the
high incidence of methamphetamine on tribal lands. The dependence and
addiction on the Crow Reservation in Crow Agency, Montana, was the
specific target. They have a media campaign to educate the youth on
effects of meth. They have an assessment on the severity of meth on
tribal lands. They are working on coalition development for the tribal
communities, and they are coordinating interaction between the treatment
providers to try to maximize their treatment capacity.

Our ATTCs are doing a lot of work on methamphetamine. They are expanding
training activities, they are bringing empirically supported treatment
knowledge and meaningful training opportunities through clinicians in
methamphetamine-affected areas, and they are providing products on the
knowledge about meth to the public and to treatment providers.

We have 15 ATTCs. They all are doing something regarding
methamphetamines, so no matter what area of the country you are located
in there is an ATTC with programs available.

Two examples, though, are the Pacific Southwest Addiction Technology
Transfer Center, which has developed our digital training module, Meth
101, and Meth 102, produced by the Applied Behavioral Health Policy at
the University of Arizona. That is a very good product, and I would be
happy to share it with any of you. I have some copies in my office if
you would like to take a look at it.

The Prairielands ATTC sponsored training in Iowa on the history and
symptomatology of meth in October. They sponsored a presentation on best
practices in assessment and treatment at the Upper Plains Summer
Institute in Sioux Falls, South Dakota, in August. They are currently
working with Minnesota and North Dakota with the SSA directors on the
2006 training plan regarding methamphetamine.

Our Block Grant is working on methamphetamine, also. They are developing
flyers and informational sheets to share with the states as to what is
available for technical assistance. They are providing examples of
technical assistance that have been provided in the past to help people
think about what they need. They are encouraging all the states to
request TA.

They are planning two regional meetings, Methamphetamine Treatment:
Effective Approaches. The first will be in Los Angeles, California,
April 5th through 7th, and the second will be in Orlando, Florida, May
23rd through the 25th.

We also have a workgroup here at CSAT to address issues on
methamphetamine. We are currently working with IHS to help them with
their planning of methamphetamine meetings that are coming up this year
and to provide resources like speakers and other things like that,
perhaps even sponsoring some people going to the conference.

SAMHSA also has a Workgroup on Synthetic Drugs that is addressing
methamphetamine use, and we are going to be working with them more
extensively as time goes on. They are going to be working with ONDCP,
also.

We are collaborating with CDC on methamphetamine and infectious disease
and also with CSAP. The two centers and the agency are going to be
working together.

As I said, we have our TIP, which is a wonderful resource on treatment
protocols for stimulant use. It is very well received, and people really
give us a lot of good feedback on it, the KAP Keys and Quick Guides that
accompany it, and our Meth 101 and 102.

If you have questions, I would be happy to entertain them now, or you
can contact me later. You can also contact Ed Kraft if you would like.
His phone is 276-1571.

**Question-and-Answer Session**

So, any questions? Yes.

DR. MADRID: Do you have on file the different state legislative
directions that legislators have taken concerning methamphetamine, like
for example the control of pseudoephedrine and stuff like that?

MS. GALLAGHER: We have some of that. We don\'t have all of it, I don\'t
think, but we can get that for specific states whenever we want to. I
mean, that is not a difficult thing to come by. If you want me to get
that for you, I can do that.

DR. MADRID: I would appreciate it, because we are planning on doing some
of those things in Texas. We have already started in the last session,
but this session there is going to be a lot of emphasis on
methamphetamine legislation.

MS. GALLAGHER: Right.

DR. MADRID: I would like to see what other states are doing.

MS. GALLAGHER: A lot of states have put the pseudoephedrine behind the
counter, and it has helped in limiting the labs in their states.
However, it has not really affected treatment because we are having just
as many people present for treatment and go to the emergency room.

The purity of the drug that is coming from Mexico is greater than what
they were making in their own labs. So we are having problems with
overdose and things like that now, too. So it is not a cure, but it is a
help.

DR. MADRID: Thank you.

MS. GALLAGHER: Yes.

DR. McCORRY: What does the picture look like in terms of methamphetamine
use? Is it continuing to increase, or is it still kind of disseminated
across the country?

MS. GALLAGHER: It is disseminated across the country. It looks like it
is increasing. However, here at CSAT, across our whole discretionary
portfolio, we have only 5 percent of our population that uses
methamphetamine. The other drugs are still ahead of them. In specific
states, though, there are more treatments in emergency rooms for meth
than for cocaine or for heroin. So it depends on where you are, and it
is spreading to the east now.

DR. McCORRY: Is there a continued slow-but-steady increase in the number
of methamphetamine users?

MS. GALLAGHER: I would have to back and look to see if it has increased
because I have only gotten the recent studies on it.

Do you know, Dr. Clark?

DR. CLARK: The Household Survey data does not show an increase in the
prevalence. It does show an increase in the number of people dependent.
So the people who are using are dependent.

But again, the other issue, though, is that we still see a proliferation
of labs. We were just talking to Ken Johnson in Maine. They busted two
labs in the State of Maine. Last year, we had a meeting with the
attorneys general for the New England states, and they were reporting
beginning dealing with this issue, but ultimately the New England states
and the northeast states have a larger cocaine and heroin problem than,
say, the Great Midwest. So you may have reached saturation points due to
competing drugs and economic interests and drug dealers and drug wars
and that sort of thing.

DR. SKIPPER: Do you have any idea why the group that was treated within
the drug court did better than the others?

MS. GALLAGHER: Well, we think that it had a lot to do with the time in
treatment because they were required to stay a longer time and
methamphetamine does require time for the brain to heal. They were in
treatment longer, so that was one factor.

Also, we think that the incentives provided by the judge were very
helpful, that kind of motivation. Not only the negative incentives and
the sanctions, but also the rewards that they got. Just standing up and
saying, \"You did a great job\" when they did a great job. They had more
clean urines than any of the other groups, too, and they were tested
twice as often because the court tested them and they were also tested
clinically.

JUDGE WHITE-FISH: Eugene White-Fish here. Do you have any numbers
regarding the Native American population on this?

MS. GALLAGHER: No, I don\'t. I really would have to refer to the people
in our agency that deal with the Native populations. Love Foster-Horton
is working with One Sky. She is a resource, and George Samoya \[ph\]
could also help with that.

DR. CLARK: Our Household Survey data shows, in terms of prevalence rate
by population, Native Americans tend to be second only to whites in the
prevalence rate of using methamphetamine. Of course, there are more
whites than there are Native Americans, so the absolute numbers are
greater among the white population. But Hispanics and American Indians
tend to be following closely on the heels of white users.

The lowest population is African American, and the next-lowest
population is Asian, in prevalence rates.

MS. GALLAGHER: Yes.

MS. JACKSON: I guess, following the conversation, living in Florida, the
trend there is not particularly high for meth. Not to minimize it
because I think that it is definitely a huge issue in certain parts of
the population, but just in following the conversation, is there some
work that you are doing or that anybody is doing? You said it is
spreading to the east. I don\'t know if it is spreading.

We, meaning my agency, along with a coalition, had a prevention grant to
look at the meth use and to do some prevention in that area. We found
pockets, but we didn\'t find a huge prevalence at all. Is there a way to
look at this in a sort of pocketed way? Now, I know the judge has
indicated that among the Native Americans it is a huge problem. Maybe
you are already doing this, but is there a way to kind of focus, and we
are not prevention, but ultimately prevention to those areas?

MS. GALLAGHER: Well, I think that is part of the reason that we focused
this last GFA on rural areas. We saw that they were having problems and
didn\'t have any treatment capacity to deal with it. Also, I think that
the ATRs identified it as a major problem in their states or, in
Wyoming\'s case, in one county. They did focus their activity toward
that area.

DR. SKIPPER: Is there an inclusion of the prescription methamphetamines
in the analysis of this?

MS. GALLAGHER: It looks like if people use the prescription things like
Ritalin as appropriately prescribed there is no greater incidence of
people becoming addicted to methamphetamine when they are older or later
in life.

DR. SKIPPER: But I\'m talking about, are we including in the stats on
methamphetamine abuse those that are smart enough to get BlueCross to
pay for their supplies?

DR. CLARK: The Household Survey does that and the DON data do that, but
they appear to be a minority of the users. The Household Survey
apparently was never designed to differentiate between prescription
methamphetamine and illicit methamphetamine produced by labs. But again,
the data do show that that tends to be a minority.

We used to have the old ADAM data. They made efforts to differentiate.
So they are lumped together.

As Cheryl pointed out, the labs are diminishing. The DEA publishes lab
seizures, so you get to see, based on the number of labs seized, what
the prevalence rate is. You do have to do it from a targeted,
community-driven point of view.

If you look at the Tennessee prevalence rate, despite the fact that
Tennessee has an ATR for methamphetamine, the TEDS data show no
substantial increase in admissions in Tennessee because it does
statewide data estimates. The Household Survey shows no particular
increase in methamphetamine in Tennessee, yet Tennessee has an ATR on
methamphetamine.

It also has, to my knowledge, the only national registry of
methamphetamine offenders. Your name is now online. You can go in and
put the county in, and people\'s names pop up if they have been arrested
for methamphetamine. They are up there next to the child molesters and
the sexual predators. So Tennessee has taken a very aggressive posture,
which clearly means that the jurisdiction feels that it is a problem,
despite the fact that the state-based data from national estimates
don\'t show that there is a problem.

As Cheryl points out, we have to work in each and every jurisdiction in
terms of their perception of the issue and their ability to prioritize
the problems.

MS. GALLAGHER: Thank you.

DR. CLARK: Thank you, Cheryl.

\[Applause.\]

DR. CLARK: Our next presentation is going to be on CSAT\'s Strengthening
Treatment Access and Retention Program and The Network for the
Improvement of Addiction Treatment. We have invited Dr. David Gustafson,
director of The Network for the Improvement of Addiction Treatment,
NIATx, to present on CSAT\'s Strengthening Treatment Access and
Retention Program and The Network for the Improvement of Addiction
Treatment.

NIATx is a technical resource center that advances the use of process
improvement methods to improve client access and retention and
treatment. NIATx operates a pure learning collaborative for CSAT\'s STAR
grantees and the Paths to Recovery grantees funded by the Robert Wood
Johnson Foundation.

Dr. Gustafson chairs the board of the Health Institute. He is a fellow
of the Association for Health Services Research and a fellow of the
American Medical Informatics Association. He is also a past chair of the
Federal Science Panel on Interactive Communications in Health.

Dr. Gustafson.

**CSAT\'s Strengthening Treatment Access**

**and Retention Program/**

**Network for Improvement of Addiction Treatment**

**David Gustafson, Ph.D.**

\[PowerPoint presentation.\]

DR. GUSTAFSON: Thank you.

I appreciate the opportunity to be here. A few of you \-- Frank,
Richard, Westley \-- have heard a fair amount of this before, and so I
would appreciate if you don\'t snore in the process.

The Network for the Improvement of Addiction Treatment is a partnership
between two tremendous organizations, CSAT and the Robert Wood Johnson
Foundation. They started out as separate initiatives. One was called
STAR, Strengthening Access and Retention, which was funded by CSAT, and
the other was Paths to Recovery, which was funded by the Robert Wood
Johnson Foundation, but we soon began to merge those two activities
together and have been calling it The Network for Improvement of
Addiction Treatment.

During this presentation, I really want to make three points. The first
one is that there is a lot of opportunity to improve access and
retention in the area of addiction treatment.

Secondly, I hope that you will leave this conversation with a sense that
process improvement is an effective way to do that. Then the third is
that in order to really spread the idea of process improvement
throughout the field that state governments are key to that. One of
CSAT\'s new initiatives in that area, I think, holds tremendous promise
in terms of widespread diffusion.

I didn\'t put any numbers up here, but the picture, I think, tells a key
story. Of all the people who need care and addiction treatment, this is
the segment that aren\'t getting anything. Of the people who enter into
care, this is the number that complete treatment, while this is the
number that needs treatment.

Those statistics vary in terms of specificity, but that picture gets the
key point across that A) a lot of people are not getting into treatment
that need to be there; and B) many people never complete treatment that
should.

I\'m an engineer. When I entered into the privilege of leading this
particular program, I didn\'t know anything about addiction treatment.
So I got myself admitted for heroin addiction, and I went through the
process of waiting the six weeks to get into my intake and assessment. I
went through the three hours of interviews that took place in both New
York City and in Madison, Wisconsin. I created a fake persona in order
to be somewhat legitimate, although in the agencies that I went through
anybody I came in contact with knew I was a fake person and I was just
trying to understand what it was like.

But it was really an amazing experience, and I learned so much from it
about what addiction treatment is like and what it is like to try to get
into it.

The persona we had created led the people to conclude that I needed
in-patient care or residential care. They said, \"But we don\'t have a
bed for you. Why don\'t you call once a week and leave a message to tell
us whether you are still interested.\" That is literally what I did. I
would call. I would get an answering message that literally said,
\"Leave a message\" and nothing else. It didn\'t even say the name of
the organization. I called once a week for seven weeks, leaving a
message but never receiving any indication of whether I was moving up
the priority list, whether things were getting closer to admission.

Finally, after seven weeks, they called me and said, \"Well, we have a
bed for you. Why don\'t you come in.\" When I came in, the first message
that I got from a person who greeted me at the door was, \"You know, you
didn\'t call in Week 5.\" Those were the first words she said to me. So
from that I got this sense that if I really were a heroin addict it
would be hard to continue on in treatment in that kind of vein.

As I got further into understanding what it is like in this field, I
began to develop an incredible respect for the people who work here. I
mean, given the low level of pay, you can understand the high turnover
rate, but it is just amazing how committed they are to caring for
people.

But what happens is that in between those caring people and those people
who desperately need help is this enormous gap of business processes,
things that can get in the way, ranging from what happens during first
contact to what happens during intake and assessment or what happens in
the transition between levels of care or the paperwork or the scheduling
or the therapeutic engagement. Those nine things that you see up on the
right-hand side there are the things that are the targets of NIATx, the
kind of processes that we are trying to improve.

\"Process Improvement\" is one of several names that characterize this
particular area. Other names include things like \"Quality Improvement\"
or \"Total Quality Management\" or things like that. But they have been
used in many industries around the world. Harley Davidson Motorcycles
and Toyota are organizations that have used it, and there has been a lot
of use of it more recently in health care through an organization called
the Institute of Health Care Improvement. When this initiative started,
it started with the idea that these kinds of strategies or approaches
could make a difference.

One of the key elements in process improvement is to be really specific
about what you are trying to accomplish and not have a bunch of
different directions that you want to focus on. So we are only
interested in four things in this activity. One of them is to reduce the
amount of time it takes to get into treatment. The second is to reduce
the number of people who don\'t show for their appointments for
assessment. The third is to increase admissions without increasing cost.
The fourth is to increase the number of people who stay in treatment.

That\'s it. Nothing else. Those are the four things that we are
interested in doing. Nothing more than that.

The NIATx activity is built around some research that has been done
where a number of researchers have compared successful organizations,
organizations that have a reputation for being innovative, against
organizations in their industry that don\'t have that reputation to try
to figure out what the factors are that distinguish between those
successful and unsuccessful organizations.

Only five things stand out. The five things that stand out are, first,
to be obsessed with understanding who your customer is, what your
customer needs, and how your customer makes their buying decisions.
Anytime that one of our organizations moves into a new process
improvement activity, we ask them to do a walk-through, like I did, to
experience what it is like to be their customers. We ask them to assume
that they don\'t have the foggiest idea what it is like to be a customer
of their organization.

Now, in addiction treatment that can be tough because a number of people
in this field of course are previous patients. So they have the right to
assume that they know what it is like, but we really push the idea of
every time they move into this area they do a new walk-through to
understand what it is like to be a patient.

The second thing is that the only kind of problems that people should
attack should be problems that, if solved, would help the CEO sleep
better at night. So they have to be very careful about selecting
problems that are right close to the agenda of the CEO and the
organization.

The third thing is that the change leader, the person who is running the
process improvement activity, should know the telephone number of the
CEO by heart, should feel comfortable in calling at five o\'clock in the
afternoon on a Sunday, and should be highly respected in the
organization. We want powerful change leaders in this activity.

The fourth is that it is very important that their search for ideas for
improvement reach beyond the boundaries of the organization into other
organizations and even into another field, like the cement industry. The
idea is that the further that you get from the boundaries of your own
organization, the more likely you are to come up with innovative
solutions to a problem.

The fifth is a mantra that we keep on pushing, and that is
organizational change is easy, it is not hard. Organizational change can
be made overnight, so get over the idea that it is a hard thing to do.
Just get out there and say to yourself, \"Monday morning, what can we
change? Now let\'s try it with a few patients.\"

When it doesn\'t work, figure out why it didn\'t work. Make it a little
bit better. Try it again with a few more patients. Try it again with a
few more patients. Do this rapid-cycle testing to get results, but get
over the idea that change is hard because it isn\'t. That focus is
something that we keep on beating into people.

NIATx is a membership organization now funded by RWJ and CSAT that
includes 44 organizations around the country. Don\'t worry about the
colors of the dots. It just is an indicator of the time when these
agencies entered into the program. It makes no other difference.

Those cute circle pictures that are there are the state agencies that
have been involved in pilot testing kind of activities. The dots are the
44 treatment organizations.

When you look at results of change, of course, one of the things that
you have to look at is what changes have been made and what are the
results of them, and then secondly, have those changes been sustained.
The results I\'m about to present to you are what changes have been made
in tests, and the issue of whether they will be sustained for another
year or two years is a very important question that we will be
examining. But for right now, we are talking about changes that have
taken place.

Thirty-seven change projects attempting to reduce waiting times in 24
treatment agencies, a 51 percent reduction. One of the things, for
example, that agencies have done is they have just dropped the idea of
making appointments. Very often, when we did site visits of treatment
organizations and we would look down their appointment books, what we
would see is all the slots filled up and then a line crossed through it,
\"No show.\" Another line crossed through it, \"Canceled.\" \"No show,\"
\"canceled,\" to the point that when you would look at these appointment
books you would find 40 percent were actually completed and about 60
percent ended up being empty slots where there was no opportunity for
productivity.

So what we are encouraging is a process of open access that says get rid
of these appointments. Just let people come in. Make room for them. It
has had a dramatic effect.

The second area is the area of reducing no-shows. Twenty-eight projects
in 21 agencies, 41 percent reduction on average in the number of people
who don\'t show for treatment. A lot of different approaches have been
taken, but one of them is to make follow-up calls to ask, \"Why didn\'t
you come?\" What kind of barriers were there. Figure out with the person
how to remove those barriers. Tell them that they are wanted, which
seems to be a big deal, and remind them of their appointment.

A 56 percent increase in admissions. One of these things is due to just
the transition of patients between detox and out-patient, where what you
do is try to reduce the fear and increase the recognition of how
important that next level of care is. So getting people to attend,
maybe, some early meetings of the next level of care down, maybe
starting a client in out-patient treatment while they are still in
residential detox. One agency\'s transfer rate has increased by 247
percent, but overall it is a 56 percent increase.

Then, increasing continuation. There are a lot of different activities
that have been engaged in doing that, but fundamentally one of the more
exciting ones is to take this idea of rapid-cycle improvement that has
been so successful in organizational change and get the patients
themselves to start thinking about that, thinking about what they can do
tomorrow. What is the most important thing that they can do tomorrow to
change their lives. Try it out, see whether it works, fix it, see
whether it works a little better, fix it, see whether it works a little
better.

Let me give you a specific experience. Bridge House is a treatment
agency in New Orleans, or at least it was until the hurricanes. It was
pretty much destroyed, and it is trying to get back on its feet right
now. It was a long-term residential facility for indigent and homeless
males with 130 beds. It was pretty much self-funded. They sold used
cars, they had thrift stores, and that kind of stuff to keep going. This
field amazes me in terms of their creativity in how to fund some of
their work.

Their goal was really to try and increase the continuation rate. They
had a continuation rate that was running about 53 percent when the
project started. They wanted to see if they could get it up to closer to
75 percent. They tried both administrative changes and clinical changes.

An administrative change was that their counselors had hours that went
from noon until 8:00 at night. While that was a heck of a lot better
than you see in a lot of places, where it is an 8:00 to 5:00 operation,
the staff had this pretty clear indication that if they stayed a little
bit longer that they might get a higher rate of people coming because it
was just difficult in many cases for these people to make it.

So one of the changes they made was to change the hours from noon to
8:00, to 2:00 to 10:00. As it turned out, then what they would do is
they measured the amount of time that was spent by counselors with
clients and found that it increased eight hours a week. Strangely
enough, the counselors and the patients were really happy.

On the clinical side, an example of the rapid-cycle improvement thing.
Their initial intent was to use motivational enhancement therapy to
increase their engagement with clients. The way they tried to do it was,
after some training, to create this reminder card that said things like,
\"On a scale from one to ten, how willing would you be to stay at Bridge
House?\" Or, \"If you are a seven, why are you not a six,\" or \"Why are
you not a five? What would it take to move you to a nine?\", and so on
like that. Then they did some reflective summarizing of what the patient
had said, and so on.

They created these cards after the training in hopes that it would help
the counselors in these interactions. It didn\'t seem to make much of a
difference, and so they said, \"Well, what is going on here?\" One of
the counselors said, \"Well, these cards that you have given us are way
too big. We can\'t carry them around. They aren\'t all that useful.\" So
they made the cards smaller and tried it again. Still no impact.

Then what they did was they sat back and said, \"Well, what is really
going on here?\" The staff said, \"You know, what we really need to do
is a lot more thinking about high-risk patients. We know who the
high-risk patients are, but we really haven\'t got a strategy for
thinking about how to deal with them.\"

So they initiated a weekly continuation staff meeting where they talked
about the high-risk clients and how they could tailor interventions to
them, and the continuation rate increased to 84 percent of people who
would stay at least 30 days in treatment. So they adopted that. It
turned out to be something that they liked.

So that is an example of the kind of changes. As you can tell, process
improvement is not rocket science. It is not one of these things where
we try to do really fancy kinds of stuff. What we are looking for are
those opportunities to make really simple changes that can dramatically
improve the lives of patients and the efficiency and effectiveness of
organizations.

In Bridge House, you can see what has happened over a period of time to
their continuation rate. If you look at the bed utilization rate, the
red line in this picture, you can see a dramatic improvement. Before,
they were running a 30- or 40 percent utilization rate. I\'m sorry. If
you look on the right-hand side they were running a 80- to 85 percent
utilization rate. They are up close to 100 \[percent\] now, or they were
before.

So I could give you many different examples of changes, but that gives
you an example of some of them. Overall, I think the project has been
incredibly successful. For that reason, then, CSAT and RWJ began to fund
a few quick pilot projects where we would ask ourselves the question,
\"What would happen if we engaged states as a primary vehicle for
facilitating or promoting the use of process improvement?\"

One of the things that we are saying here is that NIATx can work
directly with the treatment providers, but one of the things that they
can do is work with the state so that the state can improve their own
processes and so the state can create incentives that will make it in
the best interest of organizations to improve their own treatment.

So the idea behind the state project is to not only work with treatment
agencies directly but work through the state to get the states to work
on things that can be done. So what we have done is summarized on this
chart. I just said it, though.

So, in these pilot projects, what we asked states to do was to select a
particular aim, like continuation, and then partner with three to six
health care addiction treatment providers and pick particular process
targets and then quickly test those things.

Some examples. In Iowa, the single state agency acted as a convener and
used a thing that in industrial engineering we call supply chain
management. All supply chain management really is, is trying to
understand what happens as a patient flows through different parts of a
treatment system and try to figure out where the barriers to efficiency
are.

What happened was that, in Iowa, they brought together providers in the
City of Des Moines and they acted as a convener to think through these
processes and figure out what was causing increases in long waiting
times. As a result of that, on the average in the City of Des Moines,
these waiting times now have been reduced 38 percent.

North Carolina realized that one of their eligibility requirements
eliminated the opportunity for 5 percent of the detox patients to even
move to another level of care, even if they wanted to. So they changed
those eligibility requirements.

In Oklahoma, they just said the eligibility determination requirements
will be just eliminated for high-performing sites. They went back and
they looked at organizations that were great at when they said, \"We
think our patient is eligible,\" they were always right. So the state
said, for those organizations that have been very effective in
eligibility determination in the past, we are not going to do any
follow-up screening at all. The wait between first contact at a
treatment agency and treatment reduced from 30 days to three days. They
also reduced duplicative paperwork and cut down on the admissions time.

So, as a result of all of the pilot projects that CSAT was engaged in,
the conclusion was reached that this had merit and that there was
tremendous opportunity for states to really make a difference in this
area. As a result of that, CSAT has now initiated a new activity called
STAR-SI. I don\'t know the exact term for them, but you know when you
publish this thing that says, \"Hey, there is an opportunity to get
money from us\"? Whatever that thing is, it is now published. So they
are about ready to go.

I\'m big on labels. It is just my brain doesn\'t work that way. Forgive
me.

The final thing that I will mention very quickly is that NIATx provides
a number of different kinds of services to organizations. Three of those
services are, we try to get people to face-to-face to learn from each
other twice a year. We have found that to be very effective because in
reality the agencies learn so much by talking to each other. But also,
those learning sessions act as an incentive to get organizations to
really move ahead on improvement.

There are all-member calls once a month. There are also intra-circle
calls for people who are interested, for instance, in any of those
topics below. There would be a sustainability intra-circle call where
they call each other once a month and learn what each other is doing and
how they got over problems, et cetera.

Then there is coaching, where we send out process improvement coaches to
work with individual organizations. We have a website, which I would
encourage you to take a look at. It is called NIATx.net. On that, you
will see all sorts of case studies of how this thing works, and you will
see reports from the field of new changes that are taking place. You
will see various kinds of tools that we have made available to these
folks that they can use in their treatment agencies, and you will see
articles that have been published on this.

I hope that as a result of this talk you will leave with three thoughts.
One, I\'m sure you know already, and that is access and retention need
to be improved. The second is that process improvement works, and the
third is that the states are a key player in making this thing happen.

Thank you for your time.

\[Applause.\]

**Question-and-Answer Session**

DR. GUSTAFSON: Yes.

DR. MADRID: I have two questions. Have you all done any work concerning
standardizing eligibility and payer of last resort requirements for
multi-funded programs, as in, for example, a youth program? I am funded
by three HMOs that look at Medicaid very differently, one state
contract, one foundation contract, and two private insurance agencies,
and I\'m having to cater to five or six eligibility requirements as I am
bringing in the clients for treatment.

DR. GUSTAFSON: I can see we have an opportunity to help you sleep at
night. It must be incredibly frustrating.

The only thing that we have done so far is that in one of those state
pilots we have worked with the SSA and Medicaid to try to come up with a
uniform set of paperwork to at least make those two particular
initiatives more consistent. That has resulted in some real positive
feelings on the part of the providers, as you can imagine.

We will soon be having a joint meeting sponsored by RWJ and CSAT where
we are going to be bringing together managed care providers to take a
look at the potential for an initiative in that area. We haven\'t done
it yet and I don\'t know how well it will work, but certainly that is on
the radar screen as something that really needs to happen. I think it
would make a big difference if we could.

DR. MADRID: My last question is, have you done studies on the time we
are taking to do paperwork versus the time we are actually delivering
service and how success ties into these two things?

DR. GUSTAFSON: Well, one of the things that NIATx tends to avoid in
general is a lot of studies. We emphasize getting in there and making
change, collecting as little information as you possibly can to
determine whether or not the change was successful.

So while the other half of my life is running a center of excellence for
the National Cancer Institute where it is all research, on this side
what we are into is much more just promoting change. So we know that is
a problem area, but we have made no attempt to document it in any formal
fashion. It is just not what we do in this particular kind of an
initiative. It is an important question, but it is not one that we have
attempted to answer.

Yes?

MS. JACKSON: Thank you very much. I really found that to be a
stimulating presentation and one that is right on for most of us who are
operating and working to help operate centers across the country. Of
course, there is a huge national problem of access and retention, so
thank you very much for that, first of all.

DR. GUSTAFSON: Thank you.

MS. JACKSON: You didn\'t mention whether or not you were just looking at
adults or whether you have adolescents in your mix. Are you looking at
adolescents? As we all know, adolescent treatment is a challenge for all
of us. We certainly have it. I\'m from Miami and represent some of
Florida. So, how are you working with the adolescents?

DR. GUSTAFSON: We actually have treatment programs that cover all sorts
of different focuses. One program, the Perinatal Treatment Center,
treats young pregnant women who have drug problems, for instance. We
have a number of women\'s-only programs in the activity. So it is
certainly not all adult programs.

One of the things that you will find is that a number of these
intra-circle calls that I have mentioned are for organizations that have
an affinity with each other because of the type of patients that they
work with.

Fran?

MS. COTTER: In terms of the STAR-SI, there are none that are
specifically targeting adolescents. I have been in touch with Mandy
Moxley \[ph\], who has been working with a number of the adolescent
treatment program sites trying to bring some of the progress
improvements in.

DR. GUSTAFSON: Yes?

MS. BERTRAND: Thank you for sharing this morning. It is very informative
and very important, I think, to our profession to look at our system and
what it is like to access the system. It is just an important issue.

DR. GUSTAFSON: Thank you.

MS. BERTRAND: Thank you, also, for including the state in that process.
I was thinking about sometimes there are regulations that are in place
and we want them to encourage individuals to access the system and not
deter them. So, I guess I would like to know what information you have
along those lines.

Also, within organizations that you studied or looked at, did you find
that there were similar or the same types of barriers, or were they
different among the organizations?

DR. GUSTAFSON: As far as the paperwork procedures, a couple of really
interesting things have happened. Certainly, paperwork is a big deal.
During my admission, just to go back to that as an example of this, I
was interviewed, as I said, for several hours where they collected data.
I think they probably collected data on the ASI or one of those kinds of
fancy things that are collected.

Then I went to the staffing where the professionals got together to
figure out what to do with me. The person who interviewed me didn\'t
show up at that meeting. What she did was she sent a description of what
she had learned in the interview, and it was that much, handwritten on
the back of a piece of paper. That\'s all. Out of all that data that had
been collected, the decision about what would happen to me was based on
that much information. All that other paperwork was simply done to
satisfy a regulation and never had any influence on what would happen to
me in treatment. So the issue of paperwork is a big, big deal.

One of the states decided to take on paperwork as an issue to take a
look at. It was fascinating because the providers got together with the
state and said, \"Why do you require this?\" and the state said, \"We
don\'t require that.\" The agency said, \"Well, sure you do,\" and they
said, \"No, no, we have never required that.\" What happened was that as
they looked back, somehow or another the treatment agency began to add
stuff that they thought was required but never was as part of the
treatment process.

So not only were there simplifications that took place in the state but
also in the treatment agencies in terms of the paperwork. We are just
getting started on that, but it is an important thing.

Now, at my age, you can\'t possibly expect me to remember a two-part
question.

\[Laughter.\]

DR. GUSTAFSON: So we will test you and see whether you do.

MS. BERTRAND: We had a conversation similar to this this morning about
continuing to have the dialogue from the community base versus the state
level and how important that is. So we talked about this council and how
we are really happy to be a diverse group that can share these kinds of
things.

The second part was, do you find that the barriers are very similar from
agency to agency or are there things that are different?

DR. GUSTAFSON: There is a lot of similarity in what you can learn.
Obviously, from state to state there are different reimbursement
policies that influence the business case for making changes of one type
or another. The motorcycle manufacturers face the same problems. I think
that one of the challenges for a field like addiction treatment to get
over is the idea that we are different. Yes, we are different; there is
no question about it. But the opportunities to learn from other fields
are enormous. That is one of the things that we encourage.

Ken, you hand your hand up.

MR. DeCERCHIO: Hi, Dave. Good morning. Just real quickly, I want to
compliment you and CSAT for this whole initiative. In the context of
national outcome measures, state outcome measures, provider performance,
this is kind of the golden thread of performance improvement all aligned
together. In the absence of this, we have measurements without
opportunities for improvement.

This is exciting. You and SAMHSA and CSAT are really to be commended for
providing the opportunities that you have been providing.

We have two providers participating in this, and they are just excited
because it is not adopting a model program and it is not doing intensive
staff training. It is working within their processes to improve their
processes. So it is specific to their agencies and it cuts to the heart
of it. We are excited as a state, and I think states are excited,
because it is that link between what we try to measure and how we link
what we do as purchasers with performance. Without that link of process
improvement, it is a crap shoot. It is a crap shoot about, \"Gee, try
this. What works?\"

I think this is cutting edge, and I think this will go a long way to
providing that link between what we are trying to measure at a national
level, at a state level, and what providers are trying to do to improve
services. It is great work.

DR. GUSTAFSON: Thank you, Ken. I appreciate it.

Fran, you had your hand up just a second ago. Did you want to elaborate?

MS. COTTER: On the basis of the last three years, we have now compiled
empirically the data from our network on five promising practices that
have been identified for each of our four aims. Just take a look at your
packet when you have a chance. We are beginning to try to look
cross-cutting across our treatment organizations.

DR. GUSTAFSON: Yes, sir.

DR. SKIPPER: Great work. I have worked with a number of for-profit
treatment programs, all the way down to \-- I guess I shouldn\'t say
\"up and down,\" but it seems like for-profit programs are in the
business of looking at this because they have the motivation to make a
profit. I\'m wondering if the programs that want you to help them \--
this would just be a question \-- are the ones that would change
positively anyway. The ones that aren\'t interested in this are the real
problem.

For example, I worked with Kaiser Permanente in the Northwest looking at
outcomes. They actually were setting up barriers on purpose in a sense
because it improved their outcomes. They established a requirement for
six hours of attendance at meetings for entering treatment, and they
found that that improved their outcomes, really because they screened
out the ones that wouldn\'t endure that.

The thing with Chilo where different HMOs have different requirements, I
think they really want to put up barriers. So you have apathy and people
that really want to have barriers. What would you say about that?

DR. GUSTAFSON: First, another key philosophical perspective on NIATx is
that we make it hard to get in and easy to get out. We try to be very
selective in terms of the organizations. For instance, in some of our
work, we, as a requirement for entry, require that they have to make a
change in their organization within a short period of time. There is no
question that there is a heavy selection barrier.

The hypothesis or big question built around STAR-SI is, what happens now
when you try to widely disseminate. But also, in terms of this key
picture, how are we going to make it in the best interest of
organizations to want to improve their efficiency and effectiveness. One
of the key elements in this is making sure that people understand how to
look at the business case behind making these improvements.

Of course, a business case depends on the way in which reimbursement
takes place, but we have had organizations improve their contribution to
margin by as much as \$1 million a year based simply on getting rid of
these appointments and saying, \"You all come.\" So the business case is
a really key element in the way in which we approach this.

As far as the barriers that are constructed, they are certainly
constructed. There is no question about that. I wish I could solve that
problem for you, but I can\'t. At least not today. That might be another
project, but it is a really, really tough one.

DR. CLARK: Any more questions?

\[No response.\]

DR. CLARK: All right. Thanks to you for \--

\[Applause.\]

DR. CLARK: We have certainly benefitted from the information that you
shared.

We have a few minutes before we start the next component. We can take a
10-minute break. Please return. We have presenters at 10:30.

\[Break.\]

DR. CLARK: If we could reconvene. Thank you very much.

To discuss SAMHSA\'s Response to Hurricanes Katrina, Rita, and Wilma, we
have invited three knowledgeable members of SAMHSA\'s staff. Dr. Daniel
Dodgen is SAMHSA\'s emergency management coordinator.

Brenda Bruun is the special assistant to the director, Division of
Prevention, Traumatic Stress, and Special Programs in the Center for
Mental Health Services. Brenda most recently served as the incident
commander for the SAMHSA Emergency Response Center, otherwise known as
the SERC. The SERC was responsible for coordinating all of the relief
activities of the agency.

Anne Herron is the director of CSAT\'s Division of State and Community
Assistance. Anne has been deployed to the Gulf Coast states to aid
SAMHSA\'s hurricane relief efforts. She went at least twice. Three
times; that is what I thought. Every time these people disappear,
somebody has to pick up the slack.

\[Laughter.\]

DR. CLARK: Dan, Brenda, and Anne.

**SAMHSA\'s Response to Hurricanes Katrina and Rita**

**Anne Herron, M.S., C.R.C., Daniel Dodgen, Ph.D.,**

**and Brenda Bruun**

MS. HERRON: Thank you, Dr. Clark.

We wanted to start out our presentation for you this morning with
something a little bit different. We have received a slide show that was
created in the State of Mississippi that we thought might very
effectively set the tone and provide a focus for you. So with that, we
would like to, very shortly, just show you a short slide show.

\[Slide Show.\]

MS. HERRON: We wanted to show you that because we wanted to reinforce
what was down there. This project and this initiative from SAMHSA has
really deeply affected all of us, and we just wanted to start out by
letting you know that.

Let me turn it over now to Dr. Dan Dodgen to talk a little bit about
what the SAMHSA approach is and what our agency is up to.

DR. DODGEN: Thanks.

Good morning. It is certainly a very, very powerful set of pictures. I
think it does really help frame what it is that we are talking about and
why it is so incredibly important that we are doing the work that we are
doing, that we continue it, and that we do our very best to continue to
improve what we have already been doing.

Before I go any further, I did just want to take a moment and pause to
recognize and to remember the incredible work that Dr. Sheila Harmison
did throughout not just the Katrina response but throughout the time
certainly that I have been at SAMHSA and, long before that, in
participating in the Disaster Readiness and Response Matrix. I am the
Matrix staff lead for that area and have been here close to three years
doing that.

Sheila, from the very first time that I got here, was always the CSAT
person and was always the one not only working hard on these issues but
also constantly reminding us of the importance of substance abuse issues
in an integrated SAMHSA response to any kind of disaster, as well as
integrating it into planning and preparedness.

So I do just want to acknowledge the very, very important work that
Sheila did and the legacy that she has left by really making substance
abuse more fully integrated into the work that SAMHSA does in disaster
preparedness and response.

What I\'m going to do today is talk very briefly with you about the
kinds of things that SAMHSA does really from a bird\'s eye view. I want
you to understand from a federal perspective how disaster response
works, what the big picture is, and how SAMHSA fits into that picture.
If you can see that a little bit, I think it will make it easier, then,
for you to appreciate the incredible work that we have done and the
information that the two other speakers, Brenda and Anne, will be
providing to you.

How many folks have heard of the National Response Plan? Does it sound
vaguely familiar? A couple of folks have. The National Response Plan is
the plan that governs the federal response to any disaster event.
Typically, it is when there is a presidential declaration of disaster,
but there are certain kinds of events that would invoke the National
Response Plan even without a disaster declaration. For example, a
pandemic influenza outbreak in the states would invoke parts of this
plan even in the absence of a presidential declaration.

But this is the big picture. This is what governs what all federal
agencies do. It is invoked as soon as two or more federal departments
request assistance from the states.

Now, there are a couple of things that happen when the National Response
Plan is invoked. One of those is that this Intergovernmental Management
Group, the IIMG, is established, and the IIMG is comprised of senior
representatives of all of the federal departments. The idea is if you
put everybody in one room, decisionmaking happens more quickly and more
efficiently.

One of the comments that I would make about that that will be of
interest to all of you is, each department in theory has one seat at the
table. For the first time ever, HHS asked if we could have a second
person and that that person would be a SAMHSA person to address
substance abuse and mental health issues. They were recognizing even
very early on in the response how important that was.

What SAMHSA did was we arranged to have two senior SAMHSA people
available on call at any time to the IIMG because we didn\'t have
somebody that we could send to just be in that seat 24 hours a day, but
we so appreciated that the Department and, de facto, the national
government recognized the importance of our issues and did that.

So that is part of the National Response Plan. Another very, very key
factor in the National Response Plan is that it codifies an incident
command structure. An incident command is something that Brenda will
talk, probably, a little bit about in a minute. It is the structure that
governs how we work in a disaster response. It is very prescribed.
Somebody is in charge and has to make the decisions on how the lines of
command work.

That is very, very important because as you can imagine, in a disaster,
you can\'t have people second-guessing. You can\'t have people saying,
\"Well, yes, I know you are in charge of this disaster, but you are not
my regular boss and I don\'t really have to answer to you,\" whatever
things might happen. It would be another disaster if we had those kinds
of things happening.

So part of this incident command structure is really to establish what
the lines of command are so that things can work better. If there are
any knowing smiles around the room, clearly this is something that we
need to continue to work on because, although people understand it in
theory, it is not something that everyone in the federal government
necessarily has a lot of practice with. We still need to learn better
how to do it, but it is certainly in there.

Also in the National Response Plan, of course, are the roles and
responsibilities of different federal agencies and departments. Now, the
ones that are going to be most important to us are the ones that I put
on this slide.

The ESFs, Emergency Support Functions. There are 15 all together. The
ones that SAMHSA is most apt to be involved in are No. 6, which is the
mass care. The Red Cross is actually the lead for that one, but as we
know, in Red Cross shelters, which are ESF6 functions, very often there
are people who were already clients of the systems that we are
responsible for now in shelters. One of the things, of course, that is
part of working with ESF6 is how do we support the shelter activities
and still maintain the services that are needed for people with mental
health and substance abuse concerns.

No. 8 is really the one that Department of Health and Human Services is
most directly responsible for. They are the lead agency. It is public
health and medical. We worked very, very hard, and I was at many, many,
many meetings, to make sure that public health and medical was defined
to include substance abuse and mental health issues, which it previously
had not.

No. 14 is the long-term community recovery and mitigation. In theory,
ESF14 should be in the lead right now. Many of those pictures you saw,
sadly, could have been taken on August 30th or January 30th. As a
result, the distinction between the response phase and the recovery
phase has been much more difficult to determine in this disaster than in
many others simply because of the long response phase.

I think one of the things that we clearly are seeing at a national level
is this ESF14 is really not discrete from the other 14 ESFs. I think one
of the things that we are really seeing now is that we need to put a lot
more public health, transportation, small business, and all the other
things into ESF14. I think the fact that they have been discrete has not
served us well in this disaster, but it certainly is a lesson learned.

Then, of course, ESF15, external affairs, is also one that SAMHSA has a
role in, because this is really about how you communicate with the
public. Clearly, there are important psychological, mental health, and
substance abuse issues that need to be part of public communication
strategies.

Now, where does SAMHSA fit in all this. Well, of course, one of our key
roles is in the work that we do with FEMA and the ARFs, which are the
Action Request Forms. MAs, Mission Assignments. ESFs; of course, you now
know what that is. We will have a quiz in five minutes.

The mission assignment process is sometimes a long and convoluted one.
Of course, Ken knows all about this. The state says, \"We need 100
mental health and substance abuse workers to come down to help
Louisiana, and here is what we think they should do.\" So they fill out
an ARF. Then FEMA looks at it and says, \"Okay, that makes sense. We
ought to do that. Who can fill it?\" Then they call SAMHSA and they say,
\"Can you do that? Is this reasonable? What do you think?\" Then we say,
\"Yes. Here is what it would cost,\" and whatever.

There is a give and take, but it is a long process, often very iterative
with a lot of back and forth. It really depends on the nature of the
request and the ability to help whoever it is that ultimately is making
the decision at FEMA understand the importance of mental health and
substance abuse issues. Some people get it instantly and some don\'t.
There probably isn\'t a person in this entire room that doesn\'t know
what I\'m talking about when I talk about the fact that some get it
immediately and some don\'t.

So there is a lot of deconflicting. That is a term that you see a lot
of. I know Brenda is sick of me using the term, but it is such a big
part of what we do. Often you get conflicting sources of information and
conflicting pieces of information about almost everything in a disaster.
That is just the nature of it. Everybody sees their little piece of the
elephant, but very few people see the whole elephant. As a consequence,
things can get very confusing.

So a lot of this process is also just figuring out what is really the
need, who is requesting it, and how can we best help.

SAMHSA\'s accomplishments in this area are amazing. We have never before
used the mission assignment process. As you will hear from Brenda, we
did and are continuing to do an amazing job not only because of the
leadership of folks like Brenda and Anne, and Ann Matthews and Eunice
from CMHS, but also because we have been steadily making the case and
are continuing to make the case with the Department and with FEMA that
these issues are important.

I do think people are beginning to hear. I know that all of you at the
levels that you work at are also making that case. I think people are
beginning to hear it, slowly but surely.

Of course, it is important also to remember the Crisis Counseling
Program. If we had been doing this talk a year ago or two years ago or
three years ago, that would have been 90 percent of the talk, the Crisis
Counseling Program, which we have been doing with FEMA for 30 years.

Of course, in addition to working with FEMA, we do a lot of work with
other parts of the federal government, particularly with our own
department. There are twice-daily actual ESF calls with all of the ESF8
partners, so that includes not just all the other HHS folks, HRSA, CDC,
SAMHSA, et cetera, but also the VA. The VA has, as you can imagine, a
fairly large deployable workforce of direct clinicians in the substance
abuse and mental health area. They sent a lot of people into the field.
Of course, the Public Health Service Corps, which is largely part of
HHS, did that as well. The military is also an ESF8 partner that we work
every day, and the Red Cross.

We are on these calls daily trying to make sure that within the public
health and medical sector, if problems are emerging, we are addressing
them right away. If there is a conflict, if there is confused
information, or if there is just a need to make plans about what to do,
then we are all talking.

The Secretary\'s Operations Center is really the hub of ESF8 activities.
There is a picture of that in the current \"SAMHSA News.\" It is the one
that has Secretary Leavitt in it.

The Secretary also has emergency response teams in all of the impacted
states. In Mississippi, Alabama, and Louisiana, as well as for a time in
Texas, there was a team on the ground. Of course, there were SAMHSA
people. In addition to having a SAMHSA person every day at the
Secretary\'s Operations Center, we also had SAMHSA representatives at
the CERT, and we did definitely deploy CSAT people down.

Then the Secretary also established a Policy Group for the Katrina
response which also had a SAMHSA member.

So, what did we do. We were on these ESF8 calls. We, of course, spent a
lot of time maintaining contact with all of our federal partners and
non-governmental organizations like the Red Cross. We also continued to
work with other key stakeholders, including OSHA, the Occupational
Safety and Health Administration, which is responsible for support to
workers that go out in the field and respond to disasters.

The Secretary actually appointed SAMHSA to be the lead in working with
OSHA on providing support to workers because there was such a
recognition that the mental health and substance abuse issues were going
to end up being among the most critical ways that we had to support
folks.

I think I have already talked to you a little bit about these calls.

The bottom line is, what really is our role here. Anybody have any idea
what this is a picture of? Brownie points if you do.

\[No response.\]

DR. DODGEN: No huge silent film buffs in here? This is Harold Lloyd in
\"Safety Last,\" which is sort of his classic. He plays this guy who
ends up having to climb up the side of a 12-story building to win enough
money to marry his sweetheart, who is waiting at the top.

DR. McCORRY: \[Off mic.\]

DR. DODGEN: That\'s the same movie. That\'s at about the fifth floor or
so that that happens. I actually was looking at graphics for the clock,
but this, I thought, better represented SAMHSA\'s efforts, which are
really to assist the local communities in their response. Of course, I
think our role is quite a bit more active than this young lady, and the
states, of course, are a lot more empowered, probably, before Harold is
in this picture.

Nevertheless, I just wanted to emphasize that our role is not to take
over from the states but really to provide assistance to them and to
help, in a sense, pull them up in areas where extra help is needed.

Of course, to coordinate resources, assets, and activities. Assets, in
our case, are primarily people who can provide services, but sometimes
they can be other things as well. Certainly, informational materials,
things like that.

And of course, to provide subject matter experts. As you know, we
deployed a lot of folks down to the field who are DTAC \-- that is our
SAMHSA Disaster Technical Assistance Center cadre of experts \-- as well
as project officers who could assist in writing grants for states that
were applying for crisis counseling or other grants.

Then, of course, we do provide grants that I think you all are familiar
with from past talks, and coordination and response.

Does anyone know who this is?

PARTICIPANT: Charlie Chaplin.

DR. DODGEN: That is Charlie Chaplin, right, in \"Modern Times.\" The
question now is, how do we translate all this into action and what
really happens on a day-to-day at the ground level?

Anne and Brenda are, I think, the people who can really best answer
those questions for you all. So I will step aside and let them answer
those questions.

MS. HERRON: Hurricanes Katrina and Rita hit. We had a plan. We had
procedures. We knew what we were supposed to do, so how did it all work.

Very, very shortly after the hurricane hit, Mr. Curie activated the
SAMHSA Emergency Response Center, the SERC as we lovingly call it. Now,
the SERC really brought together people from all parts of the agency \--
the centers, the offices, the Office of the Administrator \-- to do what
Dan had described, to coordinate.

But it was more than a function. It was also a place. We physically took
over the conference room on the eighth floor just outside of Mr.
Curie\'s suite of offices, so we had a location that we would go to and
we would work out of. So when people said they were going to the SERC,
they really went to the SERC.

MS. BRUUN: The SERC is modeled on the incident command system, which Dan
briefly described earlier. We put up this organizational chart to give
you an idea of not only how it works within the agency but how our
operation connected with the Secretary\'s operations center. Some people
might feel it is redundant to have an incident command system and an
operations center at the departmental level and then have one in each
agency, but the reality is that the job is huge.

To manage it at the departmental level when there are 26 operating
divisions within the Department of Health and Human Services and each
one has a different function and role and specialty, meant that Dan was
our man at the Department. The Secretary\'s operations center and the
SAMHSA Emergency Response Center were in contact daily. I can\'t even
count the number of times we had to be on the phone with each other,
coordinating between what information he was receiving from our other
agency partners, us getting information from the field. Passing it back
and forth had to be a two-way street, and sometimes that was information
overload to the extreme.

There are five main functions. There is an incident commander and the
incident commander\'s staff. The incident commander during a disaster
reports directly to the Administrator. I think what is significant for
SAMHSA is it is the first time we have actually operated under an
incident command structure. What was unique about it is that you lose
any rank you have when you walk into the SAMHSA Emergency Response
Center and you report to the incident commander regardless of what your
job was during the day.

We look at it as kind of like you were deployed. Even internally you
were deployed and that was your job. Having a separate space to work was
very helpful because then people could focus on one task and not be
worrying about answering their Emails back at their desk, or their voice
mails.

MR. DeCERCHIO: \[Off mic.\]

MS. BRUUN: Well, the incident command structure has been around for
about 40 years. It started off in the emergency medical services field,
and police, fire, and rescue, but it has been adopted by the federal
government as a very efficient management structure for crises. It is
flexible and can expand to the size of the disaster. In some disasters,
you may need all of these functions. In others, you may only need one or
two, depending on what resources you need to mobilize.

DR. DODGEN: Also, Ken, if you are asking about ours, this was the first
time. We had partially activated it during the three exercises last
spring, but this was the first time it was fully activated and
operational.

MS. BRUUN: Yes. You also have personnel functions. We are going to go
into more detail about what those are. Logistics includes not only
setting up the command center but also travel, supplies, equipment,
anything that is needed.

The planning section helps craft the scope and magnitude of the disaster
and begins to help the agency and the incident commander figure out how
we are going to mobilize the agency\'s resources, partner with other
agencies for additional resources, and get those efficiently deployed.

Finance is responsible for tracking every expenditure we make, including
how much overtime staff are putting in, the travel costs for
deployments, any grants awarded, contracts that are maintained. They
have to maintain all of the audit trails for it, and that process has
already started.

Public information has a critical role. I think our Office of
Communications did an outstanding job putting out some very easy-to-read
fact sheets and getting public service announcements out to promote our
efforts.

So this is really the role of the SERC, and the incident command system
helps us convey that, but it is to mobilize our agency\'s resources very
quickly to ensure that we provide a very coordinated response and it is
consistent. We utilize our resources as effectively as we possibly can,
and this eliminates the ability for people to work across purposes even
if it is unintentional.

MS. HERRON: Since August 29th, SAMHSA has deployed both to the field and
to the SERC 257 staff. That is roughly half of our agency. Now, CSAT
specifically has deployed 55 staff. We have only about 103 FTEs, so that
gives you a sense of, really, the amount of staff time and effort that
went into these activities.

Now, when staff were deployed, they really had one of three functions or
three tasks that they might have been assigned to. Some of the staff
went to provide direct service, and that could have been direct clinical
services, for those of us who have some clinical background. Physicians,
psychiatrists, nurses, social workers, counselors, et cetera, would
participate as part of the crisis counseling teams on the ground in
Louisiana, Mississippi, and Alabama.

Now, I will tell you, that was not a cushy assignment, particularly in
the beginning. We are not talking availability of restaurants and
hotels. Many of our staff ended up sleeping in places that were not
terribly comfortable. You can see the staff nodding in the background.
People went on two-week rotations and then came back to their regular
job. So it was an interesting process, and I\'m sure we have lots of
very interesting stories if any of you want to talk to some of the
staff.

The other kind of direct care and direct services that could have been
provided had to do with direct administrative assistance, usually to the
state staff, state employees, but also to some providers as well,
providing such things as consultation around planning, around grant
development, as Dan had mentioned; some very specific kinds of
debriefing activities for state employees; special projects around
planning for the rebuilding of the system or the redevelopment of the
system.

Then, staff also were providing monitoring of some of the volunteers
that we had deployed throughout the state. We got volunteers from all
over the country, so they were really monitoring and managing some of
those teams as well.

The second kind of a thing that staff might have done really was more
support to the SERC operations. There were lots of activities, as Brenda
described, around personnel and planning and public relations. Just a
very few highlights of activities that CSAT staff had engaged in include
working to replace over 15,000 rapid HIV tests that were lost in the
storm.

Our Division of Pharmacologic Therapies provided an incredible amount of
attention, time, and effort in assisting the states in continuing the
availability of methadone treatment for people both within the state and
those who had left the state, making sure that there were some guest
services, guest dosing, and continuation of care. Fourteen clinics in
New Orleans were lost, as you may know.

Also, in relation to the methadone, again our Division of Pharmacologic
Therapies worked closely with the DEA to properly dispose of doses of
methadone that had been contaminated. Things you don\'t normally think
about when you are addressing these kinds of things.

Another big area had to do with assisting in the SERC with the
development of data to support substance abuse-specific mission
assignments. We will talk about that in a minute, but this is the first
time that there has been a FEMA-approved, substance abuse-specific
mission assignment.

One last thing before I go to this slide. I talked about three things
that CSAT staff or SAMHSA staff did in clinical services and
administrative support. The big one I want to make a point of
referencing. Dr. Clark mentioned it earlier. The half of us who were
doing direct clinical care or administrative support were really held up
by the other half of us who carried on the business of the agency. It is
an amazing amount of work when you think about it. So I want to just
recognize that.

MS. BRUUN: This disaster required SAMHSA to implement structures it had
never tested with its staff, which meant that at the time that we were
implementing and carrying out our response activities, we were also
training. I can\'t even describe how it was to watch people who had
never experienced this, wanted to help, stepped up, were willing to
learn new jobs, play new roles, work well into the night, weekends, be
called in on their few hours off to carry out jobs to do this.

One of the things that we did is, within 14 days of the hurricane, we
were able to locate some additional resources within SAMHSA\'s budget to
provide Emergency Response Grants to the four most directly impacted
states: Texas, Louisiana, Mississippi, and Alabama. Those Emergency
Response Grants allowed them to do whatever emergency need they had
prioritized at the moment.

For instance, in Texas and Louisiana, there was significant attention
paid to methadone treatment and their applications. Mississippi chose to
set up an emergency response plan for their staff so that they could
mobilize their resources quickly. Alabama also did some methadone
treatment, as well as some emergency services type of mental health
services to the impacted population until other resources could come
available.

The Crisis Counseling Program has been around for 34 years. In an
average year, we might have about 20 applications. With this disaster,
all 50 states plus the District of Columbia were eligible to apply for
crisis counseling programs. We actually received 34 applications, and
they all had to be reviewed in about a week.

The staff of that program is three, so a lot of very good project
officers from across the agency came together to help them review these
so that we could get award recommendations made to FEMA very quickly.
They are currently reviewing 24 regular services programs. This is the
longer-term needs program. It lasts roughly nine months to a year. Not
all of the states that originally applied for the immediate program
chose to apply this time around. Having some evacuees return to their
homes, they felt like who was remaining they could take care of within
their existing structure.

We also received mission assignments for the first time in SAMHSA\'s
history. Dan explained a little about how the mission assignment process
is, but the reason it is different from other kinds of grant programs or
grant assistance is that when a disaster like this occurs and a state
and a local area is completely overwhelmed and unable to obtain
resources on its own, FEMA can go to another federal agency and say,
\"Well, this is a mental health and substance abuse area that is in your
job description. Can you carry it out? We will pay you to do it.\"

In this case, we started off with, actually, Louisiana being the first
out of the gate on getting the mission assignment process to work for
mental health and substance abuse, with \$1 million specifically to
support the cruise ships parked in the New Orleans Harbor.

There are about 4,000 people remaining on those cruise ships. One ship,
the Ecstasy, is specifically for housing the police department and their
families. The other ship is fire and rescue and other city workers and
their families who lost their homes. A very large population remains on
that ship.

We received a request from the State of Louisiana for \$5 million for
100 mental health workers around the state. I think we have far exceeded
that at this point. Not too long after that, we also received \$5
million for substance abuse workers around the state, and we are
continuing those deployments.

We have also received \$300,000 for the cruise ship in Mississippi. That
population is just evacuees, and that population is declining as they
approach their March 1st deadline for relocating into land-based
housing. And, \$1 million in Alabama for mental health and substance
abuse services that came through fairly recently. We are working with
them to structure a program for those services.

As you can imagine, at this point in the disaster needs are changing
somewhat, so we have to rethink some of our deployment models. Deploying
on two-week rotations at the very beginning of the disaster was the most
effective way and very needed. At this point in the disaster that is not
always the most effective model, so we are working with each of the
states to tailor and adapt our response for their current needs.

Mississippi applied for a substance abuse and mental health mission
assignment in the amount of \$1 million as well. It was denied by FEMA.
They are appealing that process, and we are awaiting an outcome on that.

As I mentioned, we have 24 current crisis counseling applications under
review, requesting \$140 million. This is more than we have awarded in
one year, ever. They are in the process of review. FEMA thinks that the
awards may start being made sometime in March.

They are very complicated applications. I included the dollar amount
requested. That is not necessarily what will be approved because each of
those grants are decided on a case-by-case basis. But I thought it was
significant to let you see what the states perceive is the magnitude of
the need for mental health and substance abuse services in their state
as a result of Hurricanes Katrina and Rita.

We are also expecting some new emergency response grant applications
from Louisiana and Mississippi. Their original grants have run out of
funds, but the need exists. These grants are specifically to pay for
items that cannot be covered under the Crisis Counseling Program.

As we mentioned, Louisiana has, for the first time, received a substance
abuse-specific mission assignment. We are still awaiting the decision on
Mississippi\'s application.

Yes, sir?

MR. DeCERCHIO: Can you clarify what exactly that is, the difference
between the substance abuse FEMA mission assignment and regular requests
for services grants under Crisis Counseling?

MS. BRUUN: Well, under the grant programs, the state basically says,
\"We have the capacity but we don\'t have the money.\" So we give them a
grant in order to carry out a scope of work that they feel will be
helpful.

When you use a mission assignment, it is because they are saying, \"Just
giving us the money won\'t help. We don\'t even have the capacity.\" So
what we do is we either use our own resources, staff, supplies, and
materials, or we contract for resources to be brought in for the state
to utilize for however long they need.

The planning section I think is a critical section of the incident
command system. Their first job was to do an estimate of the magnitude
of the disaster. Without a full picture of what the scope of need is,
you can\'t develop a comprehensive plan for response. You don\'t know
what resources you need.

So one of their first tasks was to do projections based on what we know
about trauma, what we know about substance abuse, what we knew about the
damage areas, and then map that to our grantees, where our community
mental health centers were, where we knew that we had treatment
facilities, detox facilities, residential services, and which ones of
those were damaged. It took a significant amount of staff effort to try
and gather this data when there was nobody there to answer their phones
anymore.

So the usual methods that we use for gathering information weren\'t
always effective in some cases, and this is typical after a disaster.
You have to work on the best information available and then be ready to
change on a minute\'s notice.

We contributed to HHS documents on infrastructure recovery needs,
especially around the mental health and substance abuse treatment
system. We developed a lot of geomapping analysis, thanks to Charles
Reynolds, who I believe works in CSAP, to map damage areas onto where we
have grantees so that we could target our assistance and our requests
for information directly to those needed facilities and to determine how
fast we could help them restore services, even if it meant in temporary
locations.

MS. HERRON: In terms of public information, you all know in any kind of
disaster or situation where things are very, very fluid you need
information. You need access to resources and you need documents that
you can put your hands on, particularly as a provider or a state who is
trying to apply for some assistance. The easier it is for you to put
your hands on some information, the better.

So SAMHSA expanded our website to include a new component, \"SAMHSA\'s
Hurricane Response: Empowering Recovery.\" There are all kinds of
information, technical assistance documents, publications, fact sheets,
and all kinds of things that are available on that site.

We worked with the Ad Council and the Department to develop public
service announcements. Again, just an incredible amount of information.
If you haven\'t had an opportunity to take a look on the website and see
some of the resources that are available, I strongly encourage you to do
that.

We updated many of the substance abuse-specific kinds of related
information for this disaster, all of which is located, again, up on the
website.

MS. BRUUN: To help understand how we can mobilize with such a small
agency so many resources, one thing is, kind of using a population
exposure model, to recognize that some people can be well supported by
providing them TIP sheets or fact sheets that allow them to recognize
signs, normalize the reactions that they are having to a disaster,
promote effective coping strategies, and then point them to additional
resources. One of those resources is the National Suicide Prevention
Lifeline, which is sponsored by this agency.

We recognized instantly with the large number of displaced individuals
that a typical outreach model probably wasn\'t going to be as effective
because these people were scattered all over the country. One of the
quickest ways to give them a central point of access to disaster
information and crisis support was through our National Suicide
Prevention Lifeline.

We quickly mobilized that network. There are about 140 crisis centers
across the country that participate in that. When you call the number,
it picks up your area code and routes your call to the crisis center
closest to you. That crisis center then is available to help connect you
with local resources that can be accessed immediately if in need.

Call volume, as you can see, has spiked. It is well over 62 percent of
what it was prior to Katrina on a daily basis, and we are still seeing
some pretty significant call volume rates in Louisiana, Mississippi, and
Texas, where the largest number of evacuees are housed.

That system was overwhelmed at one point. We had crisis centers in Baton
Rouge and New Orleans. The New Orleans crisis center was destroyed. We
helped them relocate their services to a temporary facility, gave them
volunteer staff from other crisis centers around the country that we
supported their travel to. Then we worked with the other states to
offload call volume to their states as call volume increased to the
point that some centers couldn\'t handle the load. So I think that we
were able to mobilize an existing resource very quickly.

After that, we used public information as self-help kinds of assistance
that also point to referral resources, and then you start getting into
more intensive needs through crisis counseling outreach services and to
direct clinical treatment services as people get closer and closer to
the exposure of the disaster.

MS. HERRON: Personnel. This was the fun part. I can say that now because
we are looking back on it a little bit.

Some really interesting things came about when we took on this
particular task. We contracted with a consulting firm called Westover to
identify and deploy professionals from all over the country and outside
of the country into the affected areas. We deployed, as you heard,
SAMHSA staff and other federal staff. It was really an amazing process.

It brought with it some other things that SAMHSA doesn\'t typically
think about, things like how are we going to identify our deployees. I
will do my Vanna White. I will do it while you describe it. So, how do
we identify our deployees, and then what do we give them when they are
going into these areas where, as I mentioned before, there are no
restaurants and there are no comforts of home.

We came up with these Go Packs. I will be Vanna. You do the description.

MS. BRUUN: All right. Early on, we recognized that there was a large
number of disaster relief organizations, both governmental and
non-governmental, deploying to the impacted areas, and they all had a
shirt so that they would be recognizable. So we recognized that there
was actually a need for our folks to be identified as a mental health
resource that was available to them. We wanted to be very visible in the
field so that you could easily identify and recognize the helpers.

So we came up with international orange. On the back it says \"SAMHSA
Emergency Response Team.\" These shirts are very popular. Anne and I
just returned, actually, about three weeks ago from a trip through the
south and visiting some of our clinicians and visiting community
leaders, state officials, and interacting with some disaster victims
themselves. One of the things that we consistently heard is, \"Oh, you
are an Orange Shirt. You are one of the good guys.\"

There are TV ads on the cruise ships that say, \"Need to talk? Find an
Orange Shirt.\" We have newspaper ads in the Gulfport, Mississippi, area
that say that as well. They are visible in the community. If you need to
talk to somebody, if you are stressed out, burned out, whatever, \"Find
an Orange Shirt.\"

And it worked. People really very much responded to that. They said,
\"You need someone to listen to? There is an Orange Shirt for you.\"

The Go Packs was a different idea. When we first started our
deployments, the physical condition of the area was horrible. We were
sending our folks into places that they were probably not used to, to
work long hours, without access to resources that you would typically
need during the day to stay safe and healthy.

For instance, access to fresh water. You had to carry your own in.
Snacks or food to sustain you through the day. There was no place to go
buy them: no gas stations open, no 7-Elevens, nothing, no fast food
chains.

So we provided Go Packs, which is just a backpack with materials they
would need on how to work with individuals after a disaster, fact sheets
they could give out, suicide warning cards, KAP Keys on how to recognize
the difference between different substance abuse disorders or reactions.
But then it had a few other things that I think our Logistics Team
isn\'t used to buying in supplies: bug spray, sunscreen, first aid kits.

A lot of times, the best access to an individual to assess mental status
or emotional status is to fix a cut and put a band-aid on. It makes them
resourceful, plus a few of them needed it themselves when they got
injured by some debris that was lying around, things like Vicks. People
may ask, \"Why Vicks?\" Because the smell is horrible. If you put a
little Vicks under your nose, it helps a touch. It doesn\'t get rid of
it, but it helps a touch.

Sanitary hand-wash that you don\'t need water for. These are the kinds
of things that the staff needed in order to remain safe.

The other thing that we did was, we established a process for our folks
before they left, and our clinical volunteers around the country also
get this process. It is just managed by the contractor. But they are
briefed before they go out on what to expect, what their role is, what
their mission is. If there is any lack of clarity, then we do the best
we can. Then we tell them, \"Your biggest job is to do what you need to
do; be flexible. If you have any questions, call us.\"

We also established a buddy system where you got called every single day
for a check-in: how are you doing; do you need resources; can we
problem-solve with you.

We\'ve heard about a lot of staff who have come back and said, \"You
know, there were other people I was deployed with from other departments
who didn\'t get that, and they were jealous. Nobody called them to see
how they were doing.\"

It is an intense assignment. You do see an overwhelming amount of need.
The hours are long and you are sleeping in some horrible conditions. Dr.
Bazell, who might be here today, was sleeping on a bench in a hallway at
the State School for the Blind. Our staff stepped up and filled the need
despite the temporary discomforts.

MS. HERRON: The teams now, as a part of the mission assignments, what
they are doing and where they are going. They are being placed in
schools and in mental health and substance abuse clinics to provide
enhanced services, sometimes to expand the hours of operation to provide
services on Saturdays or weekends. Other times, to provide, quite
honestly, administrative respite and clinical respite for the staff
there who have been working for five months now.

They have been providing services in the trailer and the tent cities. We
could spend an entire day talking to you about what is going on in some
of the trailer and tent cities and what those situations are like. We
have teams on the cruise ships, as Brenda had mentioned, and some of the
other shelters in place.

Again, teams were deployed on a 14-day rotational basis. We are really
changing that model now. What we are doing, particularly in Louisiana,
is we are beginning to focus on identifying resources and people who are
returning to the state who may not be fully employed or are
underemployed who can provide some additional time in these clinics,
schools, and settings. So, really trying to focus on kind of a
longer-term type of local deployment.

The data. Basically, we have provided somewhere in excess of 50,000
clinical sessions. The element that I would like to point out is the
referral to local substance abuse services. In the beginning, that
percentage was fairly low. It was around 2- to 3 percent. It is, most
recently, up to around 7 percent.

The issues that the teams are seeing, just to give you a sense of what
these folks are dealing with. Those who are identified in the mental
health and substance abuse clinics and in schools really are addressing
waiting lists. There are people who are waiting a long time to see
someone, so that is one of the things that they are addressing.

They are seeing significant alcohol, opiate, and prescription drug
misuse, and there is a great connection with people who were previously
medicated for pain who no longer have that medication available to them.
They are seeing domestic violence, child abuse, assault, things that are
not surprising to you when you think about the environment and the
conditions in which folks are living and the stress with which they are
dealing.

Also, a great deal of co-occurring disorders. Again, not surprisingly,
depression and anxiety. Just remember some of the pictures from before.

The issues that folks are seeing on the ships are a little bit different
than what they are seeing in the communities. The ships have some very
interesting and very specific issues related to them. For a number of
reasons, there has been a reduction in the access to transportation for
people to get off the ships to find employment, housing, and to get into
the community. So feelings of isolation are clearly occurring.

Child care issues. Families are on the ships. There is very little child
care, if any. Most of the child care is being provided by our teams,
with recreational services, activities, parenting groups, those kinds of
things.

MS. BRUUN: The ships in New Orleans are still different than the ship in
Mississippi. The difference primarily is the location. In New Orleans,
they can get off at the River Walk and walk to services. Some public
transportation has been restored.

In Pascagoula, it is in the middle of a naval shipyard, probably four
miles to the closest part of the town that has clinical services
available, restaurants, things like that, and there is no public
transportation. So if you don\'t have a ride, you can\'t leave.

So that makes it particularly challenging \-- and in some respects I
think it is probably much more frustrating for those folks \-- how to
empower them to take control of their own situation and begin to move
and make longer-term plans. Some of the resources they need to do that
just aren\'t there. A significant clinical issue that we are working
with is frustration and anger.

MS. HERRON: That is the substance of what we wanted to tell you. The
last thing that we wanted to really leave you with is that while we are
really slowing down our involvement, the states most certainly are not.

The pictures that you saw in the beginning were taken in September and
October.

\[Slide show.\]

MS. HERRON: These pictures were taken two and a half weeks ago. There
are hundreds of miles of coastline that have not been touched. Debris
has not been removed and people still can\'t get back to their homes.

Thank you very much. We will be happy to take any questions.

\[Applause.\]

MS. HERRON: Oh, I forgot. The card is an example. We put out all the
things that were in one of the Go Packs. If you are interested in seeing
what people were traveling with, that\'s it.

**Question-and-Answer Session**

MR. DeCERCHIO: If I may, a quick comment. We just certainly have to say
thanks for all that work.

Another thing that has gotten lost amongst all of the, I guess,
criticisms and play around federal-state partnerships and response is
that I have heard positive things and I have never heard a single thing
negative about SAMHSA\'s response in all of that. I think that is a
reflection of Mr. Curie\'s leadership and the Center Director\'s
leadership and the commitment of all the staff.

There was a big piece on NPR a couple weeks ago about mental health
services. Even with a focus on that, Orange Shirts were recognized, and
the work that everyone has done. It wasn\'t a negative piece about any
of those issues that we hear a lot about nowadays in this response. So
you all are to be complimented for that.

MS. HEAPS: I was wondering if you wanted to take over the whole FEMA
process.

\[Laughter.\]

MS. BRUUN: One of the mental health commissioners that we have been
working with actually suggested that, too. I think that sometimes it is
important to do one thing and do it really well. I think, given our
druthers, we will stick to this.

MS. HEAPS: I just want to say it was very moving and absolutely
inspiring. Congratulations to you and to the staff that dedicated
themselves to this. It is remarkable. And to the SAMHSA leadership.

DR. McCORRY: Just a wonderful presentation. Thank you. It makes me feel
proud to be part of this field to see what you guys have done.

A couple of quick questions. One is, we heard up in New York about the
issues with methadone and how difficult it was for patients to get their
medication and the kind of crisis that developed around that. So I would
be interested in hearing more about how SAMHSA responded and lessons
learned from that.

Anne, you have seen it now from both sides. You ran our state\'s
disaster response for 9/11. I would be interested in, since now you have
had both the state and the federal experience, what was that? What are
some of the lessons that you see in having seen it from both sides?

MS. HERRON: Can we postpone your flight? We could sit here for a long
time.

\[Laughter.\]

DR. McCORRY: And tomorrow, we will finish up.

MS. HERRON: Tomorrow maybe.

That is very, very difficult to answer quickly, but I will say, just
very, very briefly, there was a very different scope with this disaster.
While there was some loss of infrastructure in Manhattan and around
Ground Zero, the loss of infrastructure here was almost beyond
description. We got back communication in a couple of weeks. We got back
the ability to have electricity and move about the streets in a month or
so. There are parts of the Gulf Coast where that is still not the case,
and it is five months after.

But it is an interesting point. One of the things that we are putting
together as a result of all our work is a lessons learned document, so
that will be coming.

Again, with methadone, people were appearing states and states away from
where they lived. Ray, Antoine, Arlene, perhaps you would like to
comment on it. They are all from the Division of Pharmacologic
Therapies.

But again, just the numbers and the geographic distance and the lack of
ability to access doses.

MS. STANTON: Hi. My name is Arlene Stanton. I\'m with the Division of
Pharmacologic Therapies. What happened after 9/11, actually, I think was
tremendous argument for how important recovery is to our patients. In
the midst of all the chaos, over 1,000 patients were displaced in the
New York Metro area. They were finding themselves in very different
places than they might have expected to.

What we found later was that it was a tremendous problem, of course,
because programs were already coping with their own staff, their own
patients, and then having an unexpected number of people showing up. Of
course, with methadone, you have to verify that person really is a
patient as well as verify their dose. They were trying to do that with
tremendous communications difficulties.

I think the worst case was if patients were self-reporting, it looked
later like most of them in fact knew their dose and reported correctly.
A few high-dose patients actually, if anything, underreported because of
the fear that they would not get treatment if they told the real dose.

In a few cases, when clinics couldn\'t verify the dose, they were
sometimes forced to titrate it over the course of a day. Imagine if you
need medication and there are buildings falling down around you and you
are worried about your family and your life, and you have to sit there
for several hours while they give you the dose of the medication that
you need.

The good thing that came out of this was that a number of stakeholders
have been tremendously supportive. They worked with SAMHSA and CSAT. We
came up with the idea of a centralized Web-based database that would
basically allow a program over here to access and verify that your
patients get recent dosing information.

We have done a planning feasibility study, a shorter project after that
to do some initial work related to developing infrastructure, and in the
fall of this year, we were funded for what will be a regional pilot. At
this point, we are at the point of creating the infrastructure and then
moving toward development of a pilot that would be centered in New York,
with the possibility of other locations.

DR. MADRID: I also want to commend the staff for the big sacrifice that
you all went through. In reference to methadone, I remember we received
about 1,000 people into the El Paso Civic Center. A day later, our drug
program was called because there were some people that needed methadone.

So we sent our doctor out there to do an assessment, and half of the
people were methadone clients from the methadone program in New Orleans,
but we found out the other half were inmates. We did the assessment.
They were opiate addicts, very, very sick, and we medicated them one
day, and then they disappeared the second day. So, talking about lessons
learned, I think that is certainly a lesson that we learned.

MS. HEAPS: Actually, when this happened, Dr. Clark and I got into a
discussion about the issue of clients who had been on probation or
parole or in jail who also were either mandated to treatment or in
treatment and what would happen to them as they scattered. I wondered if
you, in your experience or in the calls, have had any discussion or if
that issue has emerged in your work at all.

MS. BRUUN: Actually, it came up multiple times in the disaster in
multiple areas because the reality is that prison systems and jails,
they all have to be evacuated as well. What we found is some concern on
the part of certain shelters in accepting these folks into the
traditional sheltering population.

What I think probably is an area that really needs to be worked on is
the forensic sheltering and identifying appropriate space that they can
be safely cared for and treated as well.

DR. CLARK: Then there is the issue of people under the supervision of
parole and probation who are not incarcerated but who are unable to
maintain contacts with parole and probation officers. Then there are,
shall we say, the more severe offender who is being monitored, or the
sexual offenders and the people who are registered sexual predators. All
of these things have been at issue.

We also were dealing with another population of opiate users, and that
is those people who are not in treatment and not in the criminal justice
system. They were very happy using opiates as long as they were in the
community, and the supply dried up. So they were going through
withdrawal, and they had never had any intentions of being on methadone
because heroin or other drugs were readily available. In clinical
situations they had to deal with that. Anne, Antoine, and Kenneth
Hoffman helped with protocols for dealing with people who had
precipitous withdrawal who were not previous methadone clients.

So you get a whole spectrum of consequences. I think Brenda and all
others did a yeoman\'s duty trying to sort these things out, coming up
with models and algorithms that dealt with the reality of a circumstance
that was far greater than most people had prior experience with.

MS. BRUUN: Thank you.

MS. HERRON: Thank you.

DR. CLARK: Thank you, Dan, Brenda, and Anne. Appreciate the
presentation.

\[Applause.\]

DR. CLARK: Melody?

MS. HEAPS: Dr. Clark, in the interest of time and to make sure we have a
quorum, the issue that was raised yesterday about a letter to the
Director of HHS vis-a-vis the ATR program, I very rough draft. Ken
DeCerchio cleaned it up beautifully, and we have a copy we would like to
pass out to the council for their review and hopefully vote.

Do we all have it? We have it. Okay.

DR. CLARK: I\'m assuming, Melody, that you are proposing that we wait a
couple minutes for people to read this?

MS. HEAPS: Yes. I\'m sorry; yes. I trust when it is in final form the
English majors will make sure \-- I was one, which you would never know
\-- it is perfectly editorially okay.

DR. CLARK: We will need a final language check.

MS. HEAPS: Well, it is only minor changes, right? Minor editorial
language changes. \"Curious name\" is spelled wrong, for instance. What
else? \"Request for applications,\" second line, first page. The fifth
line down from the top there is an \"RR\" in the word \"recovery,
comma.\" It should just be one R, not two Rs.

If anyone else sees anything else, feel free.

MS. JACKSON: Melody, on the second page in the second paragraph, it
says, \"Premature conclusions about the status of the current
implementation of this initiative weaken those partnerships.\" I like
all that.

\"As with any transformation effort, ATR states must demonstrate \'early
wins.\'\" Is that clear? I guess I don\'t understand for sure what it
means, but it may be that I\'m not in that loop, so I\'m just asking.

MR. DeCERCHIO: I guess I would ask if it is clear to anybody else. I was
in a presentation around transformation by Mike Hogan from Ohio, the
mental director. One of the principles of transformation is achieving
\"early wins,\" so that is why I quoted it. I used quotation marks
because of Mike Hogan. The quotation marks kind of refer to something
outside of what we were saying.

If it doesn\'t work for folks at first reading or something like that,
then certainly we can reconsider. But that is where it came from, and
that is what I was thinking.

Linking that to Mr. Curie\'s comment yesterday about meeting first
year\'s goals, I would ask George if we accurately reflected Mr.
Curie\'s comments by including that.

MS. JACKSON: I have no problem with it. I just wondered, when it is
being read, does the Secretary understand the \"early win.\"

MS. HEAPS: Let me just suggest, instead of \"early wins,\" \"must
demonstrate some immediate successes.\"

MR. DeCERCHIO: Sure.

DR. McCORRY: \"State substance abuse offices,\" is that a single state
agency?

MR. DeCERCHIO: That is what I was thinking.

DR. McCORRY: Is that the proper term, though? \"Single state agency\" or
\"single state authority\"?

MR. DeCERCHIO: Yes.

MS. HEAPS: What line is that?

DR. McCORRY: It is the fourth line, second page.

MS. HEAPS: So, \"as well as the single state authority.\"

DR. McCORRY: Is that the proper term for it?

DR. CLARK: \[Off mic.\]

DR. McCORRY: Is that a better way to say it?

MS. HEAPS: Okay. We will leave it.

DR. McCORRY: I\'m fine either way. I just wasn\'t sure.

MR. DeCERCHIO: I thought it might be clear to someone outside of our
business. \"Single state authority\" has meaning to those of us that are
single state authorities and do this work. Outside of that, I don\'t
know that it has any resonance at all.

MS. HEAPS: So the sentence stands?

MR. DeCERCHIO: Yes.

MS. JACKSON: I think it looks like a very well written letter that says
what we discussed yesterday.

DR. CLARK: Does everyone feel they have adequate time to read the
document? The chair will entertain a motion to adopt it.

\[Moved.\]

\[Seconded.\]

DR. CLARK: All those in favor?

\[Ayes.\]

DR. CLARK: All those opposed?

\[No response.\]

DR. CLARK: The motion is adopted, and the letter as edited will be sent.

\[Motion carried.\]

DR. CLARK: I will arrange to have people\'s signatures attached to the
document.

PARTICIPANT: I guess I\'m unclear. I thought yesterday the discussion
was around Melody and Ken sending the letter on behalf of the council.
Now you are saying you all want to sign it?

MS. HEAPS: I was hoping the whole council would sign it. Can\'t we
authorize you to sign it for us? No, we can\'t?

PARTICIPANT: No.

MS. HEAPS: How does that work?

DR. CLARK: Either you can have representatives sign it or we pass it
around the whole council to sign it. Either way.

DR. McCORRY: Do you need the actual signature or can it be \"From the
CSAT Advisory Council members listed below\"?

DR. CLARK: We have used a previous mechanism where Melody sent the
letter out, so we can use that mechanism.

We have to have public comment at this point. Is there anyone from the
public who wants to have a comment? Is there anyone from the public out
there? No public?

\[No response.\]

DR. CLARK: All right. Then we should move to our last presentation. The
final topic of the agenda is HIV Rapid Testing. This is actually made
even more important given that the White House has announced a special
Rapid Testing Initiative. If you go to the White House webpage, for \'07
they have already announced it. Part of the HIV strategy is to increase
rapid testing and involving faith-based organizations as part of the
rapid testing effort.

Dr. Kirk James, the medical officer in CSAT\'s Division of Service
Improvement, is going to discuss SAMHSA\'s HIV Rapid Testing Initiative.
In addition, he will talk about recent reports of false positive results
with the oral rapid HIV tests and how SAMHSA and CSAT have responded to
the issue.

Dr. James.

**HIV Rapid Testing**

**Kirk E. James**

\[PowerPoint presentation.\]

DR. JAMES: It is my distinct pleasure to present to you today on the
SAMHSA Rapid HIV Testing Initiative. I know yesterday you heard Dr.
Kenneth Hoffman talk about hepatitis and the vaccination program, but
today what I really want to do is kind of give you an overview of the
SAMHSA Rapid HIV Testing Initiative and what we have done here at SAMHSA
as a whole. This is a cross-center project.

Some of the learning objectives that you see here are just really for me
to report out to you our mission here at SAMHSA in the context of
prevention and treatment as well as mental health when it comes to
reducing HIV/AIDS and the targeted populations.

Also, I want to give you some information specifically about training
and technical assistance associated with Rapid HIV Testing, as well as
the eligibility and readiness requirements that you see here for
sending, and I have highlighted this, free kits to our eligible
providers. Free test kits, as well as free controls for the Rapid HIV
Testing.

Then I will just talk a little bit at the very end about some of my
evaluation methods and some of our pilot data as far as results.

This slide is really a very rough structural organization chart of
SAMHSA, but just to emphasize that this is a cross-center initiative.
I\'m speaking, obviously, today as a CSAT staff member, but I have
worked with members in the other two centers as well.

Of course, you have all seen this as the Matrix. You see here one of the
redwoods on, if you will, the Y-axis is HIV/AIDS and hepatitis. I know
Dr. Kenneth Hoffman spoke about hepatitis, and I obviously will be
speaking about HIV/AIDS and what we are doing with this initiative.

What I would like to do, however, is start off with some epidemiological
background when it comes to HIV/AIDS. This is information that comes out
of the Centers for Disease Control and Prevention, CDC. There are just a
couple of slides I want to share with you. Some of you may be familiar
with these slides, but I would like to emphasize a couple of points
here.

As you will notice, this slide is focusing in on the different racial
and ethnic populations. What you see here is that for each population
there is an incline in the estimated number of persons living with AIDS,
looking at the 10-year span from 1993 to 2003.

What you will notice, if you can concentrate your eyes on the yellow
line, looking at white, non-Hispanics, back in 1993 we were talking
about 80,000 individuals who were estimated to be living with AIDS. That
has climbed up in 2003 to about 130,000.

What you see and what I want to point out here is that cross, where you
see African Americans, black non-Hispanic, starting off at about 60,000,
a little less than the white non-Hispanics when it comes to the
estimated number of persons living with AIDS, and that rising to about
170,000 by the year 2003.

So what you see and what I think this graph illustrates is that there is
a changing face of this epidemic. Of course, we knew this some time ago
as being a white male, gay disease, HIV/AIDS. I say that not to minimize
the detrimental effects it has caused for that segment of our
population, but just really to point out that it is indeed a changing
and a target population that we need to focus on.

The next slide from CDC, I think, points out we are looking at males
with an estimated number of HIV cases. I think the important thing is to
really look at not so much the cases but the rate, the cases per
100,000. What you will see as you look at the black non-Hispanics, at
127, versus your white non-Hispanic, we are talking about at least a
sevenfold increase. Looking at blacks compared to Hispanics, they make
up a double amount when you talk about the rate cases per 100,000.

That is looking at males. The next slide focuses in on females and some
of the same information when we are talking about African American
females, with a rate of 66 cases per 100,000. So we are looking at 22
times the rate when compared to white non-Hispanic individuals as far as
adults and adolescents. So it really points out a couple of things.

This last slide from CDC I wanted to illustrate here is just a
comparison as far as the mode of transmission. When it comes to being
infected with HIV, you see here, looking at your left, looking at the
pie chart for males, 63 percent has to do with male-to-male sexual
contact. The next-largest area is the 17 percent in the red for
heterosexual contact. Obviously, from our perspective as a substance
abuse agency, looking at injection drug use, 14 percent for males
compared to about 19 percent, surprisingly, for females. Actually, the
females have a higher percentage when it comes to that mode of
transmission for being infected with HIV.

So that is just some background as we go into an overview of the Rapid
HIV Test Initiative from SAMHSA. Here I will talk about the history of
this initiative, which started in June of 2004. It is scheduled,
actually, to come to an end officially in the end of March of this year.
But I will give you a little bit of history from the goals of this
initiative, the target populations we are hoping to reach and the
partners that have been assisting us with this effort.

When we talk about money, we are talking about \$4.8 million given to
SAMHSA, SAMHSA-wide, for this HIV testing initiative. I will get into
more of the specifics of that, but just to point out that \$4 million
was really to be directed towards purchase of Rapid HIV Testing kits and
another \$8 million for technical assistance and other factors which go
into really making this project happen.

Basically, our aim was to reduce the HIV incidence rates, as well as,
really, prevalence among minorities, as you see here, as well as other
high-risk populations, i.e. substance users, individuals who may have
co-occurring disorders, substance use disorders in combination with
mental health disorders.

Then, to support Rapid HIV Testing training. Obviously, we are handing
out kits, but we are in the planning stages of providing necessary
training to increase capacity to allow the testing to go on, especially
within our targeted populations, which have typically been missed in the
past.

As far as the goals, to really provide HIV testing capability to our
grantees in particular. We do provide Rapid HIV Test kits to other
organizations, but we definitely wanted to hit our grantees. They are
really our priority. Then, to do some outreach to underserved minority
and other high-risk populations which are found in what we call
non-traditional settings.

Then, to retest those individuals who may have been tested before and
were negative.

Another thing about the testing is it not only allows you to do some
testing with the Rapid HIV Testing, but you also have an opportunity to
do some counseling. It is mandated that you do some pre-test counseling.
You have the test. The test takes about 20 minutes. Then, following the
test, you have some post-counseling which needs to be done. That is
regardless of whether the screening test comes out as positive or
negative.

Here is just a list of the different target populations that we are
aiming to reach. Substance use disorders I mentioned, co-occurring
disorders, and mental health. Obviously, injection drug users,
commercial sex workers, and so forth. And definitely re-entry
populations, hopefully to stop that vicious cycle of individuals coming
out of the prison systems that may be infected and coming back into the
community and then going back into the criminal justice system.

Here is just a list of our partners involved in this initiative. We are
probably most involved with working with the CDC in this effort.

So let\'s get to the purchase. We talked about the \$4.8 million and how
that was broken down. Again, the \$4 million was to be delegated to the
purchase of the OraQuick Advance Rapid HIV-1 and 2 Antibody test kits.
This test was fairly recently approved by the Food and Drug
Administration. It was also to purchase the control kits. The critical
feature of this test obviously was the time: 20 minutes to get your
results. That is not to say that the whole process will take 20 minutes,
but an individual would come in, be given the pre-counseling, and then
take the test. Within a 30- or 40-minute period, that test would be read
and the individual would then proceed from post-counseling.

Here I think is a good time to really talk about some of the false
positives. As I think you are probably aware from some of the media that
has come out, there have been some false positive results out of New
York, San Francisco, and Atlanta. We are very conscious of that here at
SAMHSA, and we work with the FDA and CDC. I have contacts at both
agencies to report out any formal complaints that we get from any of our
providers that we will be providing kits to. They in turn do what they
need to do with that information.

I do want to point out there is a difference between oral fluid and
finger stick. Previously, it was a finger stick. You get a blood stick,
you do the test within 20 minutes, you get your results. If you look at
the finger stick, you see there is a sensitivity. That is, the
proportion of individuals who are tested and found to be positive that
are truly positive is high. It is 99.6 percent.

Now, if you compare that to the oral fluid, where we have been getting
the false positives, the sensitivity is a little bit lower. It is not
that much lower, but it is 99.3 percent. The problems that we have been
hearing about have to do predominantly with the oral fluid testing. That
was most recently approved by the FDA. I think in fact OraSure
Technologies may have plans to have this as kind of a take-home test
kit. Of course, that is raising some concerns as we hear more about
these false positives.

But I do want to caution you that, as it stands right now in my
conversations with FDA, what they are finding is that even though you
are getting these false positives, it falls within the label as far as
the number of false positives that you expect to receive.

The problem, of course, is nobody wants a false positive. If you are the
individual who has a false positive and you get that information, it is
going to be very dramatic to you and it could result in a lot of very
negative behavior. That individual could possibly take their life or
could take the life of another individual they think may have
transmitted that HIV to them. We are very conscientious of that.

But as it stands right now, the FDA is working, along with CDC and
ourselves and with OraSure, the manufacturer of this product, to try to
ensure to the best of their ability that we don\'t get outside of that
boundary, if you will, of what you expect. Of course, no test is 100
percent sensitive with 100 percent specificity. I did want to touch on
that because that is something that has been coming out in the media
quite often lately.

This is just a general picture of the apparatus that is used to provide
the testing. Fairly simple. I have attended the training myself in
Atlanta. There is a lot to it. The test itself is pretty
straightforward, but there are a lot of things that go around the
counseling. The people who are doing this testing and counseling need to
be adequately prepared.

One thing I do want to touch on, too, is that there are a number of
things that FDA is concerned about as far as the false positives. One
is, is there a problem with the apparatus. Anther possibility is, is
there a problem with the quality assurance. Are the individuals who are
doing the testing being appropriately trained.

When you are looking at this control, as you see the result window here,
you have an internal procedural control, and then there is a red line
that will come up. Sometimes that line is very faint, and that shows
whether or not that person is positive. So you really need to have good
lighting when you are looking at this. Obviously, the person\'s vision
has to be pretty good. They at least have to have glasses to correct for
any bad vision. So you need to be very careful there.

Here is a picture showing how you collect the sample with the swab
around the outer gums and upper gums. If people touch the roof of the
mouth or the cheeks, that could present a problem because that could
result in a false positive.

I\'m going to move now to our planning model framework here at SAMHSA. I
will talk a little bit about our program orientation process, site
selection, readiness requirements, of which there are quite a few,
training and technical assistance, data collection, and evaluation to
this point.

This is a fairly busy slide, but as you can see, what we found early on
in the stages of this project is that we need to make sure we have a
good relationship with the different states. I know out of DSCA,
Division of State and Community Assistance, Vic Doolan was very
instrumental in having these conference calls and pulling individuals
from single state agencies and departments of health together and
working through this process to set up these calls to get these
individuals on board in Phase 1 and Phase 2.

Ultimately, that information will be compiled. There will be a state
coordinator for each individual state that we can work with directly.
Once that individual would find out whether or not certain sites were
ready, willing, and able to conduct the test, that information would be
passed on. Eventually, it would get to me to make a final approval and
send that information out to OraSure Technologies for them to in turn
ship those kits. So it is a multi-step process.

Under the SAMHSA Minority AIDS Initiative, we received funding. We
wanted to look at the opioid treatment programs to get not just
information but get the kits out to them and to our set-aside states and
territory sub-recipients, as well as other SAMHSA Block Grant states and
territory sub-recipients, and then our data wave physicians. That has to
do with our opioid treatment programs that prescribe buprenorphine. That
would hold up the process. So we really wanted to focus on those
physicians. Also, other opioid treatment programs regulated by SAMHSA.

This slide really just kind of graphically represents the set-aside
states. You see here the targeted states where there is a high infection
rate when it comes to HIV/AIDS.

Now I\'m going to move into the readiness requirements. There were a
number of things that needed to really be taken care of before
individuals would be given these kits at no cost, along with the
controls.

Here you see the readiness requirements. Again, it is very important to
point out the state requirements. We had to be sure that we were in
alignment with what the states were doing. Sometimes we found that there
were small nuances between states when it came to conducting this Rapid
HIV test.

I do want to point out the CLIA Certificate of Waiver from the Clinical
Laboratory Information Amendment of 1988. This allows this type of test
began of its, quote, \"simplicity\" to be done in a non-traditional
setting outside of a lab. So this type of test is CLIA waived.

It was also important to us that there were appropriate linkages of care
so when we test these individuals that they would have an established
way of referring these individuals out to other organizations if they
weren\'t capable of treating those individuals who may have been
HIV-positive.

Then, quality assurance. I sort of touched on that earlier. We wanted to
make sure that there was some protocol in place to ensure to the best of
their ability that they were conducting these tests and hopefully not
getting the false positive, or false negative for that matter.

And of course, informed consent. HIPAA compliance was necessary, and
just general safety and data security. We are talking about very
sensitive information.

Finally, data collection. They would present this information to CDC.
CDC has a protocol, using their PEM System, the Program Evaluation and
Monitoring System, to collect a lot of demographic information about
individuals who are coming in to be tested for HIV.

Then, to give you kind of a summary of the training that has gone on
since the initiation of this project, the training as well as the
technical assistance, or TA. There is a manual that was initially
developed by CDC. We have since, because of our particular area, adapted
that manual to a certain extent to include some scenarios when it comes
to the counseling that would involve substance use or mental health
issues. Prior to that, it was more general in its approach.

Also, it was important to initiate enhanced Rapid Testing training for
our target-specific areas.

This graph kind of gives you an illustration of the type of testing that
was done. Initially, we started off doing the training of trainers, to
get our trainers out there, who would then, in turn, be able to train
other individuals.

With the assistance of our contractor, MayaTech, we were able to get
this underway. You can see the number as far as the number of
participants in your far right column. We are talking about upwards of
between 4- to 500 individuals. We are talking about the OraQuick HIV
testing Part 1. When Part 2 came out, we had to go back and make sure
people were being tested appropriately for both Parts 1 and 2. Not that
there was a major difference between the two, but you had to have
appropriate certification.

Just to give you a sense of where we have gone with our trainings to
date, you see the different states that we have gone to, the dates on
which those trainings were held, and the number of participants for each
one of those training sessions. There are still some additional training
sessions that are being scheduled, as indicated by this slide here.

This takes us, really, to the end of the initiative at the end of March.
It is important to note, too, that there is a maximum of 24 participants
per training.

So let\'s get down to the data collection and evaluation. I know we are
probably running a little over here, but this obviously is an area where
we want to find some information that will be helpful for us in possibly
increasing effectiveness of this particular initiative.

We do have some pilot data, which I will report out in just a moment,
but we obviously want to look at some of the process measures, both
intermediate and long-term outcome measures, and the data collection
component. You can see here a listing of some of the process measures. I
know Dr. Laura House was very helpful in gathering this information and
working with Westat to assist us in this matter.

Then, the intermediate outcome of measures, the percentage of people
tested, were they positive or negative, did you have intermediate
results. Of those people who were tested, were there referrals made for
treatment and case management. Those are some of the questions we were
trying to get answers to. Of course, this is very early on in the
process, with the project coming to an end just in March.

Here are longer-term measurements. As you can see here, the question
being posed here, did the introduction of our initiative increase the
percentage of substance abuse prevention and treatment as well as mental
health clients being tested. That is obviously the population we are
trying to reach. Did the project increase the zero positivity rate,
which is what we really expect, given what we consider to be a high-risk
population.

Some of the different data collection levels you can see here as far as
site level. Our contractor, MayaTech, was instrumental in helping us
with this area. With product level, we turned to OraSure Technologies
when it comes to distribution and tracking of the kits and controls.
Then, at the very individual level, to try to get some demographic
information regarding the individuals who were coming in for the
testing.

What we are trying to develop really is a repository of the information
that is going to come from these three different levels of data
collection and eventually we will put that into our services
accountability improvement system, which is something we have been using
at SAMHSA for some time now to collect our GPRA data.

This slide just mentions a number of different data elements. I\'m not
going to go through each and every one of them, but some of the
demographic variables that we were looking at when it came to Rapid HIV
testing.

Just in graphical form, this illustrates that this particular pilot
involved five different projects. You see Houston, Minnesota, New York,
Oklahoma, and Washington. What we found was that, out of these almost
13,000 clients, most of the clients were tested in New York and Houston,
as you see here. Again, we are talking about 13,000 clients.

I would point out that by the end of December 2005 we had distributed
some 352,000 Rapid HIV Test kits across the country.

I placed this slide into the presentation really to point out the
different types of sites that we are getting to. Again, this is limited
to those 13,000 individuals. You see here 39 percent field visits, so
more of a non-traditional way of reaching individuals who may be at high
risk for being infected with HIV. Of course, you have your public health
centers, at 28 percent. Interestingly enough, we have the prison and
jail system at 11.2 percent. As far as drug treatment, a little low at
6.6 percent, but again, this is only looking at 13,000 individuals.

This graphic just shows you gender-wise the individuals that we have
been testing at least within this pilot population of almost 13,000
clients. Predominantly, males have been the ones we have been testing.

This slide is important to show because we are talking about race and
ethnicity. Obviously, our targeted areas are minorities and other
high-risk populations. You see here that the majority of individuals
there were tested within these 13,000 clients in this pilot data were
mainly blacks, Hispanics, and others, as compared to the 31.5 percent
for white non-Hispanics.

This slide illustrates, really, just the age range. We were finding most
people come in to be tested range between the 20- and 39-year age range.

I have highlighted some areas here because I think they are of
particular interest to us, coming from SAMHSA, not that all of them
aren\'t important. This is being self-reported by individuals who are
coming in for the test. So they can put down one or more of these items
as a reason that they would come in to be tested.

To highlight the one in blue, \"No acknowledged risk,\" I can only
speculate here but it is just because of a sense of denial about why
they are coming in to be tested. For some people, as part of their
workup maybe they are being tested. But interestingly enough, you find
there are other areas. Sexual relationship with men, or MSM, the
population is 17.3 percent.

I think this really brings us to a close here. Again, I would caution
you that this is preliminary data. This is pilot data coming out of
those five project areas. I think an important thing to remember is
that, with the typical test it would take about two weeks to get a
result from your testing. What CDC has estimated is that a large
percentage of individuals were not coming back. I think the estimate has
been as high as 20 percent of individuals who were not coming back. Now
that they have taken the test, they are not coming back to receive those
results.

CDC has estimated that of 900,000 people supposedly infected with HIV,
approximately 200,000 do not know what their zero status us. So to have,
as illustrated in this graph, stayed for the test, we are talking about
20 minutes or so. Most people are going to stay. So, not 100 percent,
but we are talking about 99 percent, and that is what showed up here.

As far as the test results, what we are finding from this preliminary
data is 1.5 percent. Again, this is a screening mechanism, a screening
tool. This test has to be confirmed by another method, i.e. Western
blot, to make a confirmation of that test. But again, if someone gets a
false positive at the screening level, it raises a lot of anxiety, I
need to say. So we need to make sure that we are on top of that.

I think that the next slide is not in your handouts, but I did want to
point this out because this is sort of hot off the press. Dr. Clark had
mentioned in his opening statements the president\'s State of the Union
address as far as the money that sounds like it is going to be coming
for reaching individuals in these targeted populations.

You can see here some information specifically mentioning Rapid HIV
testing. Not your traditional testing, but Rapid HIV testing.

In the second bullet, you see the president\'s call for a nationwide
effort working closely and specifically with African Americans,
churches, and faith-based groups, as Dr. Clark mentioned, to deliver
Rapid HIV tests to millions, to end the stigma of AIDS, and to come
closer to a day when there are no new infections in America.

Other important highlights I did want to point out for particular
populations are those people who don\'t know their status. I talked
about that just briefly a moment ago. The president has a proposal to
direct a total of more than \$90 million to the purchase and
distribution of Rapid HIV tests. Then, the testing of prisoners,
obviously one of our target populations as far as the criminal justice
system, reaching those individuals. The president\'s proposal is to
direct approximately \$20 million to directly facilitate the testing of
more than 600,000 prisoners.

Finally, as far as substance use, intravenous drug users. Estimated
undiscovered cases are particularly high among IDUs. The president again
proposes to direct approximately \$20 million to distribute Rapid HIV
Test kits to drug treatment centers and health care professionals.
Obviously, this is talking about this agency and the individuals that we
fund.

I think that brings me to a close. I would like to say, before I take
your comments or questions, I am indebted to the individuals who have
worked with me. As I say, this is a cross-center initiative involving
the help of a lot of individuals, even in preparing this presentation.
I\'m indebted to those individuals, and hopefully making this initiative
worthwhile and impacting the lives of many throughout this country.
Thank you.

\[Applause.\]

DR. CLARK: Thank you, Dr. James.

Any questions from the council?

MR. DeCERCHIO: On the issue of false positives and the confirmation,
that is part of the protocol now? In other words, is that happening
through public health in terms of having the Western blot done as the
confirmation for the immediate positives?

DR. JAMES: We don\'t fund the confirmation test.

MR. DeCERCHIO: Right.

DR. JAMES: We are funding the actual HIV Rapid Testing kits. That is a
screening tool. Once that individual comes up as being positive, that
needs to be confirmed by Western blot, and there is another mechanism,
immunofluorescent.

MR. DeCERCHIO: As a quick follow-up, the sites that are doing this, do
they have to have a protocol by which they can access that Western blot?

DR. JAMES: Right, right. An established referral.

MR. DeCERCHIO: A linkage so that we are sure that those follow-up
confirmations are happening.

DR. JAMES: Like anything, we can\'t force individuals to go, but there
has to be an established mechanism in place for each of the states that
we deal with as far as the grantees who are receiving these kits.

MR. DeCERCHIO: Thanks.

DR. JAMES: Yes?

DR. McCORRY: I\'m aware of a program that I think is called Project
Wave. I was wondering about state plans. Project Wave works with local
deejays that African American youth listen to, and the deejays get
tested using the Rapid HIV test. They also have a show go on, so they
have some rappers that get up. They said this has been incredibly
successful and a number of kids show up to get tested.

What I see listed are all kind of traditional outreach sites for HIV
testing, whether it is drug treatment or a community health center. Is
there any sense of innovation in their plans in terms of using this
technology in non-traditional settings to reach populations that
typically don\'t get tested?

DR. JAMES: I think that is pointed out, actually, in one of the slides.
I think I will go back to it. It was sort of vague, I think. \"Field
visits,\" at the very top, at 39 percent.

DR. McCORRY: That\'s what that is?

DR. JAMES: Yes, yes.

DR. McCORRY: Oh, okay. Very good.

DR. JAMES: That is what we are saying. We want to be innovative in our
approach. I think our sister agency, CDC, was dealing more with the
general population. We want to reach individuals who were typically not
reached in the past.

DR. McCORRY: Very good. Thank you.

DR. JAMES: You\'re welcome.

Any other questions or comments?

\[No response.\]

DR. JAMES: Thank you.

DR. CLARK: Thank you, Kirk.

\[Applause.\]

DR. CLARK: I would like to point out that Dr. Sheila Harmison, in order
to the disaster work, was the lead person on this. Dr. Kirk James
stepped in after Sheila became ill. Dr. Harmison was responsible for
getting the bulk of the tests into the hands of the health departments
while we were developing the other aspects and working in concert with
the HIV Taskforce within CSAT and within SAMHSA.

As Dr. James pointed out, there are a number of individuals who worked
on this issue. I see Vic Doolan, Dave Thompson, Stella Jones, and Laura
House, and I think there may be other people back there. I know Cheryl
Gallagher was also involved in it. But I think people have stepped up
and we are making this initiative. We will see what happens with the
president\'s proposal. It is only a budget proposal. It is \'07 funds.
It all turns on what the Congress does, but it is clear that, for the
administration, addressing the issue of HIV is of paramount importance.

**Council Roundtable**

DR. CLARK: We have almost made it through another meeting. The final
item on the agenda is the Council Roundtable, and you now have the
floor.

Val?

MS. JACKSON: Thank you.

We started to talk about this yesterday, and then I think Mr. Curie came
in or another issue came up. I had been the lead person for the look at
e-therapy, where we might be and where we might be going on that. Dr.
Harmison had been the person who had done the presentations and was the
lead for SAMHSA. I know Ken had volunteered to be a part of that. I
think Melody also did, and Chilo did, too.

There was a lot of interest on the council about that. I would like to
bring it up and ask the council whether or not we want to continue that.
I don\'t know whether you call it a subcommittee or whatever. A
subcommittee? Thank you. A subcommittee which was formed before. So I
just need your leadership on that.

DR. CLARK: I think we have continued interest in it, particularly when
we are dealing with special populations in geographic areas. So while we
have had some staffing changes due to Sheila\'s death and some
retirements, we intend to revisit the issue of e-therapy.

DR. McCORRY: I was struck, this morning, by Chilo\'s comment to David
Gustafson when he started describing the funding streams that come into
running his program. He mentioned about four or five that are just
around a youth program.

Last time, I think in May, I had brought up getting CMS in to talk about
funding, but I\'m thinking there is a broader issue. It is more to ask
whether the council is interested in this.

I listed about 12 funding streams, permanent or temporary, just sitting
here that probably a program director is managing. Some are temporary,
some are permanent. A Block Grant is permanent. A research grant might
be temporary, or a foundation grant.

I know the financing of the system has been looked at at some level
nationally because I know I have read some studies from folks like
Dennis McCarty where they talk about the Block Grant is this percentage
of funds spent in a particular state.

To me, my sense is, even though there are these permanent funding
streams, the stability of the financing of the system is relatively
unstable. There is some permanency, but then there are these kinds of
irregular funding opportunities. Sometimes, some systems might step up
and fund. Like, criminal justice might get involved, or criminal justice
might not get involved, but everyone is doing criminal justice work.

So I don\'t know whether this is a good topic for the council, whether
it is just a presentation or whether we actually tried to look at the
impact of these multiple funding streams on stability, the
comprehensiveness of care, and the model that is actually supported in
dollars rather than the model that gets delivered. Just, a sense of how
the treatment model is supported or inhibited or impeded by the kind of
disparate set of funding streams that seem to be in these programs.

I\'m interested, even though I\'m not a financing guy. It just seems to
me like an important issue. But I don\'t know whether the council
members would be interested in pursuing it a little bit more, or whether
it is worth a group like us actually trying to do something in that
area.

DR. MADRID: I would like to echo what Frank is talking about because I
think that these are grass-roots issues that providers are confronted
with on a daily basis. These are grass-roots issues that faith-based
programs will confront as they are unfolding and coming in as providers.

So I think that perhaps sometime in the near future we should have
somebody present some type of presentation that deals with the different
payers out there, the payers of last resort, the providers of last
resort, and the whole financing system. Perhaps an overview of what is
out there, how managed care is affecting us, and so forth.

Certainly, I would like to echo, also, what Valera said because I was
working with Sheila Harmison, also. She was very encouraging to me. I\'m
pilot-testing an e-therapy program in Texas. It is bilingual. Sheila
helped me a lot with a lot of ideas.

I have a team of staffers at my agency that are working with that real
hard, and we are going to continue the struggle, continue trying to
delve into this e-therapy situation. I\'m finding it very, very
interesting, to say the least.

DR. CLARK: With regard to the financing issue, this council had actually
suggested the topic before. We weren\'t able to do it. Frank, you were
going to come and deal with it, and you weren\'t able to do that. So I
suggest that we, in conjunction with the staff person, address this
issue.

It is particularly important given your other comments with regard to
our expectation of training of individuals in the work force and the
modern demands of the substance abuse delivery system. If that delivery
system changes its portfolio of products, then it is going to, of
course, expect reimbursement for providing the services and the products
within that portfolio, and want to make sure that jurisdiction is
acknowledged, as well as the legitimacy of the efforts. Otherwise they
won\'t be able to do that.

So if a state says, \"Well, you can\'t provide the following kinds of
services,\" then that won\'t happen. Or, if the criminal justice system
says, \"We will reimburse for five of the 10 necessary services\" and
that leaves you in the hole for the other five, then that obviously
affects what it is that you do. The same thing with child welfare or
TANF or any other of the public funding entities.

Then there is always the other sometimes small, sometimes large streams,
but oftentimes limited, regardless of the size.

MS. JACKSON: I would really endorse that and be willing to work with
that as an agency. We have something like 30 different funding streams,
and I don\'t think that is uncommon. There are a lot of funding streams
that go into putting together a comprehensive agency. Even those that
may only be one piece of it still have to constantly search.

I am aware right now of an agency in North Carolina that we are doing
some technical assistance with. Last night my husband said, \"They have
83 clients. They are going to have to close their doors.\" So there are
some real economic issues there that I think are important, and we need
to investigate and look at them for future purposes. So I would endorse
that.

DR. MADRID: I mentioned at the beginning of the meeting that I was in
San Antonio last week, where we were training 60 or 70 new, prospective
service providers, faith-based mostly.

They were very concerned with should they go 501(c)(3), 501(a), limited
liability corporations. They were very concerned about the type of
Medicaid funding available. They were very concerned about should they
do indirect costing, administrative costing. They were very concerned
about, are we going to survive when we jump into this thing or are we
not. They were very concerned about the whole economy thing, the whole
financial situation.

A lot of them looked like they were very well-off groups from churches
that are very, very well intentioned, very smart people, but they don\'t
have the slightest clue as to what fiscal survival is in the delivery of
drug services.

MR. DeCERCHIO: I guess I would ask us to consider what is our focus on
financing? Just to understand the complexity? You know the complexity. I
guess I would say maybe we can be a little more focused in our feedback
or request.

If it is informational so that we understand the different funding
streams and how complex they are, that is one thing. I\'m a little less
interested in that. I know, Frank, you are very operational.

One area to maybe consider is kind of related to financing. What I hear
from our folks all the time in our community-based agencies is, \"We now
have national outcome measures.\" Well, to what extent are other funders
willing to consider utilization of those national outcome measures in
the substance abuse services that they fund.

So we may not be able to get more integration on funding streams. You
know how that goes. But it would make life easier at your level if all
of a sudden the Bureau of Justice Assistance or Juvenile Justice says,
\"That is a measure we could adopt.

We could accept that measure, or the array of measures, or part of the
array of measures,\" which then, while not eliminating the funding
streams, creates some efficiencies and economies for people at the
bottom of the funnel, if you will. That would be something we might want
to consider: other opportunities by which we look to deal with this
issue.

DR. CLARK: Anita?

MS. BERTRAND: Really quickly, I see it as an opportunity to teach
organizations how to better run their businesses in terms of being
creative.

When I think about residential treatment, I look at the children that
are in the program with their mothers and how we look for \"Help Me
Grow\" dollars and the TANF dollars to support the work that substance
abuse does. It crosses over so many areas of our life: do our leaders,
through workforce development, know how to tap into those sources to
better their programs.

We are thinking about things like consignment shops and thrift stores. I
was happy to hear that someone in Louisiana was doing those types of
things because this system is taxed in terms of what it is, and we need
to be creative. So I was thinking about it from a workforce leadership
development point of view.

DR. CLARK: Val, and then Frank.

MS. JACKSON: I think that those are very interesting points that need to
be investigated, but I also believe, in answer to Ken\'s question, that
it is quite possible that if we went about this right we could impact
some of the major funders of substance abuse. Take Ryan White, for
instance.

Ryan White in some states is providing nothing, basically, or very
little for substance abuse treatment. I happen to be in an area where
they are providing a lot, which is very good.

Now, the price of those services and what they are actually providing
for is another big question. Just as an example, in Florida, the
Department of Corrections has a very different view of what substance
abuse treatment is from what the Department of Children and Families
has. I suspect that that is true in many, many states.

So you have \$40 a day versus, whatever, \$150 a day. Well, that is a
lot of difference in services, and that means differences in outcomes
and, ultimately, differences in national outcomes. So I think we need to
look at some of those issues.

DR. McCORRY: I think these are great suggestions for what we might start
to focus on once we delve into financing. Valera was just hitting on
exactly one of the points I was thinking.

I love the idea of the workforce and tying it to outcomes, but my
contention is that there are systems that should be invested in our
system of care and that it is almost optional whether they are. Criminal
justice is a great example. Public welfare and certainly public health.
Ryan White is a good example, but there are other examples.

If you look at NOMS, the outcomes talk to the impact they have in other
systems. Yet, those other systems don\'t necessarily have an investment
in our care, or if they do, the determination of both the level of
investment as well as the focus for the investment, what they are
willing to pay for, is somehow independent of the expertise that resides
in the program. Even a single state agency might not be involved in the
determination of what another system might be willing to pay for, or
whether they are willing to pay for something at all.

So these kinds of things and looking at expectations on payers in terms
of NOMS, expectations on payers in terms of outcome, and then
investments in the substance abuse service system because of the benefit
to their mission, and trying to understand the piecemeal quality of the
financing and the way that might lead to these kinds of questions, that
might ultimately lead to some kind of position or paper or further
initiative, in which the funding gets more normalized because these
other care-giving systems or other stakeholders start to see their
responsibility in it.

DR. CLARK: All right. We will put that on the agenda for a future
meeting and raise this as a concern of the council as we refine the
arguments, recognizing that SAMHSA\'s jurisdiction is SAMHSA. But there
are partnerships that need to be forged with a wide range of entities,
and we are already doing that with criminal justice and child welfare,
et cetera. So we can elevate the scores.

So there are two topics?

DR. MADRID: Another topic that we heard at this meeting is the whole
issue of hepatitis A and B and the vaccine. So the question now is, what
are we going to do when that vaccine runs out? It is a one-time deal.
There is vaccination happening all over the country for A and B. There
is nothing for hepatitis C. The Secretary apparently allocated this
money one time and that\'s it. So, what comes next after the money runs
out, after we use up all that vaccine?

DR. CLARK: Yes, that\'s a good question. Again, we can put infectious
diseases back on the agenda. We have actually applied for resources over
time, so we may choose to submit that again when funds appear on the
horizon. I also think it\'s incumbent upon the constituency and council
members to also keep their fingers on the pulse of what is going on in
the communities.

We have often found drug treatment programs unwilling to step up to the
plate to do HIV testing or even to administer the vaccine. That is one
of the things that you heard. So perhaps our next effort is educating
clinical programs about the importance of it. The first thing we hear
is, \"We need staff people,\" or, \"Are you going to pay for this? Are
you going to pay for that?\"

So if indeed we are going to integrate care, our system needs to be able
to figure out how it can address some of these issues in a comprehensive
or holistic manner. They are adversely affected by the negative
consequences of not providing the vaccine or not doing the HIV testing,
but unfortunately the marketplace drives business behavior and people
who are living on a shoestring often learn to adapt to not having the
best of all services. So there is that tension we have to sort through.

Any other issues?

DR. MADRID: The last thing that I want to bring up, and I think I
brought it up during the meeting, is the whole issue of workforce and
maybe inviting the Annapolis Coalition to come in and talk to us.

DR. CLARK: We intend to do that. I don\'t mean to cut you off, but we
have already raised that issue and we will invite the Annapolis
Coalition. If you have some specific questions on that, please feel free
to submit that because that is an integral part of Mr. Curie\'s Matrix.
We are spending money on this, and I think it is important for this
council, based on all your experiences and your positions, to be
reassured that these issues are being adequately addressed.

Any other questions?

\[No response.\]

**Future Meeting Dates**

DR. CLARK: I would like to bring to your attention a couple of changes
in the meeting schedule for the advisory council to faciliate the
council\'s review of grant applications.

The next face-to-face meeting was originally scheduled for May 17th and
18th. We are now looking at a one-day, face-to-face meeting on June
23rd, which is a Friday.

We were also considering a teleconference meeting the week of August
7th. That date has now changed to Thursday, August 24th.

Thursday, September 21st, and Friday, September 22nd remain on the
schedule. Let me explain, briefly, the reasons for these schedule
changes.

Beginning in October of this year, SAMHSA will be switching to a new
Department-wide unified financial management system. To accomplish this
transition in time for the start of the new fiscal year on October 1st,
SAMHSA must make all grant awards by September 1st. This is two weeks
earlier than last year.

This, coupled with the late action by the Congress last year in
approving an appropriation bill for the Department, has significantly
compressed the time available to process awards and, in particular, has
required adjustments in the schedule for reviewing grants and preparing
summary statements by the SAMHSA Grants Review Office.

By adjusting the council\'s schedule, we anticipate that we will be able
to spread your review of grants over two meetings and provide summary
statements well in advance so as not to create an undue burden on you.

We appreciate your understanding and cooperation in fulfilling this
important council function.

Any questions about that?

MR. DeCERCHIO: Could you give us those dates again, the revised dates?
The revised dates are the same ones we have already been given?

DR. CLARK: Yes.

PARTICIPANT: Friday, June 23rd. Thursday, August 24, for a
teleconference call, and Thursday, September 21 and Friday, September
22.

MR. DeCERCHIO: Thank you.

DR. CLARK: In addition, on the 22nd of June, we will have an African
American in-service training, and the possibility of you attending that
is also on the table. So we will inform you of that and let you know to
give you an opportunity to attend that.

As we leave, let me repeat how grateful I am to you for taking the time
out of your schedules. You sat through a day and a half and you have
been attentive, and I really appreciate that. I know the staff
appreciate that, those that are left.

The issues are of great concern. I think, as Brenda Bruun pointed out,
and Anne Herron and Dan Dodgen, particularly with the disaster work, we
have been able to establish the legitimate role of substance abuse
prevention and treatment to the disaster. It has taken a little while to
do that, but it is important that you understand.

I think Ken, of course, knows up close and personal this issue, as well
as Dave Wandser \[ph\] and, of course, Mike Duffey, in experiencing some
of these issues. Frank, both the blackout and 9/11/01 brought that to
our attention.

So with Mr. Curie\'s leadership, we have been able to make it clear that
we are part of the larger public health delivery system and should not
be sequestered off to the side and our issues and our needs left as an
afterthought. I think Dan, Brenda, and Anne pointed that out. The larger
media tends to focus on, shall we say, the more global issues, and that
leaves the intricacies to us.

So if there is no further business, I will entertain a motion to
adjourn.

\[Moved.\]

DR. MADRID: I would like to go ahead and second it, but I would also
like to commend you, Dr. Clark, and Cynthia and certainly George and the
rest of the CSAT staff for another well organized meeting. Cynthia,
thank you for cracking the whip on me.

Thank you for your compliments. I, too, wanted to thank Cynthia and the
other staff that worked on this meeting. Unfortunately, we also had a
staff person who had an accident and hurt herself as a result of her
enthusiasm to get the job done, so I think that demonstrates the
commitment of my staff to make sure that you have what it is that you
need to make this work. We have Doug Basher and we have contractors who
have been actively involved in this.

Nevertheless, we are trying to make sure that you are able to make your
contribution to our ability to inform the Administrator as to the
various issues that are confronting the American public with regard to
substance abuse treatment.

Back to the motion. It has been moved and seconded that we adjourn.

All those in favor?

\[Chorus of ayes.\]

DR. CLARK: All those opposed?

\[No response.\]

\[Motion carried.\]

DR. CLARK: The meeting is adjourned. See you then.

\[Whereupon, at 12:48 p.m., the meeting was adjourned.\]

\+ + +

**CERTIFICATION**

This is to certify that the attached proceedings

BEFORE THE: CSAT National Advisory Council

HELD: February 2-3, 2006

were convened as herein appears, and that this is the official
transcript thereof for the file of the Department or Commission.

[DEBORAH TALLMAN, Court Reporter]{.underline}