**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration**

**Center for Substance Abuse Treatment National Advisory Council**

**Official Minutes**

**May 19-20, 2005**

**[Thursday, May 19, 2005]{.underline}**

The Substance Abuse and Mental Health Services Administration (SAMHSA)
Center for Substance Abuse Treatment (CSAT) National Advisory Council
met on Thursday, May 19, and Friday, May 20, 2005, in Rockville,
Maryland.

CSAT Director H. Westley Clark, M.D., J.D., M.P.H., convened the open
session on May 19, 2005, at 9:15 a.m. Members present included Anita B.
Bertrand, M.S.W.; Kenneth A. DeCerchio, M.S.W.; David P. Donaldson,
M.A.; Bettye Ward Fletcher, Ph.D.; Valera Jackson, M.S.; Chilo L.
Madrid, Ph.D.; Francis A. McCorry, Ph.D.; Eric Voth, M.D., F.A.C.P.;
Judge Eugene White-Fish; and Richard T. Suchinsky, M.D. (ex officio);
Also present were Richard Kopanda, M.A., Deputy Director, CSAT; George
Gilbert, J.D., Director, Office of Program Analysis and Coordination;
and Cynthia A. Graham, M.S., Executive Secretary, CSAT National Advisory
Council.

**Welcome**

Dr. Clark welcomed participants to the meeting.

**Minutes, January 26-27, 2005**

Council members voted unanimously to accept the minutes of the January
26-27, 2005, CSAT Council meeting as presented.

**Opening Remarks**

Dr. Clark discussed the importance of Council's input and summarized the
problem of substance abuse. Household Survey data for 2003 show that
19.5 million people age 12 and older are current illicit drug users, 8.2
percent of the population. Large numbers of people misuse alcohol, and
the problem of pathological gambling is growing. He stated that nicotine
addiction is addressed outside SAMHSA. He noted the importance of
working to facilitate recovery and build resilience.

At this point members of Council introduced themselves, and Dr. Clark
announced new staff assignments: Laura House, Ph.D., has joined CSAT's
Division of Services Improvement, and Kenneth Hoffman, M.D., M.P.H.,
serves as second medical officer in the Division of Pharmacologic
Therapies. Wendy Waddy is a fellow in the Office of Global Health.

**Director's Report**

Dr. Clark presented an overview of the President's proposed FY2006
budget, which, at \$2,222.7 million features a modest increase in
appropriations for CSAT. The President is requesting \$1.776 billion for
the CSAT substance abuse block grant. The budget provides for a 20
percent set-aside for prevention; set-asides also go to programs for
women, HIV/AIDS, and others. CSAT will direct the modest increase to
expanding substance abuse treatment capacity through the Access to
Recovery (ATR) Program, for which awards have been made to 14 States and
one tribal organization. The President proposed \$150 million in ATR
funds to support existing grants and seven new ones. The President also
has proposed a \$6 million increase in SBIRT funding for a total of \$31
million. Total Targeted Capacity Expansion (TCE) grants would be funded
at slightly more than \$33 million. CSAT proposes almost \$30 million to
address homelessness and \$33 million for children and families. About
\$61 million is proposed for TCE regarding outreach and treatment for
racial and ethnic minority groups disproportionately affected by
substance abuse and HIV/AIDS. About \$25 million is proposed to address
treatment needs in the criminal justice system. Dr. Clark stated that
CSAT is faring well under the constraints of the President's agenda,
although difficult choices must be made. Best Practices programs that
promote evidence-based practices will be supported by about \$28
million, a reduction of 41.6 percent. At the House hearings, Congressman
Regula expressed interest in the area of workforce development.

Dr. Clark reported that the media is focusing attention on addiction
disorders and the manufacture of methamphetamine. Major department store
chains are placing Sudafed behind counters to help stem the
methamphetamine epidemic. CSAT will not fund National Alcohol Screening
Day, the Conference Grant Program, and the Minority Fellowship Program.

CSAT is pursuing development of National Outcome Measures (NOM). Dr.
Clark noted that CSAT and State representatives have discussed
implementation of the 10 domains within three years. Preliminary 2005
block grant data show that selected States are reporting already on a
variety of domains. Data indicate that public dollars constitute a major
source of income for providers, making the block grant critically
important. He emphasized the importance of stakeholders working together
to tell the story to Congress.

Dr. Clark stated that methamphetamine is raising concerns about child
welfare issues. Misuse of pharmaceuticals, particularly opioids, is
another major issue. CSAT has opened a dialogue with major manufacturers
of opioid agents used in pain treatment; and will discuss strategies at
a follow-up meeting. Pharmaceutical companies agree that the issue
should be dealt with as a public health concern and acknowledged the
need to collect data and work with stakeholders. Dr. Clark reported that
he served on a U.S. delegation to the United Nations' Commission on
Narcotic Drugs, where he presented the U.S. position on needle exchange.
He also has presented at Congressional briefings on methamphetamine
addiction and inhalant prevention programs.

CSAT continued its e-therapy activities with several presentations and a
lead article in *SAMHSA NEWS*. Dr. Clark stated that he recognizes the
need to devise strategies to increase access to care. Dr. Clark plans an
extensive itinerary of site visits to ATR grants. In the co-occurring
area, TIP 42, "Substance Abuse Treatment for Persons with Co-occurring
Disorders," has exhausted its first printing and a second has been
requested. The advisory group for the Co-occurring Disorders Technical
Assistance Center has met to consider strategies. September's Recovery
Month's theme is Healing Lives, Families, and Communities, with a focus
on helping communities understand that recovery is possible to help them
provide the necessary supports. Details are accessible at
[www.recoverymonth.com](http://www.recoverymonth.com/). SAMHSA's website
is www.samhsa.gov.

**Discussion.** To a question from Mr. DeCerchio, Dr. Clark responded
that the U.N. discussion included a focus on prescription and illicit
drug sales on the Internet. He responded to a question from Dr. McCorry
that NOMs measure both in-treatment and post-treatment phenomena. Ms.
Jackson praised Recovery Month materials and asked about CSAT's
activities to encourage States to engage in the program. Dr. Clark noted
that CSAT will continue to leverage its limited funds in working with
States in ways to be determined. Dr. Fletcher stated that she encouraged
adoption of TIP 42 as a primary reference resource for a graduate
training program in substance abuse treatment. Dr. Karl White noted that
a study is underway on the use of TIPs, which Council members will
receive. Mr. Donaldson noted that methamphetamine use impacts on child
welfare because of incarceration. Dr. Voth noted that gateway substances
to methamphetamine use are alcohol and marijuana.

**CSAT Hispanic Workgroup Briefing**

*Ruth Hurtado, Chair, CSAT Hispanic Workgroup, Public Service Advisor,
SAMHSA/CSAT's Division of Pharmacologic Therapies,* and *Chilo Madrid,
Ph.D., National Advisory Council Member.* Dr. Madrid recognized members
of the multistakeholder workgroup and CSAT staff who participated in the
workgroup's initial meeting.

Ms. Hurtado described the U.S. Hispanic population and the workgroup's
charge. As the fastest growing minority group in the U.S., 40 million
Hispanics now account for 13 percent of the population. Two thirds of
the population is 25 years or younger, and Hispanics are projected to be
the largest minority group within 25 years. The workgroup has conducted
an internal assessment of CSAT's activities and set goals, which include
assessing the level of services CSAT grantees offer in Spanish-speaking
communities; focusing on workforce development; identifying and setting
priorities for recommendations for services improvement; and
collaborating across Centers in SAMHSA.

Research findings in 1999 show that among offenders convicted for drug
offenses, 42.6 percent were Hispanic, and only 11 percent of the
Hispanics in prison received substance abuse treatment. Survey findings
from 2002-2003 show increased illicit drug use among Hispanics; binge
alcohol use is a concern; and serious mental illness occurs among 9
percent of Hispanics.

Geo-maps show that 250 CSAT grantees are located in areas with 13
percent or greater Hispanic populations and that about 80 percent of
grantees offer Spanish-language services. The mapping process produced
information for the helpline and service locator, plus increased
treatment referral options. The workgroup also compiled an inventory of
Spanish-language publications. Ms. Hurtado reported on the May 2005
Hispanic stakeholders meeting, at which 13 key stakeholders conducted a
dialogue and developed the following recommendations for CSAT:

-   Train new Hispanic service providers using such models as
    *Promotores*; develop training opportunities for Hispanic addiction
    treatment program administrators and service delivery staff; develop
    science-to-service finance systems and license and certification
    training for Hispanic addiction treatment service providers.

-   Develop a substance abuse treatment toolbox for Hispanic service
    providers.

-   Create leadership development and mentoring training programs for
    local and regional use.

-   Work with Hispanic-serving institutions and health professional
    schools to attract more Hispanic students to the addiction treatment
    field.

-   Increase the SAMHSA/CSAT Hispanic workforce.

-   Ensure that service providers reflect the community they serve.

-   Create a center of excellence as a repository of Hispanic studies
    and other resources.

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-   With the Surgeon General develop a report to identify challenges and
    recommendations on addiction treatment issues in the Hispanic
    community.

-   Arrange uniform data collection on Hispanics by State and local
    providers.

-   Make every door a right door for Hispanic clients and their
    families.

-   Promote system integration at multiple levels for a spectrum of
    services.

-   Develop a targeted Hispanic RFA to address service capacity and
    workforce issues.

-   Mandate Hispanic staff integration for all CSAT grantees that
    operate in areas with high Hispanic service delivery areas.

-   Collaborate with the Centers for Medicare and Medicaid Services
    (CMS) to assist Hispanic providers.

-   Include Hispanics in RFA review panels and develop a Hispanic talent
    bank.

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```
-   Assist and support adaptation of CSAT's recovery program adapted for
    the Hispanic community.

Next steps for the workgroup include continuing to identify treatment
service gaps for Hispanics, continuing to expand services, and working
with CSAT leadership to set priorities and implement stakeholder
recommendations.

**Discussion.** Dr. Madrid explained that the *Promotore* concept
involves training grassroots workers to do outreach and case management.
Ms. Jackson noted that the South Florida Provider Coalition addresses
Hispanic issues and that her agency has a specific Spanish-speaking
program in addition to bilingual staff. Upon implementation of the
Spanish-language program, participation doubled. Dr. McCorry inquired
whether a national organization for Hispanic counselors exists. Dr.
Madrid, in noting that much of the Spanish community has difficulty with
the national licensing exam, stated that no association currently exists
and that few Hispanics belong to existing associations. Dr. Rafaela
Robles noted that Puerto Rico uses 25 publications in Spanish funded by
CSAP and that CSAT helped to translate the test for Hispanics. Puerto
Rico--trained counselors often go to the States where their bilingual
skills are valued. Dr. Moises Perez noted that a sense of urgency
accompanies the recommendations. Ms. Jackson observed that people in her
program who speak only Spanish have difficulties in making a living in
the community once they complete treatment, and their treatment failure
rate is higher.

**SAMHSA Data Strategy**

Stephenie Colston, Senior Advisor to the Administrator, SAMHSA,
responded to a Council request by discussing the development of SAMHSA's
data strategy. A workgroup convened in July 2003 to guide development
and continued refinement of SAMHSA's data systems. Consultants surveyed
SAMHSA and reported back to the workgroup. The consultants found that
SAMHSA lacks an enterprise model (which is soon to be a requirement in
HHS) that describes basic business processes, lacks an information
technology (IT) infrastructure to support data collection efforts, lacks
standard data definitions, lacks the ability to deliver data to policy
makers and managers in a timely fashion, has substantial overlap among
SAMHSA systems, is insufficiently involved in national data standards
and health informatics initiatives, and conducts surveys and studies
that do not justify their high precision and cost. In response, SAMHSA
convened expert subgroups for each finding to develop recommendations
and implementation plans. Consultants performed a gap analysis,
identified 33 data sets and information sources, and found that SAMHSA
is not ready for an enterprise model. SAMHSA determined that engaging in
developing an enterprise architecture will produce more efficient
business processes, cost savings, reduced burden on States and grantees,
improved data quality, and efficient and integrated IT support.

Progress is reflected in that the workgroup has developed a baseline
data reference model and determined that 44 percent of the data elements
did not match to any outcome measures. The workgroup is reviewing
administrative and programmatic performance measures in processing
grants and contracts. Eighty percent of NOMs have been defined.
Agreement has been reached with NASADAD and NSMHPD to phase in NOMs
collection in all States over three years, a significant challenge in
reducing the reporting burden. Data contracts also are being coordinated
and consolidated to increase efficiency and decrease waste.

Ms. Colston enumerated next steps: develop SAMHSA-wide performance
outcome measures; establish a SAMHSA-staffed data control board; make
the Office of Applied Studies fiscally responsible and accountable in
meeting the needs of Centers and Offices; produce management reports for
compliance and for oversight; map major surveys to SAMHSA program and
management outcomes; realign all data resources for functionality, cost,
and technology; coordinate and consolidate state data infrastructure
efforts and technical assistance; and identify IT solutions. Whether or
not state data infrastructure grants must be changed remains unknown.

**Discussion.** Mr. DeCerchio pointed out that changing state data
systems is a two-year process. Dr. Voth identified the issue of rapid
turnover of hardware and software systems, for which state agencies do
not have funds. Ms. Colston acknowledged also that every State has a
different IT structure. Dr. McCorry raised the issue of outcomes versus
processes of care, noting that in developing measures Washington Circle
has taken the approach of process of care as a model of recovery. He
asked how SAMHSA might look at that approach in terms of NOMs with an
underlying paradigm of substance abuse as a relapsing condition. He
suggested that using measures that are predictive of outcome rather than
outcome itself as the focus may help an identified person get help to
lead to recovery. In addition, Dr. McCorry advocated moving from outcome
to process-of-care measures tied more directly to the evidence base
rather than a global outcome of abstinence. Ms. Colston concurred,
stating the need first to move forward with outcome measures, in the
context of ability to demonstrate results and accountability for Federal
dollars, and then to proceed to process measures. Dr. McCorry suggested
that Council review the measures. Dr. Suchinsky suggested the need for
interagency coordination. He noted that the Department of Veterans
Affairs (VA) started a similar process doing outcome studies, which met
with disaster, and then focused more successfully on process measures.
Ms. Colston responded that an Office of National Drug Control Policy
(ONDCP) priority is a drug data initiative, and that she and Mr. Curie
advocate for common measures across Federal agencies that deal with
substance abuse. Dr. Madrid noted that the Texas data system works well
with broad support.

State Performance Measurement and Management Efforts under the Block
Grant

Anne Herron, M.S., C.R.C., C.A.S.A.C., NCACII, Director, CSAT Division
of State and Community Assistance, presented a brief history of
CSAT/SAMHSA's data activities, including experience with the Government
Performance and Results Act (GPRA) and the Performance and Assessment
Rating Tool (PART), noting that States are faced with requests for
similar data. For the substance abuse block grant, most States collect
more data for their own use than they submit to SAMHSA.

In December 2004 SAMHSA and States reached consensus on guiding
principals and on the NOMs; the State Outcomes Measurement Management
System (SOMMS) will collect, analyze, and use the data; and SAMHSA is
realigning its technical assistance resources to help States report and
use NOMs data. NOMs will be based on data already submitted to TEDS or
on ATR; States will collect admission and discharge data; and a unique
client identifier will enable tracking. Some States have reported
voluntarily on outcome domains, and SAMHSA is looking at States that are
doing a good job to be able to direct technical assistance. All States
report services within agreed-upon cost bands. Preliminary outcome data
show that States are reporting improvements in abstinence, employment
and education, housing, and criminal justice involvement.

Ms. Herron noted that NOMs appear at www.samhsa.gov, as do the Household
Survey, TEDS, and block grant application data. She explained how
different States use their data in different ways, but with similar
themes, and that performance management is a developmental process.
SAMHSA is working with the Office of Applied Studies (OAS) to modify the
TEDS system to collect data frequently upon admission and discharge, and
to provide expanded payment to States able to report NOMs data. SAMHSA
also is working with OAS on a single submission of data by States that
enables multiple uses of that data.

SAMHSA will meet soon with States about data issues. NASADAD is working
with its member organizations to support state-to-state technical
assistance and realignment of SAMHSA's technical assistance resources.

**Discussion.** In response to Council members' questions, Ms. Herron
stated that the three-year NOMs implementation period extends to the
close of FY2007 and that outcomes are measured between admission and
discharge.

**Public Comment**

*Mario de la Rosa, Florida International University, Miami, Florida,* a
member of the Hispanic stakeholder group, asked about next steps for the
process. Dr. Clark stated that CSAT will digest the recommendations and
put them into a time framework. Recommendations within CSAT's purview
will be addressed with dispatch and others will be referred to higher
management.

*Melissa Staats, National Association of County Behavioral Health and
Developmental Disability Directors,* encouraged CSAT and SAMHSA to
discuss data with county governments. She stated that in 22 percent of
States, county governments have data collection responsibilities but
operate in a communication vacuum about how to collect information to
align systems with NOMs. She encouraged CSAT to reach out to her
association. Ms. Staats also noted that the National Association of
Counties has convened a workgroup on methamphetamine.

**Screening Brief Intervention and Referral to Treatment (SBIRT)**

Tom Stegbauer, M.B.A., Lead Public Health Analyst, Organization and
Financing Branch, CSAT Division of Services Improvement, reviewed the
SBIRT initiatives. Introducing the topic he reviewed that although
substance abuse has significant social and financial consequences, and
effective treatments exist, few people obtain treatment. Illicit drug
use and alcohol abuse problems typically are not addressed in primary
care settings, although research shows that primary care is among the
best places to identify and address problems throughout the treatment
process. The SBIRT project involves emergency services, primary care,
trauma care, dental offices, and breast exam clinics, and generalist
settings.

Mr. Stegbauer explained that SBIRT's main goal is to bring screening and
brief intervention into primary care and to change how primary care
looks at substance abuse issues. The focus is to increase earliest
access to nondependent users, involve generalists and not wait for
specialists, eliminate barriers, increase numbers of brief
interventions, reduce the prevalence of disorders, and build coalitions
across providers in all areas. Core components include screening and a
brief identification using a numerical system that can trigger an
intervention or brief treatment. An intervention is an encounter that
raises awareness of persons that they have a problem, and brief
treatment can be the first step in the treatment process.

Six States and one tribal organization have SBIRT cooperative
agreements. Early data show that of 2,900 patients who entered the
system and had an intervention or brief treatment; at six-month
follow-up, a 39 percent change rate was achieved by people who were
drinking to intoxication and nearly a 20 percent improvement in the
abstinence rate was achieved by persons who used illicit drugs. Mr.
Stegbauer gave details of the SBIRT grants in Pennsylvania, Illinois,
Texas, New Mexico, California, and Washington State, and Cook Inlet
Tribal Council of Alaska. Through early May 2005, the program had
screened 15 percent more patients than targeted; the brief treatment
concept is encountering implementation difficulties among all grantees'
providers; and the number of referrals to long-term treatment is meeting
expectations. Every grantee is focusing on sustainability issues.

Other activities include work with Uniform Accident and Sickness Policy
and Provision Law Studies, CMS on coding, National Highway
Transportation and Safety Administration, ONDCP, and American Society of
Addiction Medicine. In the future grants will be awarded to colleges and
universities, possibly new grants to two more States in 2006, and
international collaboration.

**Discussion.** Mr. Stegbauer explained to Dr. Voth that SBIRT advocates
for, and grantees commonly use, the DAST. Mr. Stegbauer responded to Dr.
Fletcher's question that slightly more females than males are screened.
Dr. Suchinsky asked whether any data illustrates the impact on
individuals with dependence. Mr. Stegbauer explained that data will
emerge related to that topic, but it is anticipated that people will
move from high user to moderate user to low user. Dr. Suchinsky
suggested reporting differences with various drugs. Dr. McCorry's
question about the possibility of adding a mental health screen to SBIRT
was tabled for response by Dr. Clark. Mr. DeCerchio stated that
Florida's SBIRT program for older adults in senior settings is being
evaluated and suggested the potential for dealing with prescription
misuse and alcohol. He noted Mr. Stegbauer's comment about
implementation difficulties in brief interventions and postulated that
people may not be ready to engage in treatment. Mr. Stegbauer responded
that the program's experience matches research-informed expectations
that 20 percent of everyone screened will have a brief intervention,
that most of those people appreciate some brief advice, and that about 5
percent go on to further treatment. Ann Mahoney pointed out that
Illinois has started to make buprenorphine referrals connected to SBIRT,
but major issues are infrastructure and cost. Dr. McCorry suggested that
primary care is the best opportunity for some continuity of care, with
specialty care seen as episodic; even after extended treatment, recovery
support could be located at the primary care provider in a continuing
health relationship.

**Access to Recovery (ATR) Update**

Andrea Kopstein, Ph.D., M.P.H., Branch Chief, Practice Improvement
Branch, CSAT Division of Services Improvement, stated that CSAT has
begun to receive a trickle of GPRA data and that the Office of
Management and Budget (OMB) has just approved the ATR data collection
instrument. She enumerated ATR's requirements, noting that grantees must
assure client choice of service providers, implement a voucher system
for clinical treatment and recovery support services, conduct
significant outreach to a range of service providers including
faith-based organizations, and develop eligibility systems for treatment
and recovery support services, among others. All 15 ATR grants will be
operational by the end of May.

In discussing that status of ATR implementation, Dr. Kopstein stated
that by the end of April 2005, grantees had issued about 3,700 vouchers
and had agreed to serve 125,000 clients during the three-year grant
award period. The grantees offer a range of services and serve a range
of target populations. By the end of April, 1,700 clients had been
screened and assessed, with most getting vouchers and services. Many get
clinical treatment and recovery support services; some get one or the
other. Grantees use a variety of outreach mechanisms for clients and
providers, and are expected to manage programs based on the providers'
performance as assessed, in part, by client service satisfaction.
Grantees have many reporting requirements.

Dr. Kopstein summarized grantees by implementation status, target
population, and nature of services. ATR grantees include California,
Connecticut, Florida, Idaho, Illinois, Louisiana, Missouri, New Jersey,
New Mexico, Tennessee, Texas, Washington State, Wisconsin, and Wyoming,
and the California Rural Indian Health Board. All grantees have made
recent progress, and numbers of clients served and vouchers issued are
expected to swell. CSAT is providing technical assistance to grantees.
Dr. Kopstein stated that many grantees have training programs to help
nontraditional providers achieve eligibility standards and that ATR
supports multiple pathways to recovery and requires grantees to manage
performance based on outcomes that demonstrate client success.

### **Discussion.** Dr. McCorry inquired about the most difficult aspects of implementation. Dr. Kopstein responded that barriers included the relative lack of information regarding the recovery support services component and insufficient infrastructure to track vouchers issued and outcomes. Dr. Kopstein explained that grantees must determine how to bill for recovery support services, which apparently grantees are doing because increasing types of services are provided. Mr. DeCerchio emphasized the great differences in ATR from traditional systems and stated that infrastructure is a major challenge. Dr. Kopstein stated that adding recovery support services to the two grantees that already had established voucher systems for clinical treatment has challenged them. Dr. Clark emphasized that recovery support services are a cornerstone of the endeavor and that the list of providers will expand to community- and faith-based organizations. Ms. Bertrand commented that nontraditional services help people recover, despite their lack of sophistication. Dr. Kopstein stated that a new round of site visits is planned to observe barriers and issues and to determine needs for technical assistance. Mr. DeCerchio observed that a lasting benefit are the partnerships forged among faith- and community-based organizations and licensed providers. 

### 

### **Addressing Women's Treatment Needs: Opportunities and Barriers**

### Sharon Amatetti, M.P.H., Public Health Analyst, Coordinator, CSAT's Women and Families Coordinating Committee, CSAT Office of Program Analysis and Coordination, in response to a Council request, described CSAT's activities regarding women's treatment and barriers to treatment. Approximately 14 million men and almost 8 million women reported in 2003 that they had behaviors related to alcohol and other drug use that reflected a need for treatment, but only 9 percent of men and 8 percent of women who needed treatment got treatment. The vast majority of people who did not receive treatment did not feel they needed treatment. Forty-one percent were not ready to stop using; 33 percent cited cost or insurance barriers; 20 percent cited stigma; 17 percent felt they could handle the problem; and 12 percent reported access barriers. Ms. Amatetti noted that the issue remains of whether the treatment infrastructure would be in place if everyone were ready to access treatment. 

For the 5 percent of people who know they need treatment but do not get
it, barriers include cost, stigma, and other program characteristics.
Cost-related barriers for women include Medicaid coverage limitations
and restrictions on welfare payments due to criminal justice status.
Women are held to higher standards, especially in the role of mother or
expectant mother, and HIV status adds to reluctance to talk to family
members. Program barriers include restrictions on children in
residential facilities, family/partner resistance, higher prevalence of
co-occurring mental health needs and medication, greater prevalence of
trauma and programs unwilling to deal with it, unmet need for drug-free
housing with children or who want to be reunited with children, and
limited Narcotics Anonymous and Alcoholics Anonymous women-only
meetings.

CSAT's discretionary grant programs that serve predominantly women or
women only account for 25 percent of the portfolio. Women also are
served through the block grant set-aside for pregnant and parenting
women, and several ATR programs serve women specifically. Grantees have
undertaken strategies to address the barriers identified, including
helping clients applying for Medicaid and welfare, providing family and
couples support activities, conducting women-only groups, and providing
mental health assessment and services, among others.

**Discussion.** Dr. Fletcher asked about research findings on addiction
variability, and Ms. Amatetti responded that women use substances for
shorter periods of time at lower amounts than men to have serious and
multiple problems. Ms. Jackson stated that her program has worked with
women and children since 1992 and has had waiting lists throughout that
time. She concurred with Ms. Amatetti's list of barriers and noted that
the system to detect drug use at birth is poor. She suggested exploring
the Healthy Start program's screening tool, which seems to show that few
women need treatment. She observed that comprehensive treatment programs
for women, although expensive, are cost-effective when treating the
whole family. Ms. Amatetti noted that the National Center on Substance
Abuse and Child Welfare, which looks at the involvement of families in
the child welfare system due to parental substance abuse, is analyzing
State's policies on screening children in state hospitals that would
result in early intervention services.

Preliminary data show that States have had diverse responses; few
resources are available; and local interventions are better. Ms.
Amatetti reported that CSAT is working with NIDA and NIAAA to plan a
national women's conference on the evidence base. Mr. DeCerchio asserted
that block grant set-asides on targets for women**,** a significant
strength of Florida's substance abuse system, have resulted in a
proliferation of women's and children's programs that are funded
independently. He recommended looking into improving in-home services
that involve programs such as wraparound, harm reduction, and SBIRT. Ms.
Amatetti noted that CSAT has been organizing States' women's treatment
coordinators, has compiled and analyzed States' women's treatment
standards, and will share the analysis. Dr. Madrid noted that the threat
of losing their children is a barrier to women seeking treatment in
Texas. He asked about work undertaken by CSAT in this realm and about
Medicaid barriers. Ms. Amatetti responded that the National Center works
with state agencies and provides in-depth technical assistance.
Anti-stigma work regarding state agencies' responses to substance abuse
clients is ongoing, and investigation into other models is under way.

On Medicaid issues Ms. Rita Vandivort stated that substance abuse is an
optional program under Medicaid, but that she has spoken to most
grantees on how to use Medicaid to expand coverage. She asserted that
working with States is a better strategy than asking CMS to move in a
different direction. Mr. Voth suggested expanding SBIRT into student
drug testing or testing on demand with recovery support services. Dr.
McCorry suggested asking CMS to present to Council on financing the
system of care and Medicaid's role. Ms. Vandivort acknowledged that
bridges could be built around mutual initiatives. Dr. McCorry suggested
adding child care services for women in treatment to the ATR portfolio
and discussing with NIDA how the real role of women who are responsible
for children can be reflected in future research. Ms. Amatetti responded
that CSAT has revised its comprehensive model of women's services to
include child care; this will be reflected in the upcoming women's TIP.
Ms. Jackson noted that her agency has reached beyond child care to
assessing every child and providing developmental mental health services
to them, in an effort to prevent or bring to light earlier a next
generation of addiction. Her agency has negotiated joint custody with
the State for children under its care, which serves as an incentive for
mothers to remain in treatment. Mr. DeCerchio suggested asking the
Robert Wood Johnson Foundation and the Administration for Children and
Families to discuss financing and overcoming barriers. Ms. Vandivort
stated that SAMHSA is developing a comprehensive catalog of funding for
providers and then will focus on blending and braiding funding streams.
Ms. Amatetti responded to a question from Mr. Donaldson about the
Healthy Marriage Initiative that CSAT has worked closely with the Office
of Family Assistance, whose legislative language for reauthorization
stipulates that substance abuse treatment can be an allowable work
activity.

**Partners for Recovery Workforce Development Update**

Karl White, Ed.D., Public Health Analyst, Practice Improvement Branch,
CSAT Division of Services Improvement, and Donna Cotter, M.B.A.,
Partners for Recovery Coordinator, CSAT Office of Program Analysis and
Coordination. Dr. White described an upcoming report on workforce
development, the product of an initiative that began in 1999 and that
included an environmental scan of relevant activity on the subject
followed by stakeholder meetings in 2004. The background work revealed
problems and inconsistencies in the composition of the workforce.
Problems include mismatch between the workforce and clientele, lack of
formal undergraduate addiction training, and insufficient full-time
medical staff and nurses. Trends that impact the workforce include
insufficient capacity to meet demand, a changing profile of persons
needing services, increased public financing of treatment, low literacy
in English and Spanish, challenges and barriers to adopting
evidence-based practices in many settings, increased use of medications
in treatment, movement to a full spectrum of recovery support services,
provision of intervention and treatment in nontraditional treatment, use
of performance and patient outcomes**,** and stigma.

The report examines such infrastructure issues as a workforce shortage
reflected in staff turnover/churning for better pay and increased
treatment capacity but insufficient providers to treat clients;
accountability, performance measures, aging leadership and management;
sustainability and replacement of leaders; recruitment issues such as
low salaries and few individuals certified as addiction specialists
across disciplines; inconsistent academic education and lack of
accreditation; and retention difficulties and lack of safety net.

Recommendations include establishing career paths, loan forgiveness for
addiction counselors, training for clinical supervisors that includes
implementation of evidence-based practices, attending to leadership
sustainability and financial training, expanding recruitment of health
care professionals, improving diversity in academic programs, supporting
adoption of accreditation standards for health professions, addressing
substance misuse and relapse in the workforce, and encouraging NIDA- and
NIAAA-funded studies. Next steps include content clearance and
dissemination of the report, incorporating findings into the substance
use disorder treatment portion of SAMHSA's Strategic Plan for Workforce
Development, and engaging stakeholders.

Ms. Cotter noted that Partners for Recovery (PFR) supports the workforce
report and leadership institutes, which are intensive six-month programs
that offer a variety of training opportunities. Fifteen leadership
institutes have been scheduled for regions across the nation from 2003
through 2005, with 145 emerging leaders trained and two institutes
focused on Hispanic clinicians. Intended outcomes are to develop and
retain potential leaders for the addiction field and to build capacity
to meet organizational and system demands. The six-month institute
offers protégés a formal assessment, five-day immersion training,
individual leadership development plan, experiential
learning/mentorship, and awarding of CEUs, among other benefits.
Evaluation criteria are under development and a second round of
institutes will begin in October 2005. ATTCs have been involved with the
institutes.

Additional PFR activities include the "Know Your Rights" brochure, also
to be released in Spanish, with pilot regional trainings nationwide,
stigma-reducing activities, logistics support on a September 2005
recovery summit to define principles of recovery and discuss systems of
care to support recovery, and a 2004 forum to initiate dialogue for
substance abuse treatment, prevention, and mental health. A reconfigured
PFR steering committee, with representation from the three disciplines,
is to reconvene in July 2005. Among several other activities PFR
supports state conferences and developing a website, www.pfr.samhsa.gov.
Although PFR is targeted for a 50 percent cut in the FY2006 budget,
staff will do its best to keep the initiative alive.

**Discussion.** Mr. DeCerchio and Dr. Madrid complimented CSAT on the
initiative. Dr. Madrid suggested partnerships on activities the Hispanic
workgroup described.

**Treatment for Persons with Co-Occurring Disorders**

Charlene E. Le Fauve, Ph.D., Branch Chief, Co-occurring and Homeless
Activities Branch, CSAT Division of State and Community Assistance,
discussed CSAT's efforts regarding co-occurring disorders. She described
the breadth of circumstances in which co-occurring disorders reveal
themselves, but noted that how to address service delivery issues and
challenges in real-world settings nationwide is not well understood.

Dr. Le Fauve noted that recent data show high prevalence of co-occurring
disorders and that people with co-occurring disorders are at greatest
risk of committing suicide. Protective factors are clinical treatment
for mental illnesses and substance abuse and successful encounters with
care, but the percentage of persons who receive treatment is far lower
than that of those who need it. Up to half of homeless adults have
co-occurring disorders, and the criminal justice system is overly
represented with people with co-occurring disorders.

The field wants to know about best screening and assessment approaches,
evidence-based practices, payment strategies for services, and workforce
development. In response, SAMHSA works collaboratively on barriers and
challenges associated with co-occurring disorders and provides policy
and planning, funds for contracts and grant programs, information
dissemination, and tools to help the field. [Some]{.underline} SAMHSA
initiatives [highlighted]{.underline} include Co-occurring State
Infrastructure Grants (COSIG), Co-occurring TCE Grants, a quadrant
validation and screening instrument, quadrant operationalization, and
homeless initiatives. SAMHSA's Co-occurring Center of Excellence (COCE)
provides technical assistance and funding to COSIG States in
collaboration with CMHS, supports grantees in systems change and
infrastructure development, helps overcome service delivery barriers,
enhances service coordination, improves financial incentives, and shares
information among stakeholders. Fifteen grantees have COSIGs. The
quadrant model serves as a conceptual framework to improve systems of
care by addressing individuals' symptom severity and level of service
coordination, and a study is underway to operationalize the framework.
The co-occurring policy academy model helps to develop state action
plans to enhance provision of services. CSAT is exploring a national
summit on co-occurring disorders for American Indian/Alaska Native
populations, and CSAT is working with the Co-occurring Disorders Matrix
Workgroup to identify user-friendly bits of TIP 42 targeted to primary
care. Dr. Le Fauve noted that COCE products and activities are available
at www.coce.samhsa.gov and emphasized the importance of comprehensive
and integrated systems of care.

**Discussion.** Dr. Madrid asked about funding strategies for
chemotherapy for individuals with multiple diagnoses. Dr. Le Fauve
stated that CSAT is collaborating with NIAAA on medications for alcohol
dependence and buprenorphine and those discussions on pharmacotherapies
for co-occurring disorders will continue. CSAT has no active
pharmacotherapy program to treat co-occurring disorders. Dr. Hoffman
anticipates continued work with CMHS on evidence-based practices and
integration of fields. Dr. McCorry noted the need for integrated care
within the substance abuse and mental health systems for persons whose
mental health issues do not place them in the category of serious mental
illness. He also questioned what effective functional models of
coordinated care look like between systems. Dr. Le Fauve responded that
TIP 42 offers general guidelines for models and targets particular
disorders. Dr. Jim Herrell stated that the small number of NREPP
submissions on interventions for co-occurring disorders does not refer
to systems, and Dr. Le Fauve noted that COSIG grants have not yielded
answers on what such a system should look like. Dr. Herrell stated that
COSIG grants aim to reorganize the way States provide services, and some
States may produce good evidence.

Ms. Jackson asked whether any agencies across the country that use
pharmaceuticals have an assessment system for co-occurring disorders.
Dr. Clark stated that TEDS data show use of pharmacotherapy for
addiction, but not for co-occurring disorders. He noted the need, in a
no-wrong-door paradigm, for Medicaid eligibility to prescribe
medications. He stated that jurisdictions vary in their definitions for
eligibility for mental health benefits, but most include serious mental
illness at a minimum. Mr. DeCerchio stated that, according to service
providers, financing of psychotropic medications is an increasingly
difficult issue.

Dr. Clark suggested the need for cognitive behavioral strategies to
facilitate treatment adherence, but the issues raised must be addressed
by both the substance abuse and mental health fields. From a disability
point of view, many persons with substance abuse problems are not
recognizably disabled and thus are ineligible for Medicaid-funded
medications. Dr. Voth noted that the Council emphasizes the need for
affordable psychiatric medications at all levels. Dr. Clark concurred
with the need to use existing resources to highlight these issues.

Ms. Bertrand observed that much of the day's discussion involved
integrating co-occurring disorders, women's issues, and trauma into
substance abuse [issues;]{.underline} she asserted that these
discussions relate to workforce development and finding ways to leverage
assistance from systems outside substance abuse systems. Ms. Jackson
concurred, noting the practical difficulty in treating people with
co-occurring disorders without coordination with other relevant systems.
Dr. Clark observed that the aim of the co-occurring policy academy,
COSIG strategy, and COCE is to develop an integrated, no-wrong-door
policy and identify barriers to care.

**Council Roundtable**

Mr. DeCerchio noted the reduced budget for evidence-based practices and
urged continuation of work with NIDA and NIAAA. Ms. Jackson noted that
NIDA is concerned with methods to sustain evidence-based practices and
move them into general practice. She recommended that the NIH connection
continue. Dr. Clark enumerated the several ways in which SAMHSA is
working with NIH Institutes, including sponsoring attendees at NIDA's
CPPD meeting on research developments and translating science to
services. He cautioned, however, that if effective programs are not
implemented in practice, they do not work. Ms. Jackson identified the
issue that many evidence-based practices are too costly to implement,
citing the need to compile manuals of group processes the field knows to
work. Dr. Clark stated that the interagency dialogue is important and
will continue. Dr. McCorry stated his desire to understand how to cross
systems in financing systems.

The meeting adjourned at 4:50 p.m. and reconvened the following day.

**Friday,** **May 20, 2005**

***Closed Session***

Dr. Clark opened the closed session of the CSAT National Advisory
Council at 9:00 a.m. for a secondary review of grants.

***Open Session***

The open session of the Council meeting resumed at 10:00 a.m. with a
welcome from Dr. Clark.

**Recovery Month Update**

Ivette Torres, M.S., M.Ed., Director, Consumer Affairs Office, CSAT
Office of the Director, highlighted the societal benefits of Recovery
Month, to reduce stigma and empower people in recovery. Recovery Month
helps to spread information that leads to addressing addiction issues
and increasing the number of people who enter treatment. CSAT has
created a variety of materials and activities to support Recovery Month,
and the campaign has won more than 10 awards. The www.recoverymonth.gov
website is nearing 1-million hits per month. CSAT hosts a series of
webcasts in more than 150 cable markets and sells CDs and tapes to
communities that use them for training. Ms. Torres showed a Road to
Recovery promo and explained the resources available on the website. She
encouraged Council members to participate in ask-the-expert online
panels.

Ms. Torres explained that CSAT is supporting events in new communities,
particularly rural and urban areas. At least 10 Major League Baseball
teams participate. Forty-seven events were planned for 2005 prior to kit
distribution; the 417 events in 2004 represented 44 percent growth over
previous years. The goal for 2005 is 1,000 events. CSAT has invited the
Veterans Volunteer Network to collaborate. Governors, majors,
legislators, tribal administrators, and other leaders sign
proclamations. Ms. Torres showed the two public service announcements
(PSAs), in English and Spanish, produced for Recovery Month that will be
shown nationwide on prime-time television. She noted that either the
webcasts or the PSAs are in jeopardy because of budget constraints, and
CSAT is seeking foundation or other agency help. Ms. Torres noted that
CSAT might work with NCADD on PSAs compatible with the Recovery Month
message.

**Harm Reduction and Drug Policy**

Eric Voth, M.D., National Advisory Council Member, as background for his
discussion of a change in what he termed "so-called harm reduction
policy," presented a brief overview of the movement. He explained that
traditional drug policy is abstinence based, including harm elimination
for treatment, primary or harm prevention, and an emphasis on no drug
use as the goal. He noted the difficulty in achieving the goal and that
legal enforcement underlies the policy. He asserted that as community
enforcement policies and norms change, the paradigm shifts to more drug
use. Currently three philosophies are prevalent in the drug policy
arena: abstinence-based policy, legalization of drugs, and a hybrid
harm-reduction/legalization orientation.

Dr. Voth asserted that harm reduction is most effective only in
promoting legal, socially acceptable behaviors, such as seatbelt or
helmet use. He noted that the so-called harm reduction movement
undermines prevention efforts by seeking to encapsulate users and to
reduce societal harm, focusing only on addicts, and offering little to
nonaddicted drug users. He highlighted the need to look at the whole
population in an effective drug policy. The movement promotes
"responsible use" messages targeted to underage youth, medicalization,
and needle exchange, forms of methadone maintenance, heroin handouts,
"safe crack kits," and treatment moderating use rather than aiming for
abstinence.

Dr. Voth identified several examples of failures of harm reduction
policy. Despite alcohol being the biggest addictive problem second to
tobacco, massive alcohol advertising campaigns target teens. The book
It's Just a Plant targets pre-teens with a "responsible marijuana use"
message. Dr. Voth characterized the medical marijuana movement as a
diversionary tactic for legalization. He noted that needle exchange
programs began with good intentions, but negatives include insufficient
numbers of clean needles to meet addicts' needs and millions of
discarded needles annually in the U.S. alone. He noted that a rigorous
meta-analysis, undertaken in Sweden, of research that has supported
needle exchange reveals such methodological problems as small sample
sizes, no control groups, self-selection of participants, high drop-out
rates, and self-reporting of behaviors; moreover, randomized controlled
trials show no differences in benefits and diverse results. Several
additional studies show riskier needle-use behaviors and higher rates of
HIV/AIDS seroconversion and incidence of hepatitis B and C among
needle-exchange participants than nonneedle-exchanging populations.
Although needle-exchange proponents have claimed that their programs are
gateways into treatment, a Puerto Rican study shows no significant
change in injection habits and that only 9.4 percent of participants
entered treatment. With Denmark's open needle exchange with no
guidelines, HIV incidence remained steady for the period 1991-1996;
Norway and Sweden, with limited or no handouts but aggressive reporting,
counseling, and intervention, experienced an HIV rate one third as high
as Denmark's.

Problems with needle exchange include poor rates of needle return, no
clear reduction in HIV or hepatitis B and C, no strategy to change the
underlying destructive behavior of intravenous drug use, and creation of
an atmosphere supportive of use. No advantage is shown over outreach and
abstinence-based programs. There appear to be a waste of limited
financial resources, potential product liability risks, risk to the
community for needle sticks, and risk from homicide or disease.

The Swiss heroin handout program was tainted by migration that resulted
in no comparison groups in addition to such problems, for example, as
self-reported results, no data on addicts, no independent random drug
testing, and no independent HIV evaluation. Dr. Voth noted Baltimore's
progress with mandated treatment and not just harms reduction. He stated
that a lenient drug policy has led Canada to become a source country for
drugs; in addition to needle exchange, a heroin handout policy is being
initiated. England has seen a significant increase in marijuana use, and
police think decriminalization was a mistake. Holland's harm reduction
policy and marijuana tolerance have led to high use among adolescents,
increased organized crime, and ecstasy exports.

Dr. Voth stated that he supports, on international basis, a broad
approach to prevention, treatment, and interdiction---harm elimination
through treatment. He asserted that some segments of the harm reduction
movement have developed into a harm production movement.

**Discussion.** Ms. Jackson noted the necessity to discuss harm
reduction in applications for Federal grants and asked about agencies'
policies. Dr. Voth noted that policies are diverse and sometimes
contradictory, but that the White House does not support harm reduction
or related policies. He asserted that CSAT should not support harm
reduction.

Dr. Suchinsky observed that although the literature has shown that
treatment can produce improvements despite an imperfect technology,
persons who promote legalization and harm reduction activities
nevertheless consistently ask for proof that treatment works. Dr.
Suchinsky asserted that the crucial issue is stigmatization and bias
involved in attitudes towards people who use substances and people who
treat people who use them, and emphasized the necessity to address
stigma. Dr. Voth noted cynicism among harm reduction proponents, who
would encapsulate addicts and keep them from hurting society.

Dr. McCorry stated that he takes another view of harm reduction, which,
he asserted, is larger than merely syringe exchange programs. He noted
that New York State's syringe exchange program has reduced HIV rates and
that the SBIRT program employs a harm reduction approach in helping
problem drinkers reduce their alcohol use---not to achieve abstinence,
but rather less problematic use. He asserted that individual therapists
use a harm reduction approach to retain persons in therapy, recognizing
the propensity to relapse. Dr. McCorry acknowledged that countries' drug
policies are a separate discussion. He stated that he would be
interested in more discussion about the data, which he had thought to be
not as poor as presented. He requested a copy of the Swedish
meta-analysis. Dr. Voth responded that a focus on harm reduction as an
endpoint is dangerous and that the ultimate goal should be abstinence
based. He acknowledged that an element of needle exchange in the process
of trying to gain control over addicts' situations may be reasonable.
Dr. McCorry identified the clinical tension in how much one can tolerate
in an individual patient's behavior without acting on it. He noted that
recovery encompasses much more than nonuse and that harm reduction on
the path toward recovery is an appropriate clinical model. As a default
into an acceptance of a lifestyle detrimental to the community as well
as the individual, "harm reduction" expectations are not sufficient
therapeutically. Dr. Clark pointed out that Federal dollars cannot be
used to support needle exchange programs.

**E-Therapy Update**

Valera Jackson, National Advisory Council Member, and Sheila Harmison,
D.S.W., L.C.S.W., Special Assistant to the Director, CSAT, updated
Council members on e-therapy. Ms. Jackson described the routine use of
Internet technology in telemedicine, matchmaking, psychiatry, education,
and counseling, and identified the necessity to look at providers'
qualifications and outcomes. Ms. Jackson acknowledged that she recently
has become more open to the possibilities of e-therapy. Online therapy
can be conducted by e-mail and by participation in webcasts and
listservs. She noted that articles have appeared recently on behavioral
counseling and the Internet, and that more studies are underway. She
observed the need to admit the impossibility of providing face-to-face
treatment to all people and in all places where there is need.
Underserved populations currently include Native American communities,
rural clients, prescription drug abusers, older adults, and clients with
co-occurring disorders, women, juveniles, and gay, lesbian, bisexual,
and transgender individuals. Barriers to face-to-face therapy include
transportation and stigma. She noted that her program plans to teach
juveniles how to interact with an aftercare group, give each young
person a \$200 computer, and do follow-up and aftercare through the
Internet. Research has shown that attrition is lower in online
treatment.

Challenges to e-therapy include credentialing of counselors and
geographical considerations, measuring outcomes and effectiveness,
confidentiality and privacy issues, lack of technology and expertise,
reimbursement for services, cultural issues, cost/benefit analysis, and
ethical and legal guidelines. Ms Jackson noted that nothing in Florida's
reimbursement rules precludes Internet counseling, which could fit into
services already provided through the block grant, state maintenance, or
other SAMHSA programs. While some raise the concern of how to do therapy
without the inputs of eye contact and body language, studies have shown
that people have grown sufficiently comfortable with technology to
establish bonds without them.

Dr. Harmison described CSAT's e-therapy activities, including
presentations to help minority students understand e-therapy and to
inform the Appalachian Regional Commission on telehealth and SAMHSA's
focus on substance abuse prevention, treatment, and mental health
services.

Suggestions from the field include the possibility to reimburse
e-therapy services in a way that is budget neutral, performance based,
and does not depend on the modality of the therapy. The Texas Juvenile
Probation Commission proposes a pilot project to provide culturally
competent mental health and substance abuse treatment through
telemedicine for a diverse juvenile population in a program that offers
recovery support services provided by faith communities. Secretary
Leavitt issued a report that highlights the urgent need for investment
in information technology and for stakeholders to understand the
potential benefits and costs of health information technology. Dr.
Harmison stated that CSAT is participating in discussions on electronic
health records. She suggested that CSAT's Council establish a
subcommittee on e-therapy and that CSAT support the effort with a
comprehensive literature review, help rank issues, convene advisors and
experts, support a preliminary needs assessment on the lack of access or
capacity for substance abuse treatment, and support development of an
e-therapy TIP.

**Discussion.** Ms. Jackson noted that establishing a subcommittee would
allow Council members to participate in panels and meetings. Dr. Madrid
stated that he is working with the Texas Juvenile Probation Department
to develop Spanish-language e-therapy; among the issues that confront
this effort are sustainability and outreach to access probationees in
rural, remote, frontier, and other areas. He volunteered to be part of a
study group. Dr. Clark noted that the VA has used telemedicine as an
adjunct to medical and psychiatric care.

Council approved unanimously Ms. Jackson's motion to establish a Council
subcommittee that addresses e-therapy's treatment and recovery in
substance abuse through electronic modalities and to explore. Judge
White Fish volunteered to serve on the subcommittee, noting his concerns
about cultural and quality issues. Mr. DeCerchio expressed his belief in
the promise of e-therapy and the need for developing standards and
addressing licensure issues.

**Update on Community- and Faith-Based Activities**

David Donaldson, National Advisory Council Member, and Jocelyn
Whitfield, CSAT, updated the Council on the faith-based subcommittee,
whose members include Dr. Fletcher and Ms. Bertrand. He observed that
the faith community is becoming increasingly involved in social outreach
and more willing to partner with government. Faith communities have
opportunities to provide a continuum of care, including recovery support
services, and to reduce and eliminate stigma, fostered by government
affirmation of the value of faith-based organizations. He asserted that
the mission of the partnership is not to publicly fund proselytizing,
but to increase the capacity of faith- and community-based organizations
to provide clients with higher quality treatment and/or recovery
services.

Mr. Donaldson presented his "5R" Strategy: building relationships
between faith communities and government agencies; representation,
building coalitions to apply jointly for resources; results, and
becoming certified to provide services; resources, leveraging private
with public funds and engaging in grant-writing education; and
replication, multiplying and documenting effective models and teaching
how to adapt them. Obstacles include skepticism about accepting
government resources, need for operational definitions, and limited
capacity. Strategies to address the challenges include meeting training
needs through organizational assessments and conducting local mentoring.

Ms. Whitfield stated that Dr. Clark will visit each of the 15 coalitions
formed as a result of CSAT/SAMHSA's technical assistance. In describing
the coalitions, she noted that most providers have nonprofit 501(c)(3)
status, three years of operational experience, and staff capacity to
provide services in their communities. Some are certified and licensed
by their States and others are meeting recovery standards. CSAT has
provided technical assistance in certification, fiscal management, grant
and proposal writing, and project management---all of which has produced
good results. Mr. Donaldson stated that outcomes sought include
developing a strategic plan for each organization, equipping and
mobilizing volunteers, identifying candidates with highest potential to
deliver ATR resources, securing sustainable funding, identifying grant
opportunities, writing proposals and managing grants, documenting model
programs, and evaluating outcomes for continuous quality improvement. He
highlighted the Full Circle Health model, which serves 1,500 active
patients and has received a \$467,000 grant from the Red Cross. He noted
the importance of continued adequate funding.

**Discussion.** Ms. Bertrand noted the importance of making it clear
that inclusion of faith- and community-based organizations is a priority
of this Administration. She urged Council members to think of ways to
ensure the integrity of the program and to work with organizations. Dr.
Clark noted that both the President and Secretary have made clear that
organizations need not write grants, but just provide competent services
and account for the funds. Faith-based organizations with relationships
with individuals adversely affected by alcohol and drugs are valuable.
Ms. Jackson observed that while ATR is an important movement, its reach
is limited. She urged expanding ATR to other jurisdictions. Dr. Clark
explained that a basic tenet of ATR is consumer choice, and that
organizations that over time demonstrate accountability and support
recovery, and whose clients do well will do better than those
organizations that do not. He asserted that innovative programs need not
suffer under ATR. Dr. Madrid extended an invitation to an international
drug treatment conference in July 2005 that will address ATR issues.

Dr. Fletcher noted that ATR outcomes include building indigenous
capacity within communities and organizations learning about best
practices to help further social ministry in communities. ATR offers the
opportunity for cooperation with institutions of higher learning in
communities to help sustain efforts in community building. Ms. Whitfield
noted that Clif Mitchell and she have worked over the past several years
to build and sustain capacity among faith- and community-based
organizations in communities. Mr. DeCerchio observed that relationships
between faith-based organizations and State agencies cannot be based on
funding alone; conversations must focus on how to connect and benefit
from clinical treatment, access to training, and supports for
communities. He urged States and territories to initiate dialogues
before funds appear on the horizon, since sustainability depends on
enduring partnerships and commitments.

Dr. McCorry asked for the names of persons involved in the New York
coalitions. He drew a parallel between the role of SBIRT, where
treatment is an episode in a continuous health relationship, and the
role of faith- and community-based organizations that have ongoing
familial and community links.

**Council Roundtable**

Ms. Jackson raised the issue that the cost of training for certain
evidence-based and best practices, including practices developed with
public funds, is so high that it serves as a barrier to scaled-up
implementation. Dr. Clark echoed her concerns about the issue of
privatizing of public sector--driven knowledge, and cited the need to
monitor these developments. He noted that CSAT has used Best Practices
funds to translate research developed by others into digestible
components to make knowledge acquisition more affordable. He observed,
by comparison, that the laser eye surgery community revitalized
ophthalmology by slashing surgery prices because of increased
availability of services and efficiencies. Dr. McCorry stated that
copyright issues also are involved with research conducted with public
dollars. Dr. Clark noted the paradox of inviting faith- and
community-based organizations to participate and making the cost of
doing business prohibitively expensive.

Dr. Clark noted that Council will meet by teleconference on September 7,
2005, to review remaining grants and again on September 14-15. He
invited Council members to bring agenda items to Ms. Graham's notice.
The meeting adjourned at 12:35 p.m.

I hereby certify that, to the best of my knowledge, the foregoing
minutes are accurate and complete.

[\_\_\_\_\_02/03/06]{.underline}\_\_\_\_\_\_\_
\_[/s/]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Date H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Chair

CSAT National Advisory Council

Director

SAMHSA's Center for Substance Abuse Treatment

####