**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration (SAMHSA)**

**Center for Substance Abuse Treatment (CSAT)**

**Minutes of the**

**45th Meeting of the**

**CSAT National Advisory Council**

**February 2-3, 2006**

**1 Choke Cherry**

**Sugarloaf and Seneca Conference Rooms**

**Rockville, Maryland 20857**

**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration**

**Draft Minutes**

**45th Meeting of the**

**CSAT National Advisory Council**

**Rockville, Maryland**

**February 2-3, 2006**

**[Thursday, February 3.]{.underline}** CSAT Director H. Westley Clark,
M.D., J.D., M.P.H., convened the open session on February 2, 2006, at
9:15 a.m. Members present included Anita B. Bertrand, M.S.W.; Kenneth A.
DeCerchio, M.S.W.; Melody M. Heaps, M.A.; Valera Jackson, M.S.; Chilo L.
Madrid, Ph.D.; Francis A. McCorry, Ph.D.; Gregory Skipper, M.D.; Judge
Eugene White-fish; and Richard T. Suchinsky, M.D. (ex officio). Also
present were George Gilbert, J.D., Acting Deputy Director, CSAT, and
Cynthia A. Graham, M.S., Executive Secretary, CSAT National Advisory
Council.

**[Welcome.]{.underline}** Dr. Clark welcomed participants to the
meeting and observed a moment of silence in memory of Dr. Sheila
Harmison, former special assistant to Dr. Clark, and Christine Peterson
Braverton, daughter of Council member David Peterson.

**[Minutes, May 14-15, 2005.]{.underline}** Council members voted
unanimously to accept the minutes of the May 14-15, 2005, CSAT Council
meeting as presented.

**[Council Introductions.]{.underline}** Council members introduced
themselves and highlighted recent activities. Dr. Heaps reported that
Illinois is considering an alcopops tax. Her organization, TACS, has
earned press coverage for its work in the state's largest corrections
treatment center. Dr. Madrid is working to develop his state
association's legislative agenda for 2006 and reported that the
Association of Substance Abuse Service Providers sponsored a faith-based
conference for 300 teenagers and 100 parents that offered counseling and
interventions. Dr. McCorry stated that New York State is promoting
adoption of a mental health screen in its substance abuse programs in an
effort to adopt a no-wrong-door policy for co-occurring disorders and to
support adoption of evidence-based practices. Dr. Clark noted that New
York has increased its substance abuse budget by 11 percent. Ms. Jackson
noted that she serves as chair of the South Florida Provider
Association. Florida now allows managing entities increased autonomy in
funding local service providers, including combining substance abuse and
mental health dollars. Dr. Suchinsky reported that the Department of
Veterans Affairs has implemented its Mental Health Strategic Plan, which
increases funding for substance abuse treatment and targets expansion of
buprenorphine availability. The VA will hold regional training programs
for its physicians for buprenorphine certification. Judge White-fish
stated that the National American Indian Court Judges Association and
the National Congress of American Indians are addressing the
methamphetamine problem. Their work focuses on how to surmount
jurisdictional difficulties related to the sovereignty of Indian
nations. State and courts are working with Indian courts to address
communities' substance abuse problems, particularly by drug courts. Dr.
Skipper serves as co-principal investigator on a national study of
physician health programs, which enjoy success in substance dependence
treatment. He noted that ethyl glucoronide (EtG), a marker to determine
abstinence, has come onto the market, but false positives warrant
further study. Ms. Bertrand stated that her work with minority
adolescents has expanded to a variety of projects, including peer
recovery support and making a documentary film. Mr. DeCerchio reported
that Florida is implementing Access to Recovery (ATR), CSAT's Strategic
Prevention Framework, and mental health transformation. A workgroup of
state agency heads focuses on reducing underage drinking; communities
are developing local action plans to integrate substance abuse and
mental health services to families in the child welfare system; Brief
Referral Intervention Treatment to Elders (BRITE) is generating
reductions in use among older adults; and disaster recovery programs
continue to provide substance abuse and mental health services.

**[Director's Report.]{.underline}** Dr. Clark enumerated staff changes
at CSAT. Richard Kopanda serves temporarily as CSAP acting director, and
George Gilbert serves as CSAT's acting deputy director. Karl White is
representing SAMHSA in Vietnam, working with the Office of Global Health
on HIV and substance abuse. Dr. Clark pointed out that retirement of
CSAT staff members offers opportunities for younger staff to advance.
New employees include Jorielle Brown, Sherrye Fowler, Christina Lynn,
Lisa Creatura, and Linda Kaplan. Anne Herron serves as acting director,
Division of Service Improvement, and John Campbell serves as acting
director, Division of State and Community Assistance.

Dr. Clark reported that Congress passed the FY 2006 budget, which
appropriates \$398.9 million for CSAT, a reduction of \$48.2 million
from the president's request and a \$23.5 million reduction from FY
2005. Congress continued ATR funding at current levels, decreased
funding for SAPT block grants by \$17 million (at \$1,758.6 million)
from FY 2005, imposed a 1 percent across-the-board reduction in funding,
and omitted substantial Congressional earmarks. Work on the FY 2007
budget continues.

Dr. Clark stated that Congress has removed a ban on the 30-patient limit
for group practices to administer buprenorphine, and CSAT expects to
issue a Notice of Proposed Rulemaking that addresses removing the
30-patient limit on individual practitioners. Several jurisdictions are
moving toward electronic prescription monitoring, an activity under
discussion at SAMHSA.

CSAT convened a meeting of community and faith-based organizations to
increase ATR's focus on recovery support services. CSAT's Community and
Faith-Based Technical Assistance Initiative helps community and
faith-based organizations build capacity to provide effective services
and successfully apply for and receive federal grants. CSAT is pursuing
ATR education forums, HIV/AIDS expert panels, and capacity building in
communities on HIV/AIDS.

Recovery Month in September 2005 began with a major prevention effort,
and planning has begun for 2006. Dr. Clark emphasized the need for
communities to view recovery as beneficial to the entire community. One
event was the release of the 2004 National Survey on Drug Use and
Health, which found that youth ages 12-17 have decreased their drug and
alcohol use, but young adults ages 18-25 have not. Recovery Month
encompassed 41 community events that reached approximately 35,000 and
generated a collective media circulation of 3 million. The "Treat Me"
2005 PSA received two silver Omni Awards and a gold Mercury award.

CSAT is working with the governments of Mexico and Vietnam. Dr. Clark
reported that although the number of home labs that produce
methamphetamine has declined, use of the drug has not. Purity, cost, and
related crime are also increasing. Mexico exports methamphetamine to the
U.S., making a positive relationship with Mexico important to address
the issue.

Dr. Clark enumerated several additional CSAT activities. CSAT and the
National Association of Children of Alcoholics launched a pilot
nondenominational recovery training program for clergy leaders and
congregants. Several new consumer publications are available. CSAT is
working with NIH to obtain the most recent information possible to share
with communities. CSAT's helpline usage continues to grow. CSAT will
host community education forums on medication assisted therapies.
Tracking of buprenorphine reveals some diversion among people who cannot
afford the medication, but drug companies have created a compassionate
program to which people without resources can apply. Two publications on
methadone are under development.

***[Discussion.]{.underline}*** Ms. Heaps suggested adding presentations
on SBIRT and ATR to an upcoming Council agenda. Ms. Jackson suggested
renewed focus on e-therapy.

**[SAMHSA Update.]{.underline}** Mr. Charles G. Curie, M.A., A.C.S.W.,
Administrator, SAMHSA, noted the evolution of recovery from a personal
process to ATR, a presidential initiative that embraces public policy
and public finance. Initial ATR data from states indicate areas of
success and areas for additional attention. Mr. Curie asserted that ATR
reflects many pathways to recovery. He noted the need for accountability
based on outcomes, a focus on public safety, and ensuring that providers
are eligible and transparent. He discussed the political issue related
to faith-based providers, asserting that ATR is based on choice and
noting the importance of acknowledging persons' experiences with faith
in their recovery. Although Mr. Curie stated that he considers CSAT's
reduced budget to be a lost opportunity to expand treatment capacity,
ATR has met its first-year goal of serving 25,000 clients, and
participation of recovery support services providers, including
faith-based providers, is increasing. Mr. Curie noted that many success
stories are emerging. The ATR program is the first major initiative to
implement the National Outcome Measures System (NOMS) to measure
recovery and the impact of services. Mr. Curie views NOMS as a way to
measure the effectiveness of all SAMHSA's discretionary and block grant
initiatives with states. He noted states' concerns about how outside
groups may rank state data. Profiles of ATR states are presented on the
SAMHSA website ([www.samhsa.gov](http://www.samhsa.gov/)).

Mr. Curie announced updates to the SAMHSA Matrix. Disaster response and
readiness, formerly a priority program, has become a cross-cutting
principle; suicide prevention has been added as a priority; and
workforce development has been moved from a cross-cutting principle to a
priority. Mr. Curie assured Council members that the proposed FY 2007
lean budget nevertheless will reveal opportunities for innovation and
further operationalization of recovery.

***[Discussion]{.underline}**.* Dr. McCorry suggested framing ATR as a
way to provide continuing care in the community for treatment for
substance abuse, much as primary medical care is followed up in one's
home. Faith-based providers of recovery support services offer important
ongoing relationships. Mr. Curie concurred, noting, however, that
controversy arises over situations in which persons choose to access
faith-based recovery support services without prior contact with medical
care. Nevertheless, many people in recovery claim that each experience
helps incrementally, a claim supported by the research. Ms. Heaps stated
that ATR represents a systems change and asserted the need to help
smaller community- and faith-based organizations develop capacity and to
communicate that it will take time to enhance the infrastructure. She
noted that federal demonstration programs traditionally have at least
three years to develop their projects. Mr. Curie concurred, responding
that it is necessary to refer to the expectations cited in the RFA,
especially when looking at the early data. He noted that states varied
in their use of vouchers for ATR's first year, but he congratulated them
for their accomplishments. Dr. Madrid stated that, as a provider, he is
becoming more comfortable with ATR. Drug court activity is rising, a
positive development. He encouraged training groups of faith-based
providers.

Mr. DeCerchio cited concerns about federal oversight agencies' rating of
the block grant as ineffective in its ability to demonstrate its
effectiveness. Mr. Curie responded that as NOMS generate data on how
states spend their block grant funds, positive outcomes data will
demonstrate accountability to federal oversight agencies. He noted that
SAMHSA might encourage and work with states to spend block grant dollars
in ways that can demonstrate outcomes more quickly. He asserted that
pressure from oversight agencies to produce positive outcome data does
not imply an automatic cut to block grant funding; however, low scoring
programs may be subject to cuts. Ms. Jackson urged retaining
discretionary funds as part of the block grant and developing a system
for using skilled, but unlicensed, volunteers in disaster response. Mr.
Curie concurred with the need to discuss unintentional barriers with
states. Ms. Bertrand reported that she participated in the National
Recovery Summit, lauded the administration's efforts to focus on
services at the community level, and stated that outcomes can be
improved by enlisting volunteers.

**[Recovery Summit Update.]{.underline}** Cathy Nugent, M.S., LGPC, CP,
Project Officer, Addiction Technology Transfer (ATTC) Program, CSAT,
reported on the September 2005 CSAT sponsored summit, at which diverse
stakeholders shaped a vision of a recovery oriented system of care.
Approximately 100 representatives of the treatment and recovery field
developed new ideas to help move toward a recovery oriented paradigm;
articulated principles and measures of recovery; and generated ideas for
advancing a recovery-oriented system of care in a variety of settings
and systems. The summit followed a planning group meeting whose
participants, representing diverse stakeholder groups, discussed key
issues and informed the agenda. This group met again to synthesize and
validate the summit's findings and to develop next steps.

The summit developed 13 overarching principles of recovery at the
individual level and 17 elements at the systems level of a recovery
oriented system of care. The summit also developed recommendations for
CSAT and for systems professionals, researchers, treatment providers,
recovery service providers, advocates, and mutual aid groups. The summit
recommended that CSAT conduct an inventory of recovery oriented
products, programs, activities, and services; convene a research summit;
conduct outreach; convene regional meetings; provide education and
technical assistance on recovery oriented approaches; facilitate a
discussion of the ethical framework for peer recovery support services;
promote and encourage development of financing models; and continue to
ensure that CSAT initiatives reflect a full range of voices of recovery.

The summit's deliberations are informing a CSAT action plan to infuse
recovery principles and measures into policies, programs, and services.
CSAT plans to host a series of regional meetings to vet and refine the
principles and elements of recovery, and to develop strategies to
implement the recommendations at the community and state levels. The
synthesis group developed a working definition of recovery from alcohol
and drug problems, "a process of change through which an individual
achieves abstinence and improved health, wellness, and quality of life,"
that will be vetted with the field. CSAT staff are developing a report
of the summit.

***[Discussion.]{.underline}*** Ms. Bertrand stated that the summit
participants anticipated ongoing dialogue. Dr. Madrid noted that
participants concurred in the multiple pathways to recovery approach.

**[Partners for Recovery Update.]{.underline}** Donna Cotter, M.B.A.,
Coordinator, Partners for Recovery, CSAT, stated that Partners for
Recovery (PFR) (and its predecessors) has operated for an unprecedented
nine years within CSAT/SAMHSA. Ms. Cotter presented an overview of its
new website (www.pfr.samhsa.gov), which highlights mental health and
prevention as well as substance abuse disorders, and provides
information and resources related to specific focus areas, and latest
news. She asked Council members to provide state-level input to populate
the website and also links to their websites.

PFR plans to conduct approximately 22 events nationwide, some in
conjunction with partner organizations. One effort will educate state
legislators on performance measures in addiction treatment and on the
phenomenon of relapse. Publications include "Know Your Rights," to be
used in regional training programs. Ms. Cotter asked Council for
recommendations for attorneys to be targeted for attendance. She noted
that people in recovery, provider organizations, and state
representatives are encouraged to attend, and that the Legal Action
Center will offer technical assistance to states that have not
experienced direct training.

**[Public Comment.]{.underline}** There were no comments from the public
during the Public Comment period.

**[Council Discussion.]{.underline}** Dr. Clark announced SAMHSA's
National Conference on Returning Veterans, scheduled for March 2006, in
partnership with the Therapeutics Communities of America, with a focus
on roles that community-based organizations, states, and others can
play. Ms. Jackson highlighted the importance of SAMHSA's workforce
issues priority. Dr. Clark stated that workforce development encompasses
the needs of state officials and their policies for certification,
licensing, reimbursement, and related issues; providers' needs; and
services to use. The Annapolis Coalition continues to work on the issue,
and CSAT is preparing a response to Congress. Dr. McCorry urged
increased attention to the NIDA Oval treatment model, which addresses
the complexities of treatment and includes wraparound, case management,
clinical supervision, and medication management services.

**[National Health Information Infrastructure.]{.underline}** John
Carnevale, Ph.D., President, Carnevale Associates, LLC, and Chair,
Behavioral Health Treatment Standards Workgroup, described the National
Health Information Infrastructure (NHII), whose origins in concerns
about a health care crisis in the 1990s and a 1990 Institute of Medicine
(IOM) report on the issue, led to the impetus for a modern electronic
health information support system to improve effectiveness of the
delivery of health care services. Dr. Carnevale cited a series of events
that led to the public-private partnership to build NHII, including a
2004 Executive Order that established the Office of the National
Coordinator for Health Information Technology (ONCHIT) and set a goal
for broad adoption by 2014 of interoperable electronic health records
(EHR). The National Health Information Network refers to a
comprehensive, interoperable knowledge base under construction, but not
central or national in scope.

ONCHIT's American Health Information Community, a committee of
representatives from hospitals, insurance companies, information
technology (IT) experts, and federal and state agencies that advises the
HHS Secretary, focuses on EHR, a system that includes longitudinal data
for and about people, enables electronic access to people- and
population-level information by authorized users, provides knowledge and
decision-support systems, and promotes efficiency in the industry. The
EHR is maintained by providers; a patient health record (PHR) is a
subset of that information that incorporates a person's history.

Dr. Carnevale identified as challenges the management of information to
improve patient care and safety, while also protecting patients' rights
and privacy, and integration of substance abuse and mental health
treatment into national efforts to modernize and become more mainstream.
Research has found that IT in these systems is used primarily for
administrative reporting purposes, and that the necessary capacity is
lacking to improve clinical decision making or program planning.

The Behavioral Health Treatment Standards Workgroup works toward
increasing knowledge, understanding, and use of behavioral health
standards in substance abuse and mental health. It identifies
opportunities to influence standards and setting activities by
organizations that coordinate information exchange standards. Volunteer
membership in this policy group includes almost three dozen entities
representing national, state, and local substance abuse and mental
health organizations, software vendors, and consumer groups. The
workgroup's long-term priorities include developing standards regarding
the EHR, e-prescription drug monitoring programs, and performance
measurement and management. The workgroup's current activities include
raising awareness about the issues, participating in standard setting,
and expanding its membership.

***[Discussion.]{.underline}*** Dr. McCorry observed the importance of
proactive involvement in setting standards. Dr. Carnevale stated that
much work must be done with limited resources. He noted that CMHS and
CSAP have joined CSAT in the process. Dr. Carnevale explained that
standard setting will be completed soon, and that consumers factor into
the equation in that the standards focus on patient safety, care, and
health.

**[Campus Screening and Brief Intervention.]{.underline}** Tom
Stegbauer, M.B.A., Acting Branch Chief,

Organization and Financing Branch, CSAT, presented an update of the
SBIRT (Screening Brief

Intervention and Referral to Treatment) college program, which targets
low-risk drinkers for

education and at-risk drinkers for an intervention. In addition, the
program helps people who are

dependent to access appropriate care. In FY 2003 SAMHSA awarded SBIRT
grants to six states

and one tribal organization, and an effort is underway to address
college and university drinking

patterns.

Research shows that 43 percent of students consume alcohol at at-risk
levels; college students are more likely to binge drink than other
groups; and more people aged 18-22 enrolled in colleges drink
excessively than other cohorts of the same age. In addition, a third of
students use illicit drugs or prescription drugs in an inappropriate
way. Research also reveals evidence of the epidemic consequences of
college drinking in terms of deaths, assaults, and injuries.

CSAT has made awards to 11 universities and one junior college, each of
which integrates screening and brief intervention (SBI) uniquely into
its campus health programs, to screen 70,000 students annually. One
institution is private and the rest public; some use computer based
technologies; some accept judicial referrals; and many work with their
athletic programs. Mr. Stegbauer highlighted various features of the
programs, many of which refer their treatments outside the university
and several of which are just beginning to operate.

Although no data was available for the college program, GPRA performance
data reported by SBIRT grantees show that six months after an
intervention, 50 percent of participants have abstinence from alcohol of
more than 30 days. In addition, the use rate for illicit drugs has
declined by 42 percent. Of 320,000 patients, more than 15 percent
receive either an intervention or treatment, and more than 5 percent
receive either brief or long-term treatment.

In describing future activities, Dr. Stegbauer stated that FY 2006 funds
are expected to be available for another round of RFAs at the state
level, and a study is underway to help groups and states overturn laws
that deny insurance coverage for medical treatment for alcohol or
illicit drug use. CSAT is conducting a cross-site evaluation to
understand variability between sites. A Sustainability Workgroup is
looking at issues to carry forward the work.

***[Discussion.]{.underline}*** Dr. McCorry observed that large numbers
of screened college students bypassed the brief intervention and entered
treatment. To Dr. Madrid's question on numbers of students sent through
the ATR system, Mr. Stegbauer responded that information has not been
collected on that dimension and the concept behind the SBIRT grant did
not incorporate ATR.

**[Institute of Medicine Report.]{.underline}** Constance Weisner,
Dr.P.H., M.S.W., Professor, Department of Psychiatry, University of
California--San Francisco, Investigator, Division of Research, Kaiser
Permanente Medical Care Program, discussed the new IOM report "Improving
the Quality of Health Care for Mental Health and Substance-Use
Conditions, Quality Chasm Series"
(http://darwin.nap.edu/books/0309100445/html), a sequel to the IOM's
"Crossing the Quality Chasm" (www.nap.edu/books/0309072808/html). Dr.
Weisner noted that the earlier report omitted a focus on mental health
and substance use (MH/SU) treatment.

In its new report the IOM explores implications of "Quality Chasm" for
the field of mental health and addictive disorders; identifies barriers
and facilitators to achieving significant improvements along its six
dimensions (safety, effectiveness, patient centricity, timeliness,
efficiency, and equitability); examines environmental factors and health
care organization and delivery issues; and presents an agenda for
change. A committee of representatives from the MH/SU fields concluded
that improving care delivery and outcomes for any problems of mental
health, substance use, or general health depends upon improving care
outcomes for the other two areas; the committee acknowledged the issue
of comorbidity versus primary disorders. Their overarching
recommendation is that health care for general, mental, and substance
use problems and illnesses must be delivered with an understanding of
the inherent interactions between the mind/brain and the rest of the
body.

The committee identified issues that warranted compilation of an
additional report, including increased stigma, discrimination, and
coercion in MH/SU compared to health; patient decision-making ability
less anticipated and supported by the system; more subjective diagnoses;
less-developed quality measurement and improvement infrastructure; more
separate care delivery arrangements; less involvement in NHII and use of
IT; more diverse workforce and more solo practice; and a differently
structured marketplace. Dr. Weisner summarized the IOM report's
discussion of problems in the quality of health care and MH/SU and
proposed solutions:

1.  Change the culture at care delivery sites to combat stigma and
    consumer support decision making; involve consumers more in the
    design, administration, and delivery of care; provide decision
    making support to consumers, including peer support and advance
    directives; support recovery programs and practices; make
    transparent policies for determining decision making capacity and
    dangerousness; and preserve patient decision making in instances of
    coercion.

2.  Weak measurement and improvement infrastructure. The MH/SU fields
    have not produced an evidence base efficiently. Strategies include
    filling gaps in the evidence by studying existing programs that are
    doing well; standardizing and coding interventions, outcome
    measurements, and coordination of initiatives to analyze the
    evidence; building infrastructure for measuring and reporting
    quality; and supporting Quality Improvement practices.

3.  Poor linkages across separations in care. Accountability for
    coordination is unclear. Mechanisms should be put in place for
    coordinating care and sharing patient information between providers,
    with patient knowledge and consent; targeted screening for health,
    mental health, and substance use in each system of care; better
    evidence based coordination and linking mechanisms, and high-level
    policy coordination mechanisms that achieve and model collaboration
    at the federal and state levels are needed.

4.  Lack of involvement in the NHII in the design of EHRs, data
    standards, and a platform for exchanging information across clinical
    settings. Actions needed involve DHHS and the VA to charge ONCHIT
    and SAMHSA jointly to develop and implement a plan to ensure that
    the NHII addresses MH/SU health care as fully as general health
    care.

5.  Insufficient workforce capacity. Issues include an aging workforce;
    greater variation in the MH/SU workforce and its education and
    training than in other health care. Remedies include sustained
    national attention and creation of a federally funded public private
    Council on the Mental and Substance Use Health Care Workforce, which
    would collaborate with SAMHSA and institutions of higher learning to
    develop standards for training and licensure.

6.  Differently structured marketplace. The MH/SU marketplace is
    dominated by government purchasers, a carve-out system for most
    services, more limited coverage compared to other health conditions,
    and substance use not as well covered as mental health, including
    Medicaid. Recommended strategies include tools for reducing adverse
    selection by insurers, enactment of insurance coverage parity,
    re-orientation of state procurement entities to quality rather than
    only cost savings, and using quality measures in making funding
    decisions.

***Dr. Weisner highlighted selected IOM report recommendations:***

-   Individual clinicians should focus on patient centered decision
    making, screening for co-occurring conditions, routinely assessing
    outcomes, finding ways to share information clinically with other
    providers, and provide coordination.

-   Organizations providing care should develop policies to enable and
    support all clinicians' actions; involve patients and families in
    the design, administration, and delivery of services; link with
    other systems; and become involved in the NHII.

-   Health plans/purchasers should pay for recovery-oriented services,
    peer support, and illness self-management; provide patients with
    comparative information on quality of services and providers; remove
    payment and service exclusions; support development of quality
    measurement and improvement; work on sharing patient information
    appropriately among primary care, mental health, and substance use;
    provide incentives for IT; use tools to reduce adverse risk
    selection; and use measures of quality and coordination.

-   State policy officials should make coercion policies transparent,
    revise laws that make communication between providers difficult,
    create high level mechanisms to improve collaboration and
    coordination across agencies, work on parity, and reorient state
    procurement processes toward quality.

-   Federal policy officials. DHHS should coordinate identification of
    evidence-based practices, develop procedure codes for administrative
    data sets, use evidence-based approaches to disseminate and promote
    uptake of evidence-based practices, assure use of general health
    care opinion leaders in dissemination, fulfill essential quality
    measurement and reporting functions, provide leadership in quality
    improvement, and provide a continuum among federal agencies. The
    federal government also should revise laws, rules, and other
    policies that obstruct sharing of information across providers,
    taking confidentiality into consideration; continue to fund
    demonstrations to transition to evidence-based care; make sure that
    the NHII addresses information infrastructure and MH/SU care;
    authorize and fund a council on the workforce; support faculty
    leaders in health profession schools; and provide leadership
    development support, and funding for research and development on QI
    in care.

-   Accrediting bodies should adopt standards to measure patient
    centered decision making throughout care; involve consumers in the
    design, administration, and delivery of services; require formal
    linkages with community resources; and use evidence-based approaches
    to coordinating care.

-   Funders of research should support development and refinement of
    tools easy to use in screening and in assessing response to
    treatment, creation of a set of MH/SU "vital signs," and take
    advantage of what is known on the ground.

Dr. Weisner stated that the recommendations on improving health care in
"Quality Chasm" should be applied throughout MH/SU health care, tailored
to reflect the its unique characteristics.

**[Institute of Medicine Report: CSAT's Activities.]{.underline}** Sarah
Wattenberg, LCSW-C, SAMHSA

HIPAA Coordinator, CSAT, noted that three substance abuse
representatives served on the committee of two dozen persons. Ms.
Wattenberg stated that CSAT co-sponsored a meeting with the Robert Wood
Johnson Foundation (RWJ) attended by substance abuse treatment leaders
to elicit the field's priorities. Although they observed that a context
for providing substance abuse treatment was omitted, they asserted that
sufficient information and recommendations enabled them to endorse the
report.

Because CSAT has been taking a number of recommended actions, it appears
that the Center is on track. CSAT will use the report to identify new
initiatives and support those in the pipeline. The first recommendation
is to create a crosswalk between IOM recommendations and CSAT's
activities to identify gaps and to set priorities for resources. In this
effort, it is hoped that IOM will make a second presentation to CSAT on
the report.

***[Discussion.]{.underline}*** Dr. McCorry expressed concern that
substance abuse in the criminal justice system was not addressed in the
report and noted the limited press coverage of the report's release. Ms.
Wattenberg responded that the final report may be relaunched, but that
the field has begun to respond. Dr. Clark noted that the report also
omitted reference to the Health Resources and Services Administration
(HRSA). Dr. Weisner stated that the HRSA model program must be discussed
broadly. She noted that another topic omitted from the report, because a
separate IOM study focuses on it, is health care in minorities and
culture. IOM focuses on health reports, but the report alluded to school
problems and addressed such issues as criminal justice in mention of
linkages outside the health care field. Ms. Wattenberg responded that
funding and process issues may impede IOM from producing supplementary
materials, but that a journal might devote an issue to the substance
abuse field's response to the report. Dr. Weisner responded to a
question from Mr. DeCerchio that the issue of carve-out versus
integration is a heated issue on the IOM committee, reflecting lack of
consensus in the field on action steps. Ms. Heaps urged CSAT to find a
mechanism to translate the IOM report and set standards for treatment in
the criminal justice system. Dr. Clark observed the need to examine the
IOM report's framework and address its specifics in order to advise the
administrator on areas of concern specific to substance abuse treatment
and prevention. He noted that mention of the child welfare system and
the issue of impaired health and other professionals were omitted in the
report. He also suggested that the report be viewed in the context of
the needs of community and faith-based organizations as providers of
recovery oriented services within the continuum of care. Dr. Clark noted
that CSAT is contributing subject matter expertise to the NHII process.

**[SAMHSA Hepatitis A and B Vaccine Initiative.]{.underline}** Kenneth
Hoffman, M.D., M.P.H., Medical Officer, Division of Pharmacologic
Therapies, CSAT, described the SAMHSA Hepatitis A and B Vaccine
Initiative, which aims to establish cooperative agreements with
substance abuse treatment settings in order to enhance vaccination
against hepatitis A and B infections for patients at risk for HIV and/or
hepatitis C, and also to evaluate the vaccine's distribution and
outcomes. Although the main focus ultimately is on hepatitis C,
inoculating high-risk individuals for A and B can help to improve
quality of life, survival, and capability to function while focusing on
the individual as a whole, rather than on the specific disease of
substance abuse. The initiative is unique in SAMHSA.

Approximately two dozen organizations that assess and manage HIV and HCV
have accepted CSAT's invitation to participate, including opioid and
buprenorphine treatment settings and CSAP and CSAT Minority AIDS
Initiative grantees. Contractors distribute the vaccine and conduct the
descriptive evaluation.

Analysis to date estimates a potential of 50-2,000 patients per program,
up to a total of 15,000 patients. The initiative has achieved its target
with response from larger programs, and Dr. Hoffman explained that it
may be possible to make some vaccine available to smaller programs. The
analysis reveals the percentage in each group completing one, two, or
three shots, as well as safety and adverse events as reflected in VAERS.
Dr. Hoffman explained that the initiative aims to identify missed
opportunities and to describe connectivity between immunization and
substance abuse treatment programs in order to identify best practices.

***[Discussion.]{.underline}*** Dr. McCorry commented on the gap between
county health departments and substance abuse treatment programs, and
noted that the initiative may serve as a catalyst to bring them
together. New York State has initiated a pilot program in which two
county health departments vaccinate everyone in substance abuse
treatment. Dr. McCorry suggested the need also for pneumonia
vaccinations. Dr. Hoffman added tuberculosis to the list. Dr. Madrid
pointed out that insufficient resources remain impediments to
vaccination. Dr. Clark stated that SAMHSA anticipated this issue, and
HHS has allocated funds to address it. He pointed out that SAMHSA is
working with the National Institute on Drug Abuse (NIDA) and the Centers
for Disease Control and Prevention (CDC), and that this initiative
represents a concrete effort to integrate CSAT's work with primary care.

**[Council Roundtable.]{.underline}** Ms. Heaps requested a briefing on
the workforce development project and asked to see the report on the
issue. Dr. Clark responded that once the report to Congress is complete,
it will be shared with Council members. He highlighted the importance of
adequately trained staff and an appropriate financing structure to
address co-occurring depression, anxiety disorders, and psychosis with
substance abuse. Dr. Madrid suggested inviting the Annapolis Coalition
to make a presentation to the Council.

**[Adjournment.]{.underline}** The meeting adjourned at 4:27 p.m.

**[Friday, February 3]{.underline}**

The open session of the Council meeting resumed at 9:10 a.m. with a
welcome from Dr. Clark.

**[Methamphetamine Update]{.underline}**

Cheryl Gallagher, M.A., Public Health Advisor, Systems Improvement
Branch, CSAT, discussed CSAT's response to the methamphetamine problem,
which began in 1998 with a diverse seven-site Methamphetamine Treatment
Project (MTP). A website was established, and two journals published
articles about the successful project. MTP found that the Matrix model
and sites' treatments-as-usual provided clients with recovery at the
same rate as recovery from other drug dependence, with best results from
the drug-court site. CSAT also published TIP #33 and companion products
on treatment for stimulant use disorders, participated in an Interagency
Task Force on Methamphetamine
(www.ojp.usdoj.gov/nij/publications/methintf/index.html), collaborated
with the State Department to provide technical assistance to Thailand on
the Matrix model, and conducted a comprehensive community treatment
program on behavioral therapies for gay male stimulant users and alcohol
users.

Ms. Gallagher explained that CSAT sponsored a series of conferences and
awarded Targeted Capacity Expansion grants to address the problem. CSAT
Drug Court grantees are encouraged to establish partnerships with local
Drug Endangered Children programs. This program and the MTP program,
which offer incentives to enter and stay in treatment, have produced the
best results. In ATR Tennessee and Wyoming have identified
methamphetamine as their specific target area. CSAT and the Drug
Enforcement Agency (DEA) fund governors' summits to develop strategies
to address the problem in communities. One Sky, the American
Indian/Alaska Native National Resource Center, held a 2005 summit to
develop a strategy for tribal lands. ATTCs are expanding training
activities, including digital training modules and a presentation on
best practices (www.psattc.org). The substance abuse prevention and
treatment block grant offers technical assistance to states and is
planning regional meetings on effective approaches to treatment. CSAT's
methamphetamine workgroup is collaborating with the Indian Health
Service to plan meetings; SAMHSA's Workgroup on Synthetic Drugs
addresses methamphetamine use; SAMHSA intends to work with ONDCP; and
CSAT is working with CDC and CSAP on methamphetamine and infectious
diseases.

***[Discussio]{.underline}**n.* In response to questions from Council
members, Ms. Gallagher offered to provide information on state responses
to methamphetamine, a drug that is distributed across the country and
appears to be on the increase, especially toward the east. Across CSAT's
discretionary portfolio, only 5 percent of the population uses
methamphetamine. Dr. Clark stated that while the Household Survey does
not show an increase in prevalence, it shows increased numbers of people
dependent. Also, the number of labs is growing. Ms. Gallagher explained
that the drug court site showed better outcomes because of longer
treatment periods and positive incentives. Dr. Clark stated that the
Household Survey shows Native Americans to be second to whites in the
prevalence rate, followed by Hispanics, Asians, and African Americans.
Ms. Gallagher noted that treatment capacity in rural areas is a problem.
Dr. Clark stated that the Household Survey shows prescription
methamphetamine users to be a minority. He noted that Tennessee has
highlighted the need to address the methamphetamine problem in every
jurisdiction.

**[CSAT's Strengthening Treatment Access and Retention Program/Network
for the Improvement of Addiction Treatment]{.underline}**

David Gustafson, Ph.D., Director, Network for the Improvement of
Addiction Treatment (NIATx), described NIATx, a partnership that merged
CSAT's STAR program and RWJ's Paths to Recovery. Dr. Gustafson asserted
that treatment access and retention must improve the overwhelming
proportion of people who need care receive no care, and some people
leave care prematurely; process improvement works; and state governments
are essential to diffusing process improvement.

Dr. Gustafson described his simulated first hand experience in trying to
gain access to inpatient or residential care for substance addiction. He
identified barriers to care and the dedication of people who work in the
field, and found gaps among a range of business processes that impede
access. Using process improvement techniques, NIATx aims to reduce
waiting times and no-shows, and to increase admissions and continuation
rates. Research shows the importance of understanding the customer,
targeting only key problems, selecting powerful change leaders,
identifying ideas outside the agency, and doing rapid-cycle testing of
changes.

Results to date show that 37 change projects in 24 treatment agencies
reduced waiting times by 51 percent by instituting walk in appointments;
28 projects in 21 agencies reduced no-shows by 41 percent by identifying
and removing barriers, encouraging attendance, and reminding about
appointments; 23 projects in 16 agencies increased admissions by 56
percent (one agency by 247 percent) by fostering the transition from
detox to outpatient care; and 29 projects in 23 agencies increased their
continuation rate by 39 percent by identifying and instituting simple,
targeted, rapid-cycle changes. Sustainability of these results is to be
determined down the road.

Dr. Gustafson described NIATx's pilot projects for states, which
revealed great opportunity for states to improve their own processes.
States selected particular aims, partnered with several health care
addiction treatment providers, selected process targets, and tested
those processes. Iowa reduced waiting times by 38 percent, North
Carolina changed eligibility requirements to enable detox patients to
move to the next level of care, and Oklahoma eliminated eligibility
determination for high performers, reduced waiting time for treatment to
three days, reduced duplicative paperwork, and reduced the time
necessary for admissions. A follow-up CSAT activity is STAR-SI. Dr.
Gustafson explained that NIATx offers all member learning sessions,
all-member telephone calls, interest circle calls, coaching, and a
website (www.niatx.net).

***[Discussion.]{.underline}*** In response to questions from Council
members, Dr. Gustafson stated that CSAT and RWJ plan to convene managed
care providers to explore merging funders' disparate eligibility
requirements. He noted that NIATx focuses on change rather than
documenting problem areas. Ms. Fran Cotter stated that no current
STAR-SI projects target adolescents specifically, although efforts to do
so are underway. Dr. Gustafson explained that paperwork reductions have
been addressed successfully in dialogue between providers and some
states. Similarities with fields beyond addiction treatment provide
opportunities for learning. Mr. DeCerchio observed that the approach
links what states try to measure with performance. Ms. Cotter stated
that NIATx has compiled empirical data on five promising practices for
each of its aims. Dr. Skipper noted that some organizations establish
barriers purposely to improve their outcomes. Dr. Gustafson noted the
need to look at the business case behind improvements and to provide
incentives for organizations to improve their efficiency and
effectiveness.

**[SAMHSA's Response to Hurricanes Katrina and Rita]{.underline}**

Anne Herron, M.S., CRC, CASAC, NCACII, Director, Division of State and
Community Assistance, CSAT, presented a slide show illustrating
Mississippi's experience. Daniel Dodgen, Ph.D., Emergency Management
Coordinator, SAMHSA, noted the late Dr. Harmison's contribution to
integrating substance abuse into SAMHSA's disaster preparedness
readiness response. Dr. Dodgen then described the National Response
Plan, which governs the federal response to any disaster event. An
intergovernmental management group of (typically) one senior
representative from all federal departments is established; following
the 2005 hurricanes, HHS requested a second person from SAMHSA to
address substance abuse and mental health issues. The plan also codifies
an incident command structure to establish lines of command and federal
entities' roles and responsibilities. SAMHSA is involved in several
emergency support functions (ESF): ESF6 (maintaining services for people
with substance abuse and mental health concerns in shelters), ESF8
(ensuring that public health and medical incorporates substance abuse
and mental health issues), ESF14 (long-term community recovery and
mitigation), and ESF15 (external affairs---communication with the
public, taking into consideration psychological, mental health, and
substance abuse issues).

SAMHSA works with the Federal Emergency Management Administration (FEMA)
to fulfill states' requests for assistance. Dr. Dodgen asserted that
HHS, FEMA, and others are beginning to understand the importance of
SAMHSA's contributions to disaster response, including the Crisis
Counseling Program (CCP). SAMHSA participates in ESF8 calls to address
emerging problems and participates in other key stakeholder groups. Its
role is to provide assistance to states in areas where extra help is
needed; coordinate resources, assets, and activities; provide subject
matter experts; and provide grants for planning, coordination, and
response.

Ms. Herron and Brenda Bruun, Special Assistant to the Director, Division
of Prevention, Traumatic Stress and Special Programs, CMHS, described
how the disaster response structure translated into action when
Hurricanes Katrina and Rita hit. Ms. Herron introduced the SAMHSA
Emergency Response Center (SERC), which coordinated SAMHSA's activities.
Ms. Bruun explained that the SERC coordinated information between the
HHS Secretary's operations center and SAMHSA. Its incident command
structure, activated for the first time, managed the SERC's personnel,
logistics, planning, finance, and public information functions. Ms.
Herron stated that SAMHSA has deployed 257 staff to the field and the
SERC, half the agency, including 55 of CSAT's 103 staff. Some staff
provided direct clinical services, direct administrative assistance to
state employees and providers, and managed and monitored volunteers
deployed to disaster areas from across the country. Other staff
supported SERC operations, including working to replace rapid HIV tests
lost in the storm, continuing methadone treatment, disposing of
contaminated methadone, and developing data to support substance
abuse-specific mission assignments. Staff members who remained at SAMHSA
headquarters carried on the business of the agency, a daunting
enterprise.

Ms. Bruun stated that as SAMHSA responded, it also trained staff on new
responsibilities. SAMHSA provided Emergency Response Grants to Texas,
Louisiana, Mississippi, and Alabama to address immediate needs. Staff
reviewed initial applications for CCP from 34 states in about a week,
and were reviewing 24 complicated applications for regular services
programs for the longer term. SAMHSA received mission assignments from
FEMA for the first time, including assignments to support the cruise
ships in the New Orleans and Pascagoula, Mississippi, harbors, and to
support mental health and substance abuse workers in Louisiana and
Alabama. An appeal for Mississippi's request for a substance abuse and
mental health mission assignment denied by FEMA is pending. SERC
planning staff first estimated the scope of the disaster and then mapped
that information to target assistance to grantees.

Ms. Herron explained that SAMHSA expanded its website to include
information on hurricane response, arranged for creation of public
service announcements, and updated substance abuse-specific information,
all of which appear on the website. Ms. Bruun stated that SAMHSA
mobilized the National Suicide Prevention Hotline as a central point of
access for information and assistance. Ms. Bruun and Ms. Herron
described SAMHSA's process for supporting deployed personnel, including
a contractor to manage deployment, go-packs with emergency information
and supplies, orange T-shirts for identification, and frequent personal
contact.

SAMHSA continues to provide services, but with a longer-term focus.
Referrals to services have increased, and long wait times are being
addressed. Providers observe significant alcohol, opiate, and
prescription drug misuse; pain management issues; domestic violence,
child abuse, and assault; co-occurring disorders; and, on cruise ships,
feelings of isolation, child care issues, and frustration and anger.

***[Discussion]{.underline}**.* Council members congratulated SAMHSA on
its work, and presenters responded to members' questions. Ms. Herron
stated that the 9/11 response benefited from far less infrastructure
loss than hurricane-affected areas, many of which still lack
electricity. A lessons-learned document is forthcoming. CSAT's Arlene
Stanton described methadone treatment challenges during 9/11, but noted
that several stakeholders have since helped SAMHSA and CSAT develop a
centralized online database to access and verify methadone dosing
information, and a pilot project will be developed following creation of
the infrastructure. Dr. Madrid stated that in the aftermath of the
hurricanes, his organization provided methadone to evacuees and former
inmates, and the inmates disappeared by the next day. Ms. Bruun stated
that forensic sheltering and care provision is an area that warrants
attention. Dr. Clark raised the related issues of maintaining contact
with persons under parole and probation supervision, monitoring sexual
predators, and dealing with opiate users whose supplies suddenly are
disrupted.

***[ATR - Council Support.]{.underline}*** The Council unanimously
agreed to send a letter to the HHS Secretary expressing support for the
goals of ATR and the manner and method by which SAMHSA/CSAT has assisted
states in transforming their systems to integrate recovery support,
including support by faith-based organizations, into the substance abuse
system of care.

**[Public Comment.]{.underline}** There were no comments from the
public.

**[Rapid HIV Testing Initiative.]{.underline}** Kirk E. James, M.D.,
HIV/AIDS Coordinator and CSAT Participant Protection Officer, Systems
Improvement Branch, CSAT, presented an overview of this SAMHSA-wide
project. Dr. James reported that 1993-2003 data show increasing numbers
of persons with HIV/AIDS and proportionally increasing numbers of
African Americans and Hispanics. Transmission data show 63 percent of
cases in males from male-to-male sexual contact and 17 percent from
heterosexual contact, and 14 percent from injection drug use (IDU)
(compared to 19 percent IDU for females).

Dr. James explained that the \$4.8 million, two-year initiative provides
rapid HIV testing kits and training and technical assistance to
facilitate the project. The project aims to provide rapid HIV testing
capability to SAMHSA's grantee sites, outreach to underserved minority
and other high-risk populations in nontraditional settings, and retest
individuals who previously tested negative. Pre- and post-test
counseling is mandated in the program, which targets persons with
substance abuse, mental health, and co-occurring disorders; injection
drug users; commercial sex workers; and re-entry populations. CDC is
among SAMHSA's partners in the project. Four million dollars was
allocated to purchase test kits, which produce results within a
40-minute period.

The media have reported false positives in oral-fluid testing, but the
FDA has found the numbers of false positives expectable under the label.
FDA is working with SAMHSA, CDC, and the manufacturer to ensure that
false positives do not exceed acceptable boundaries.

Dr. James described the program orientation process, site selection,
state readiness requirements, training and technical assistance for
administering the tests, and data collection and evaluation. The
initiative will look at process measures, intermediate and long-term
outcome measures, and the data collection component. Site, individual,
and product data have been collected in anticipation of developing a
repository of information to incorporate into SAMHSA's Services
Accountability Improvement System.

Preliminary data show that most clients were tested in New York and
Houston (13,000 clients). By December 2005, 352,000 kits had been
distributed across the country. Sites included field visits (39
percent), public health centers (28 percent), criminal justice settings
(11.2 percent), and drug treatment sites (6.6 percent). Mainly males
were tested, and mainly African Americans, Hispanics, and others
(compared to 31.5 percent for white non-Hispanics). Most persons tested
were ages 20-39. Participants self-reported on their reasons for
testing. Results showed that 99 percent of participants remained to hear
the results of their tests, and that 1.5 percent were preliminarily
positive and required follow-up testing. In closing, Dr. James
highlighted the mention of rapid HIV testing in the State of the Union
message.

***[Discussion.]{.underline}*** Dr. James stated that the initiative
does not fund confirmation tests, but that states in the program have
established referral links. He noted that innovative, nontraditional
means of reaching individuals for tested are encouraged.

**[Council Roundtable.]{.underline}** Ms. Jackson inquired whether
e-therapy will continue as an interest of the Council, and Dr. Clark
stated his intention to revisit the issue. Dr. McCorry suggested a
presentation on sustainability of funding systems for programs, and Dr.
Clark noted that the issue relates also to workforce training and
reimbursement for new services in a delivery system's portfolio. Dr.
Madrid added that prospective local service providers have voiced
concerns about reimbursement. Mr. DeCerchio supported a presentation
focused on operational matters, for example, agreement on outcome
measures across agencies. Ms. Bertrand identified the need for workforce
leadership development. Ms. Jackson pointed to opportunities for large
funders, such as the Ryan White program, to invest in substance abuse
treatment. She also noted that differences in services across agencies
produce variability in national outcomes. Dr. McCorry asserted that the
criminal justice, public welfare, and public health systems should
invest in treatment as part of their mission. Dr. Madrid suggested
adding the issue of infectious diseases to the agenda, and Dr. Clark
asked Council members to be aware of community activities and the need
for educating clinical programs about the importance of immunization.

**[Adjournment.]{.underline}** Dr. Clark noted that Council will have a
face-to-face meeting son on June 23, 2006, teleconference meeting on
August 24, and a face-to-face meeting on September 21-22. The meeting
adjourned at 12:48 p.m.

\_\_[09/18/06]{.underline}\_\_\_\_\_\_\_\_
\_\_[/s/]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Chair

CSAT National Advisory Council

Director

SAMHSA's Center for Substance Abuse Treatment

####