**DEPARTMENT OF HEALTH AND HUMAN SERVICES**

**Substance Abuse and Mental Health Services Administration**

**Center for Substance Abuse Treatment**

**Minutes of the**

**48th Meeting of the**

**CSAT National Advisory Council**

**September 20, 2006**

**Rockville, Maryland**

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

**September 20, 2006**

**Rockville, Maryland**

The Substance Abuse and Mental Health Services Administration (SAMHSA)
Center for Substance Abuse Treatment (CSAT) National Advisory Council
met in open session on September 30, 2006, at 9:12 a.m. at SAMHSA's
headquarters in Rockville, Maryland. CSAT Director H. Westley Clark,
M.D., J.D., M.P.H., convened the meeting at 9:12 a.m. Members present
included Anita B. Bertrand, M.S.W.; David Donaldson, M.A., Bettye Ward
Fletcher, Ph.D.; Melody M. Heaps, M.A.; Valera Jackson, M.S.; Francis A.
McCorry, Ph.D.; and Gregory E. Skipper, M.D., FASAM. Also present were
George Gilbert, J.D., Acting Deputy Director, CSAT, and Cynthia A.
Graham, M.S., Executive Secretary, CSAT National Advisory Council.

**Welcome and Opening Remarks**

Dr. Clark welcomed participants to the meeting and emphasized the value
of Council members' contributions to SAMHSA. He explained that following
Charles Curie's resignation effective on August 5, Dr. Eric Broderick
has served as SAMHSA Acting Deputy Administrator.

Members introduced themselves and identified activities in which they
have been involved. Ms. Bertrand continues her work with Recovery Month.
Dr. Skipper has been involved in a national study of the efficacy of
physician health programs and in consulting on the ethyl glucoronide
(EtG) issue. Mr. Donaldson has engaged in relief and development work in
Africa and the Middle East. Ms. Jackson has been involved with the
privatization of services in Florida. Dr. McCorry attended SAMHSA/CMS's
Medicaid invitational conference, which highlighted the need for
sustained dialogue on the lack of a financing model for substance abuse
services. The Washington Circle is working on performance measures for
adult screening for alcohol abuse in primary and other settings. Dr.
Fletcher's organization is co-sponsoring a training event for pastoral
leaders and clergy on substance abuse treatment in collaboration with
the National Association of Children of Alcoholics. In teaching a
graduate course in substance abuse intervention, Dr. Fletcher finds the
Treatment Improvement Protocols (TIPs) highly valued by her students.
Ms. Heaps and her organization have helped the Drug Enforcement Agency's
(DEA) new museum in Illinois develop its local treatment and prevention
story, have contracted with NIDA to train judges, and are involved in
building networks of treatment and partnership. She anticipates
participating in a major prevention initiative to defer and deflect
individuals from the justice system, and is involved in developing
research projects for buprenorphine and the criminal justice system, and
for community systems and medication support.

**SAMHSA Update: Acting Deputy Administrator's Report**

SAMHSA Acting Deputy Administrator Eric B. Broderick, D.D.S., M.P.H.,
greeted Council members and described his background. A dentist by
training and a member of the Commissioned Corps of the United States
Public Health Service, he served as a clinician and public health
program manager in the Indian Health Service. More recently has worked
on tribal policy for the HHS Secretary. Dr. Broderick stated that the
selection process for a new SAMHSA administrator is underway and assured
that SAMHSA will continue to pursue the goals enumerated in the SAMHSA
Matrix.

Dr. Broderick expressed personal interest in improving access to care
for substance abuse problems in locations where resources are
insufficient to meet the burden of disease, particularly in communities
with disparate amounts of substance abuse. Other interests include the
related issues of suicide prevention, co-occurring disorders, substance
abuse prevention, and developing ways to involve public health and
primary care providers as points of first contact---and more
contact---with people with substance abuse needs. Dr. Broderick invited
Council members to communicate with him about their concerns.

***Discussion.*** Dr. Broderick discussed a geographical information
systems approach: using epidemiological data on substance abuse, mental
health problems, and multiple other indicators to map areas of greatest
need for services. Ms. Jackson supported this strategy, which has
implications for prevention.

**Recognition Ceremony for Retiring Members**

Dr. Clark recognized the contributions of Drs. Madrid, Skipper, and
Voth, and Ms. Jackson and Mr. Donaldson during their terms on the
National Advisory Council, which end in November.

**Director's Report**

Dr. Clark announced staff changes at CSAT, including the retirement of
Terry Schomburg, Nita Fleagle, and Lonn Aussicker. In addition, Rick
Dulin has moved from the Division of State and Community Assistance
(DSCA) to the Division of Pharmacologic Therapies (DPT), and Rasheda
Stevenson has moved to the Center for Mental Health Services (CMHS).
DSCA has gained Alejandro Arias, Juli Harkins, and Bryant Goodine. Ting
Mei Chau has joined as an emerging leader intern. The Division of
Services Improvement's (DSI) new director is Jack Stein, joined by
Natalie Lu and Dawn Levinson. Paulette Waiters has left SAMHSA. Danielle
Johnson and Shavonne Reed have joined the Office of Program Analysis and
Coordination. Changes in the Office of the Director include the detail
of Stephen LeBlanc to the National Institutes of Health and his
replacement by Hardy Stone, detailed from CMHS. Millie Nevels now serves
as Rich Kopanda's staff assistant. Dr. Clark's new staff assistant is
Dee Encarnacion, who replaces Elsie Fisher. Dr. Clark acknowledged the
contributions of Anne Herron and John Campbell, who recently served as
DSI Acting Director and DSCA Acting Director, respectively.

Dr. Clark presented highlights of SAMHSA's 2005 National Survey on Drug
Use and Health (the full report appears on CSAT's website), which found
that slightly more than half of all Americans age 12 and older reported
being current drinkers of alcohol---126 million, up from 121 million in
2004. More than one fifth of persons age 12 and older participated in
binge drinking---55 million, about the same as in 2004. Heavy drinking
was reported by 6.6 percent, or 16 million, similar to the previous
year. Among young adults ages 18--25, the binge drinking rate was 42
percent and heavy drinking was 15.3 percent, similar to rates in 2002
and 2003. Current use among youth ages 12--17 has declined significantly
to 16.5 percent from 17.6 percent in 2004, but current use in the 12--20
age range remains the same. Binge drinking among youth ages 12--17
declined from 11.1 to 9.9 percent, but heavy drinking, at 2.4 percent,
did not change significantly. Overall, drinking for ages 12--20 remained
unchanged; in 2005 about 10.8 million persons reported drinking alcohol
in the past month.

Among persons ages 12--20, past month alcohol use was 12 percent among
Native Hawaiians or other Pacific Islanders, 15.5 percent among Asian
Americans, 19 percent among African Americans, 21.7 percent among
American Indians/Alaskan Natives, 24 percent among persons reporting two
or more races, 25.9 percent among Hispanics, and 32.3 percent among
whites. In 2005, about 13 percent of persons age 12 or older, 31.7
million people, drove under the influence at least once in the past
year, a significant drop from 2002. Across age groups, drinking under
the influence peaks at 21--25 and does not decline significantly until
age 55.

An estimated 19.7 million Americans age 12 and older were current
illicit drug users, about 8.1 percent; the group ages 12--17 showed a
statistically significant drop since 2002, due probably to the
confluence of such factors as parental involvement, media message,
prevention efforts, and the faith community. The main drug of choice is
marijuana, but nonmedical use of prescription medications is the second
most prevalent area at 6.4 million; cocaine, hallucinogens, and
inhalants follow at rates similar to, or not statistically different
from, the previous year. Past-month use of methamphetamine declined
slightly for persons age 12 and older, but its use continues to move
from the West Coast to East Coast. Although rate of use shows a decline,
people who use tend ultimately to present for treatment; the delivery
system must be prepared.

Past-month nonmedical use of prescription drugs among persons age 12 and
older increased from 2.5 to 2.6 percent; 50--60 percent of survey
respondents obtain their drugs free from friends or relatives. This is a
key issue in terms of how physicians can educate their patients that
prescription drugs should be treated like guns in the house: Lock them
up and don't share. Internet purchase is less of a problem than once
thought, but it remains an issue. The lower the age of beginning use,
the earlier greater problems arise. The mean age of use of pain
relievers is 21 and for heroin, 22; for PCP, inhalants, and marijuana,
first use is much earlier. Dr. Clark asserted that many pathways exist
to communicate about the dangers of substance abuse.

In 2005 an estimated 22.2 million persons, 9.1 percent of the population
age 12 or older, were classified with either substance abuse or
dependence. Specific illicit drugs at highest levels of past-year
dependence in 2005 continued to be marijuana, at 22.0 million, followed
by cocaine and then prescription drugs, both around 1.5 million. Dr.
Clark noted that although Household Survey estimates of the problem's
magnitude may be challenged, it documents dependence or abuse related to
decrements in function. Although rates for males of abuse and dependence
are higher than for females in all age groups, they are similar for
persons ages 12--17.

In 2005 3.9 million persons, 1.6 percent of the population age 12 and
older, received treatment for a problem related to alcohol or illicit
drugs, more than half in self-help groups. That year 20.9 million people
classified as needing substance abuse treatment received no treatment in
a specialty facility; the vast majority of these people felt they did
not need treatment, highlighting the need to identify people in need of
treatment---in physicians' offices, emergency rooms, houses of worship,
for example---and then to have adequate treatment capacity. From a
public safety point of view, drug dealing problems go unaddressed
because people depend on their dealers to get their drugs. Of the 1.2
million people who felt they needed treatment, only 296,000 made an
effort to get treatment. Reasons that a minority of people who made the
effort to get treatment did not receive it included cost, insurance,
stigma, and other access barriers, while some were not ready to stop
using. Dr. Clark emphasized CSAT's role in early intervention: changing
people's attitudes about the misuse of psychoactive substances.

Dr. Clark noted that the House and Senate full budget committees have
met on the FY 2007 budget. The President's budget included \$375 million
in discretionary funds, with \$1.76 billion for the block grant,
totaling \$2.134 billion. The House gave CSAT about \$26 million more
than President's budget, while the Senate mark is \$3 million less.
Although funding for the Access to Recovery Program (ATR) is not
included in these budgets, the House reallocated ATR funds to the block
grant and the Senate increased the block grant by \$30 million. A
continuing budget resolution is expected. Both houses have agreed on a
\$25 million methamphetamine program that would leave voucher decisions
to states. Planning has begun for FY 2008 funding. SAMHSA has submitted
a budget to the Office of Management and Budget; the request will be
announced in February 2007.

***Discussion.*** To a question from Ms. Jackson, Dr. Andrea Kopstein
replied that the Household Survey is conducted in Spanish as well as
English. Ms. Rita Vandivort replied to Dr. McGorry that SAMHSA reports
on all public and private spending on mental health and substance abuse;
an upcoming report will cover 1993 to 2003 and will project major public
and private payers to 2014. Specialized studies provide additional
details on major payers such as Medicare, Medicaid, and others. SAMHSA
is seeking good criminal justice data. Ms. Heaps suggested getting such
data from corrections departments; Ms. Vandivort replied that the
available datasets are problematical, and she welcomed suggestions. She
noted that state and local governments are the largest payer for
substance abuse at 40 percent of all spending.

Mr. Donaldson noted that the ATR program assisted 48 percent more
clients than originally targeted and questioned the congressional
committees' motivation to discontinue the program. Dr. Clark responded
that the rationale is not clear, but that the Administration continues
to work toward its inclusion in the final bill. Ms. Heaps suggested that
NASADAD's opposition to ATR as it stands vis-à-vis the block grant may
have influenced Congress's direction. Dr. Clark pointed out that rural
providers in particular need a core financial stream; if they go out of
business, a whole community is without a provider.

**Minutes, June 23, 2006**

Council members voted unanimously to accept, as presented, the minutes
of the June 23, 2006, CSAT Council meeting.

**CSAT's Alcohol Dependence Treatment Initiatives**

Dr. Clark stated that the Household Survey demonstrates that alcohol
remains a major issue in society. The FDA has approved acamprosate and
naltrexone for extended-release injectable suspension, the first new
medications available for treatment of alcoholism in more than a decade.
An updated TIP on naltrexone will include the newer medications,
including oral naltrexone and disulfiram. Dr. Clark noted that
experimental biochemical measurements to assess objectively patients'
current or past alcohol use hold promise for measuring acute alcohol
consumption and relapse. These biomarkers, if used appropriately, can be
good indicators of alcohol use, presupposing no other illnesses or
problems. CSAT is developing an advisory about the role of biomarkers in
treatment that covers indirect (for example, liver functions) and direct
(for example, alcohol and EtG) measures of alcohol exposure.

Biomarkers complement self-report measures and represent an objective
laboratory test to assist in outcome measures for treatment and studies,
to screen to detect problems, and to provide some evidence of
abstinence. Limitations exist for these strategies in clinical and,
especially, forensic contexts, where biomarkers must be more rigorous.
In treatment biomarkers can be used to screen for alcohol use problems,
using feedback to motivate change in drinking behavior, to identify
relapse, and to evaluate interventions. Forensic use of biomarkers to
document abstinence (for example, in child custody cases and for
impaired professionals) requires close attention in terms of outcomes.

Issues in biomarker testing, discussed in an upcoming advisory, involve
understanding sensitivity, specificity, and positive predictive value;
estimating the prevalence of a problem; and understanding the
relationship among sensitivity, specificity, prevalence, and positive
predictive value. Reliance on a test as evidence of alcohol consumption
ignores exposure to such products as aging juice, foods cooked with
alcohol, over-the-counter or prescribed medications, the propellant in
nasal inhalers, and household products---all of which produce low-level
positives. Dr. Clark stated that the difference between breathalyzers,
which require considerable alcohol to produce a reasonable positive, and
biomarkers, some of which can detect alcohol at 50 nanograms, is
substantial---but 50 nanograms in the body bears no relationship to
intoxication.

Dr. Clark asserted that further research is critically necessary to
determine cutoff levels that clearly distinguish consumption of beverage
alcohol from exposure to alcohol in other products, factors that
influence an individual's biomarker response to alcohol, the window of
assessment associated with various levels of alcohol use, the
reliability of laboratory testing procedures, and products that can give
a positive test result at specific cutoffs. Issues involved in
establishing a good cutoff value include the risk/benefit of a correct
label or of an incorrect label to the patient, the cost of working up or
of missing a false positive case, and a test-only alcohol detection
program that requires 100 percent specificity for no false positives.
The advisory advocates that people focus not on the absolute nature of
biomarkers, but instead on their utility in general clinical assessment.
Dr. Clark noted that CSAT is developing a TIP on medications for
treatment of alcohol dependence to ensure that primary care physicians
and students have the latest information. He observed that if abstinent
people are accused of using on the basis of biomarkers, recovery efforts
are vulnerable. He urged scientific honesty and recognition of
biomarkers' limitations.

Dr. Skipper commented on the regulatory aspect of biomarkers from the
perspective of his work with health and other professionals with
substance abuse problems and in introducing EtG and EtS testing into the
United States. More than a dozen laboratories conduct 20,000--30,000
tests monthly, mainly to monitor people who have agreed to be abstinent.
EtG testing is highly effective in terms of negatives, but problematic
in terms of positives, particularly in forensic settings where
incontrovertible evidence is wanted. Biomarker tests pose the dilemma of
substance abuse as crime or illness, warranting punishment or treatment.
Dr. Skipper expressed concern about the rigid and sometimes punitive
manner in which some agencies use the tests, and the limited role
medical review officers (MROs) take in these issues.

Dr. Skipper stated that he personally issued advisories in 2004 and 2005
warning agencies that positive EtG tests could result from incidental
exposure, but the field virtually ignored them. He hears from a dozen or
so people a day who claim they are falsely accused of drinking, many of
whom are returned to prison, lose custody, or lose their licenses. He
expressed hope that SAMHSA's upcoming advisory will influence persons in
positions of authority to use care in using the potentially valuable
tests.

Dr. Skipper recommended that SAMHSA convene a meeting of regulatory
licensing boards, criminal justice representatives, and others who use
the tests to help them understand advisory and how to use the tests
properly. He noted that clinicians can use low positives in clinical
settings to detect early relapse. Dr. Clark added that the test might be
useful to advise about environmental exposure to alcohol in prevention
of relapse. Dr. Skipper stated that he is studying Purell; breathalyzers
register up to 0.2, while blood levels show 0.01 or 0.02. He cautioned
that alcohol without liquid (AWOL), sold in Europe, may become a problem
in the United States.

**Public Comment**

Lorie Garlick, Nancy Clark, and Tina Schroeder recounted their
devastating experiences with EtG testing that resulted in loss of their
respective professional licenses. Ms. Garlick pointed out that no
literature supports EtG cutoff levels, and no studies have been
published on the effect on EtG levels of medications, gender, endogenous
alcohol production, or individual variations in metabolism. She urged
CSAT to communicate the test's limitations to all licensing boards,
third-party administrators, MROs, and criminal justice programs; to
require, not suggest, clinical correlation; to issue warnings to
laboratories against unethical marketing practices and remind them of
their duty to educate and inform clients about both good and bad
effects; and to urge the National Institute on Alcohol Abuse and
Alcoholism to add the issue to its research portfolio. Ms. Clark noted
the lack of clinical correlation following positive EtG tests and
pointed out that although boards and monitoring agencies are responsible
for test interpretation, lab statements about cutoff levels leave little
room for interpretation; agencies are victims, also, because labs give
them bad information. Although the issue was raised with the American
Society of Addiction Medicine, the situation has not changed.

**Council Discussion**

Council members agreed that additional research on biomarker tests (EtG)
for alcohol consumption is needed and suggested draft language to add
the advisory (see Council Roundtable, below). In addition, Council
members unanimously recommended that CSAT Council members and staff take
a leadership role in creating a strong educational campaign for criminal
justice agents and professional regulatory bodies nationwide on the
limitations and properties of the biomarker test and its potential for
negative effects. A dissemination plan would be an important component
of the campaign, with emphasis, for example, on physician assistants,
clinical boards, lawyers, and anyone with potential to make punitive
decisions. CSAT should convene a meeting to be attended by an
appropriate representative of each state.

**Proposition 36 Cost Study**

Larry Carr, Deputy Director, Office of Applied Research and Analysis,
California Department of Alcohol and Drug Programs, UCLA, introduced an
overview of his agency's cost/benefit analysis of the Proposition 36
initiative. California voters passed Prop 36 in 2000 as the Substance
Abuse and Crime Prevention Act (SACPA), whereby adults convicted of
nonviolent drug-related offenses may be sentenced to probation with
community drug treatment.

Angela Hawken, Ph.D., Policy Analyst, Integrated Substance Abuse
Programs, UCLA, an author of the study, enumerated key findings: Prop 36
substantially reduced incarceration costs (about \$800 million over the
first five years), created more savings for certain eligible offenders
than others, and can be improved for increased efficiency. The analysis
incorporated three studies. The first found a savings of \$2.50 for each
dollar invested in the program when cost outcomes of all SACPA-eligible
offenders are compared to a comparison group. The second study, which
compares costs outcomes among those referred to SACPA based on degree of
treatment participation, found cost outcomes better for treatment
completers, a savings of \$4.00 for each dollar invested. In comparing
cohorts, the final study found that cost outcomes for years 1 and 2 were
stable. All estimates are based on administrative data on many outcome
domains obtained from state agencies. Conducted using a
difference-in-differences design from the perspective of the taxpayer,
the study includes only costs and benefits that affect state- and
local-government budgets. Data on welfare and mental health did not lend
themselves to inclusion in this study.

Dr. Hawken summarized Study 1 findings: Significant savings due to Prop
36 per offender were realized in prison costs (\$3,500 on average) and
(\$1,500) jail costs. Probation costs rose slightly, while costs for
parole declined with fewer individuals in prison. Arrest and conviction
costs rose an average \$1,300 per person, an issue of concern; but
compared with the comparison group, more persons stayed on the street
and had more opportunity to be arrested for a new crime. Further study
found that most Prop 36 offenders were significantly less costly, but a
tiny group drives up these costs; the best predictor of a high-cost
offender was five or more prior convictions in the 30 months preceding
arrest. An increase in costs for treatment programs was expectable.
Health care costs spiked upon entering treatment, but then settled down,
thus demonstrating the value of longer-term evaluations. Finally, Prop
36 offenders paid more in taxes and more people were employed than in
the comparison group, a factor important for its social implications.
The study found a total savings of \$2,800 per offender across domains.

Study 2 found much greater savings for offenders who complete treatment.
Treatment completers add less arrest and conviction costs than
individuals who do not complete treatment. Noncompleters are more costly
in terms of criminal recidivism. Individuals who never enter treatment
fall into two groups: those with clean histories and those who find
themselves re-incarcerated. Cost of treatment is more costly for
completers.

Study authors recommended continued funding of SACPA, improved treatment
entry and treatment retention in the program, and exclusion of offenders
with five or more prior convictions or increased offender and agency
accountability. Additional recommendations include improved treatment
matching, increased residential placement for high addiction-severity
offenders, expanded use of narcotic replacement therapy, cultural issues
addressed to enhance treatment completion, and improved assessment and
treatment show rates by locating assessment at or near the court,
incorporating drug-court approaches where possible, allowing walk-in
assessments, and completing assessment in one visit. Other research
evidence findings and recommendations include expanded use of graduated
sanctions/rewards to help offenders comply with terms of their
treatment, and an ongoing evaluation cycle of the program. The study
concluded that Prop 36 has saved California taxpayers significant money.

***Discussion.*** Dr. Hawken explained that treatment was defined by
California's 58 counties, each with a different model. Ms. Jackson
suggested that knowing more about the criteria and assessment tools
could be helpful to look at outcomes. Dr. Hawken responded that the next
round of evaluation will look at best practices. She noted that some
offenders with co-occurring disorders received mental health treatment,
although not under Prop 36. Her group is working with alcohol and drug
programs to define a study to understand that aspect better, and a
mental health report on Prop 36 offenders is forthcoming. Ms. Heaps
inquired how states fund the extra costs of recidivism and noted the
effectiveness of a treatment continuum under case management in reducing
the costs of residential care. Dr. Hawken responded that state and
county costs are taken into consideration and analyzed in the report, as
is the issue that jail overcrowding is so severe that jails do not
experience cost savings as a significant reduction. California is
working to increase treatment capacity along the continuum of care.

**E-Therapy Update**

Ms. Jackson, the Council's E-therapy Subcommittee chair, explained that
the e-therapy work group has held several meetings and identified a
group of e-therapy experts. The work group defines e-therapy for
substance abuse treatment as the use of electronic media and information
technologies (e.g., the Internet, PDAs, text messaging, telephone,
videoconference) to provide services for participants in different
locations. It is used by skilled and knowledgeable professionals (e.g.,
counselors, therapists) to address a variety of individual, familial,
and social issues. E-therapy can include a range of services to engage
persons in therapy, to treat as a standalone modality, and to treat in
continuing care and relapse. The challenge is to identify the services
and find practices to make them work at a comfortable cost.

E-therapy's key components include community resources, state and other
regulations and legislation, cultural and linguistic competence,
efficient administration, rigorous evaluation, and targeted outreach.
Regulation and legislation involve mandated reporting and
confidentiality requirements, informed consent, insurance liability, and
legal protections against malpractice. Elements of cultural and
linguistic competence apply to most interventions. Administrative
challenges include insurance, electronic billing, and client record
keeping. Targeted outreach is a controversial issue that appears to have
relevance in isolated rural areas and in urban areas where
transportation to therapy is an issue; underserved and hard-to-reach
populations warrant more consideration. Ms. Jackson and Ms. Heaps urged
SAMHSA to develop guidance to the field on issues related to e-therapy,
with a view to future evaluation, demonstration, or pilot programs.

***Council Discussion.*** Capt. Stella Jones, Federal Project Officer
for the initiative, responded to Dr. Fletcher's question that the
literature does not cite research on the effectiveness of e-therapy. The
guidance in preparation will identify some practitioners who have
enjoyed success with various modes of technology and certain
populations. Ms. Heaps asserted that CSAT has responsibility to caution
the field about the current lack of science and also to inform about
proven methods and best practices. Ms. Jackson noted that e-therapy
currently is being practiced, and that CSAT should apply parameters on
what might be a service-to-science focus. Mr. Donaldson urged progress
on this modality, which is valuable for its anonymity. Dr. Skipper urged
investigating existing technology for e-therapy management and
volunteered to share information about a system that notifies and
reports on drug testing through an online mechanism. Ms. Bertrand
suggested researching the ways in which Weight Watchers and 12-step
support programs have overcome barriers to e-therapy. Dr. Fletcher
identified the need for knowledge transfer mechanisms for professional
development in e-therapy.

**Public Comment**

Thelma King Thiel, Chief Executive Officer, Hepatitis Foundation
International, noted the lack of information provided in schools about
liver health and described the unique approach of using humor and
analogies to help assess and change behaviors risky for liver damage.
She looks forward to increased collaboration with CSAT and enumerated
activities undertaken on behalf of CSAP grantees, methadone counselors,
and others. The foundation has produced 14 videos on hepatitis and
substance abuse prevention, used, for example, in STD clinics. A new
video geared to adolescents has been released.

**Substance Abuse Treatment Services for Individuals with Disabilities**

Ruby V. Neville, M.S.W., L.G.S.W., Public Health Advisor, CSAT,
explained that the focus on treatment services for individuals with
disabilities originated with the 2001 President's New Freedom Initiative
to promote full access to community life through efforts to implement
the Supreme Court's *Olmstead* decision. A subsequent executive order
directed Federal agencies to remove barriers to community living, and
the 2005 Deficit Reduction Act directs states to engage fully in the
workplace individuals with disabilities.

Ms. Neville explained that the Americans with Disabilities Act (ADA)
provides civil rights protections to persons with disabilities. But drug
and alcohol addictions alone do not count as a disability; only if a
drug or alcohol addiction is a contributing factor material to a finding
of disability would addiction count as a disqualifier. The fundamental
question is whether the disability would remain in the absence of drugs
or alcohol.

Barriers in accessing substance abuse services include providers' lack
of information in determining the level of service for disorders. Access
to services depends on the type of coexisting disability; for example,
persons with cognitive and physical disabilities are at higher risk for
substance abuse disorders, but less likely to receive effective
treatment than persons without the coexisting disability, and persons
with traumatic brain injury may be unable to benefit from didactic
training or group interventions, and a lack of abstract reasoning
abilities and reduced ability to solve problems may be undetected by
providers. Persons who are blind/visually impaired, deaf/hard of
hearing, or non-English speakers have their own unique access
challenges, including lack of formalized assessment tools and training
for rehabilitation professionals. These professionals often focus on the
disability and miss signs of substance abuse, which makes clear the need
to develop plans and training to conduct accurate assessment and develop
treatment plans.

CSAT's activities include support for treatment at the Minnesota
Chemical Dependency Program for the Deaf and Hard of Hearing, a study at
Ohio State University of methods to improve the ability to engage
persons with traumatic brain injury in treatment for coexisting
disorders, Wright State University's Substance Abuse Resources and
Disability Issues program, Chestnut Health Systems' Exemplary Treatment
Model Program, and Anixter Center. CSAT also provides technical
assistance to states to target the coexisting disability population. The
Surgeon General's 2005 Call to Action to Improve the Health and Wellness
of Persons with Disabilities aims to increase understanding nationwide
that people with disabilities can lead long, healthy, and productive
lives; increase knowledge among health care professionals and provide
them with the tools to screen, diagnose, and treat the whole person with
a disability with dignity; increase awareness among people with
disabilities of steps they can take to develop and maintain a healthy
lifestyle; and increase accessible health care and support services to
promote independence for people with disabilities.

CSAT's next steps are to promote increased access to substance abuse
treatment for individuals with disabilities; encourage inclusion of
members of all disability groups in treatment programs; provide support
to programs to engage in cross-agency activities; encourage grantees to
target services to coexisting populations; encourage linkages among
substance abuse treatment providers and other providers; initiate
inclusion of coexisting populations within CSAT activities that focus on
criminal and juvenile justice, workforce development, cultural
competence, children and families, and suicide prevention; support the
*Olmstead* decision; encourage and expect CSAT-funded providers to
include in their strategic plans efforts to extend treatment to persons
with coexisting disabilities; provide training; and explore additional
publications.

***Discussion.*** Dr. McCorry stated that New York State has implemented
a traumatic brain injury screen, but in many places no psychologists are
available to do neuropsychological assessment. In addition, he noted,
many providers have no knowledge of how to modify their treatment
services to incorporate people with cognitive impairments. Ms. Neville
replied that some states have promising practices, and solving these
issues will take collaboration, idea sharing, and replication of what
works. In addition, technical assistance through ATTCs or the SARDI
program is available to providers.

**Screening, Brief Intervention, Referral, and Treatment (SBIRT), and
Access to Recovery: Update**

Jack B. Stein, L.C.S.W., Ph.D., Director, DSI, CSAT, explained that
SBIRT, launched in 2003 as a paradigm shift in treatment for substance
use and abuse, screens individuals with, or at risk for, nondependent
substance abuse within communities and/or specialty settings in order to
triage them to appropriate services. SBIRT's screening process uses
specific instruments to engage individuals in a brief intervention,
brief treatment, or referral to more comprehensive treatment. Promising
results have emerged to date.

Seven state agencies and one tribal organization, each with a unique
model, received the original grants. In 2005 SBIRT awarded grants to 12
colleges. Many programs serve Latino/Hispanic communities. Ongoing data
collection reveals 165,000-plus cumulative screenings; the number of
screenings exceeded the 2006 target. New state grants have been awarded
to Colorado, Wisconsin, Florida, and Massachusetts. With the American
College of Surgeons, National Highway and Traffic Safety Administration,
and Centers for Disease Control and Prevention (CDC), CSAT is developing
a Web-based toolkit to target the medical arena, including primary care
physicians; a quick guide for trauma surgeons and coordinators aims to
provide tools to conduct screening and brief interventions; and training
modules are under development.

ATR, a three-year, \$300 million discretionary voucher-based grant
program that ends in August 2007, aims to expand treatment capacity,
support client choice in accessing treatment, and increase the array of
faith- and community-based providers for clinical treatment and/or
recovery support services. ATR's goal is to serve 125,000 clients over
three years; preliminary data indicate that the target of screening
individuals who perhaps would not have been screened through other
mechanisms is within reach. Grantees include 14 states and one tribal
organization. Data show that more than 63 percent of clients have
received recovery support services; 48 percent of expenditures paid for
recovery support services; 25 percent of dollars were paid to
faith-based organizations; and faith-based organizations provided 23
percent of recovery support services and 35 percent of clinical
treatment services. Early outcome data show a 64 percent increase in
abstinence rates, 28 percent increase in stable housing, 30 percent
increase in employment, 57 percent increase in social connectedness, and
82 reduction in involvement in the criminal justice system.

Dr. Clark added that SBIRT identifies dependent, as well as
nondependent, users in settings where they seek health care, an
advantage beyond the program's initial conceptualization, and that SBIRT
is welcomed by the community. ATR reaches a broader population, involves
alternative practitioners, and. with its satisfactory results, ATR is a
justifiable strategy.

**Fentanyl: Update**

Ms. Heaps explained that last fall and early winter, the State of
Illinois, the press, and providers noticed increasing overdose deaths
and admissions with a new compound substance of heroin and fentanyl,
which when combined, results in immediate suppression of cardiopulmonary
effects---but on the streets of Chicago, the combination produced a
"fabulous high." Within five to six months, more than 100 deaths
occurred. Illinois' administrator convened state and county public
health officials and treatment agency leaders to discuss action steps.
The effect continues, but indicators show declines. Ms. Heaps contacted
Rep. Danny Davis, who called a press conference; the Illinois
congressional delegation requested increased funding for treatment, in
view of long methadone wait lists; the DEA investigated the source of
the fentanyl (Mexico).

Ms. Heaps recommended that CSAT invite DEA to make an annual
presentation on latest trends in drugs of choice to help communities
plan for upcoming problems. Mr. Robert Lubran stated that SAMHSA,
charged with responsibility for an integrated Federal response, has
engaged DEA, Justice, Office of National Drug Control Policy, CDC, and
more than 50 state and local public health/law enforcement officials in
weekly conference calls. Dr. Ken Hoffman shared details about CDC's
initial detection of the problem and noted that representatives from the
National Institute on Drug Abuse's Community Epidemiology Work Group and
the Food and Drug Administration have joined in the effort. ONDCP
conducted a forum in July 2006 that focused on looking at the problem in
terms of an early warning, detection, and response system.

***Discussion.*** Dr. Clark stated that CSAT is working to develop
practicable solutions, including fostering increased awareness among
substance abuse public health authorities and among users. Dr. Clark
stated that a report from DEA coupled with information from the National
Survey on Drug Use and Health and TEDS data would be useful. He noted
that DEA's Web site includes state-specific information on popular
drugs.

**Council Roundtable**

Dr. Donna Bush, CSAT, reported on the new language that will introduce
the advisory on EtG: "Currently the use of an EtG test in determining
abstinence lacks sufficient proven specificity for use as primary or
sole evidence that an individual, prohibited from drinking in a
regulatory compliance context, has truly been drinking. Legal or
disciplinary action based solely on a positive EtG or similar unproven
test is inappropriate and legally and scientifically unsupportable at
this time. These tests should currently be considered as potential
valuable clinical tools, but their use in forensic settings is
premature." Ms. Heaps suggested adding the "criminal justice" context to
the statement. She also urged convening a conference call to suggest
revenue-neutral mechanisms to get the word out. Dr. Clark agreed to
follow up on development of the public information campaign.

Ms. Jackson noted the passing of Marilyn Culp, and Dr. Clark noted the
loss of CSAP's Steve McElray, both important contributors to the
substance abuse field.

Ms. Jackson urged addressing the large percentage of the population that
acknowledges the need for substance abuse treatment but does not access
it; an initial approach might be to determine specific target
populations, such as people who have experienced trauma or disabilities.
In addition, she expressed her strong belief in the need for
discretionary grants.

Regarding the ATR initiative, Mr. Donaldson and Ms. Heaps urged
continuing attention to provision of recovery support services along the
continuum of care and use of the voucher approach. Mr. Donaldson
endorsed the value of the faith community in providing the continuum.
Dr. Clark responded that the Administration is considering how to inform
Congress of ATR's utility. He added that community-based organizations
are important in this initiative that promotes personal empowerment
rather than professional paternalism. CSAT has an ancillary program for
community recovery support services program that is subject to
charitable choice.

**[Adjournment.]{.underline}** The meeting adjourned at 4:25 p.m.

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

[5/31/2007]{.underline}
[/s/\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_]{.underline}

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

Chair

CSAT National Advisory Council

Director

SAMHSA/Center for Substance Abuse Treatment