***DEPARTMENT OF HEALTH AND HUMAN SERVICES***

***Substance Abuse and Mental Health Services Administration***

***Center for Substance Abuse Treatment***

***Minutes of the 50th Meeting of the CSAT National Advisory Council***

***June 28, 2007***

***1 Choke Cherry Road***

***Rockville, MD***

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

**June 28, 2007**

**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 June 28, 2007, at the SAMHSA Building, 1 Choke
Cherry Road, Rockville, Maryland. CSAT Director H. Westley Clark, M.D.,
J.D., M.P.H., convened the meeting at 10 a.m. Members present included
Anita B. Bertrand, M.S.W.; Kenneth A. DeCerchio, M.S.W.; Bettye Ward
Fletcher, Ph.D.; Valera Jackson, M.S.; Chilo L. Madrid, Ph.D.; Juana
Mora, Ph.D.; Gregory E. Skipper, M.D., FASAM; and Judge Eugene
White-Fish. Also present were Richard Kopanda, M.A., Deputy Director,
CSAT; George Gilbert, J.D., Director, CSAT Office of Policy Coordination
and Planning; and Cynthia A. Graham, M.S., Executive Secretary, CSAT
National Advisory Council.

**Welcome and Opening Session**

Dr. Clark welcomed the participants and expressed his appreciation for
the service of the Council members and their commitment to the field.
His request for a motion to adopt the minutes of the March 22 meeting
was met with a motion from Ms. Jackson, which was seconded by Dr.
Fletcher. The motion passed unanimously, and the minutes were adopted as
presented. Dr. Clark formally welcomed Dr. Mora to the Council. He also
welcomed Dr. Madrid back to the Council after successful bypass surgery.

Council members introduced themselves and discussed their recent
activities. Dr. Madrid, the chief executive officer of Aliviane No-AD,
Inc., mentioned his involvement in the Texas legislative session, where
he lobbied for funding for people who are addicted and involved in the
criminal justice system. Ms. Bertrand, the executive director of the
Northern Ohio Recovery Association (NORA), announced that NORA recently
signed its third lease to open a resource center in Akron and has been
working with local funding bodies and their executive directors to
ensure that recovery support services are linked to professional
treatment services in the northern Ohio area. Judge White-Fish, a tribal
judge in the Forest County Potawatomi tribal court and the president of
the National American Indian Court Judges Association, reported that the
Indian court judges are concerned about the impact of the
methamphetamine problem across Indian Country. Ms. Jackson is the
executive director of New Century Institute Systems, Inc., which is a
collaborative of six human resource agencies in Florida working to
affect the quality of services in the community. Dr. Skipper, medical
director of the Alabama Physician Health Program, mentioned that he is
working internationally to promote physician health in Switzerland and
Austria. Dr. Fletcher is the president and chief executive officer of a
research and evaluation firm in Jackson, Mississippi, that helps
foundations evaluate and design initiatives and works with the local
treatment program to strengthen its outcome evaluation for services
provided in a homeless shelter and in a treatment program focused on
women. Mr. DeCerchio, Assistant Secretary for substance abuse and mental
health in Florida, reported on the recently passed Substance Abuse and
Mental Health Criminal Justice Reinvestment Act, the Brief Referral
Intervention Treatment for Elders (BRITE) initiative, and his new
position at the National Center for Substance Abuse and Child Welfare.
Dr. Mora, a professor of Chicana/o Studies at California State
University, Northridge, engages in participatory action research with
communities, in particular, in the areas of violence, substance abuse,
and environmental health; she also is beginning a new initiative on
substance abuse issues along the border.

**Director's Report**

Dr. Clark welcomed new SAMHSA staff and interns to the meeting and
apologized to Council members who experienced delays in their
reimbursements due to the establishment of a new accounting system.

Dr. Clark reported on some CSAT activities from the last quarter. CSAT
funded grant and contract continuations throughout the period of
continuing resolutions. New grant opportunities are currently being
prepared for awards, including a new round of Access to Recovery (ATR)
grants, Targeted Capacity Expansion (TCE) grants, TCE/HIV grants, and
Addiction Technology Transfer Center grants. At this point, both the
House and Senate have completed markups and restored the cuts to a
number of Science to Services programs. Furthermore, the Senate has
endorsed increased funding for the Pregnant and Postpartum Women program
and criminal justice and drug courts. The executive and legislative
branches will negotiate and resolve these matters. Dr. Clark stated that
the Council should be thinking about 2010 and the activities it will
entail.

In terms of administrative matters, two divisions have been reorganized:
the Division of Services Improvement (DSI) and the Division of State and
Community Assistance (DSCA). DSI now comprises three branches: Health
Systems, Target Populations, and Quality Improvement and Workforce
Involvement. DSCA's reorganization consolidates CSAT data collection,
reporting, and analysis of grantee and State block grant data into one
organizational unit - the Performance Measurement Branch.

ATR grantees are in the final year of a 3-year grant period, and CSAT
has been conducting a series of sustainability trainings for providers.
Up to \$96 million will be available for ATR programs, and 18 grants
will be awarded. It is expected that \$25 million will be spent to
address the methamphetamine issue. Dr. Clark represented CSAT at a
crosscutting breakout session on methamphetamine abuse at the Department
of Health and Human Services (HHS) 9th Annual Tribal Budget Consultation
session, where he emphasized SAMHSA's continued commitment to creating
healthier tribal environments. In terms of electronic health records,
CSAT staff members have been actively involved in developing an improved
strategy.

A joint SAMHSA/Centers for Disease Control and Prevention (CDC) work
group on HIV and methamphetamine met in Atlanta to consider privacy,
security, and other relevant health information technology standards. A
new Web site for the National Registry of Evidence-Based Programs and
Practices was launched on March 1. The Recovery Community Services
Program convened on May 30 to address organizational infrastructure,
peer practice, ethical framework, and guidelines for peer practice and
evaluation of peer recovery services.

The 2007 Request for Applications (RFA) for TCE grants was posted on
March 29 and closed May 25. Projects to be funded have been categorized
in four major areas: Native American/ Alaska Native and Asian American/
Pacific Islander populations, e-therapy, grassroots partnerships, and
other populations' emerging substance abuse issues. Total funding will
be \$8 million, and 16 grants are expected to be funded. CSAT also has
carried out training initiatives in faith-based communities.
Participants have developed program sustainability plans and have been
able to effectively market their program services to potential donors.
Dr. Clark highlighted the Progress for Recovery initiative, which is a
collaboration of communities and organizations mobilized to help
individuals and families achieve recovery. Dr. Clark concluded his
report by commending CSAT staff for their excellent work on
award-winning public service announcements (PSAs).

***Council Discussion.*** Judge White-Fish expressed his thanks on
behalf of the Native American communities for Dr. Clark's participation
in the tribal consultation sessions. Dr. Clark clarified that CSAT's
role is to provide subject matter expertise about substance use and
mental health to tribes and tribal organizations. Dr. Madrid commented
on the issue of sustainability and noted that service providers need
more direction and technical assistance. Dr. Clark noted that the Office
of Management and Budget (OMB) is concerned about what happens at the
end of a program and that new technologies adopted by local communities
will facilitate service delivery.

**Methadone Misuse/Abuse/Mortality**

Mr. Bob Lubran, Director, CSAT's Office of Pharmalogic Therapies (DPT),
and Dr. Kenneth Hoffman, Medical Officer, DPT, presented on methadone
use, misuse, and unintentional mortality. Mr. Lubran explained that in
2003, SAMHSA convened a multidisciplinary group for a national
assessment of methadone associated deaths. In 2001, authority had been
transferred from the Food and Drug Administration (FDA) to SAMHSA for
responsibility and oversight in regulation of methadone in treatment in
the United States. There was some question about whether the new
regulations had an effect on the change in mortality.

The Methadone Associated Mortality Assessment Report was published in
2004. The findings from the report showed that nearly all narcotics,
including methadone, were increasingly associated with diversion, abuse,
and deaths; both respiratory depressant effects and/or cardiovascular
effects at high doses of narcotics can be fatal; and methadone treatment
for narcotic addiction has a proven safety record and actually reduces
mortality in this population. Mr. Lubran stated that 4 years after the
report was issued, the problem continues to be serious because of
misuse, diversion, and abuse of methadone. Significant increases in
methadone-related deaths are being reported.

Dr. Hoffman highlighted information from the Drug Abuse Warning Network
(DAWN), CDC, and the Florida medical examiners data. According to DAWN,
methadone ranks third among all of the opioid analgesics, fourth among
all of the controlled pharmaceuticals, and eighth among all of the
controlled substances. Dr. Hoffman reviewed the CDC ranking of States
with the highest number of methadone deaths in 2004; Florida was ranked
number one. He also cited a study of deaths of clients in methadone
treatment in Texas from 1994 to 2002. The study found that
opioid-addicted patients remaining in treatment generally had much lower
mortality rates than those who left treatment.

Mr. Lubran described a number of CSAT initiatives that are under way:
improvement of education of OTP physicians and patients through
continuing medical education courses and the Patient Community Support
and Education Project. Another initiative will improve the education of
physicians managing pain with methadone, with specific attention to the
identification of addiction problems, recommended actions in primary
care and emergency room settings, and continuing medical education
courses. An open discussion with medical organizations involved in
medical education and residency training will improve substance abuse
disorder treatment competency for future physicians. Finally, CSAT
intends to coordinate actions with the Office of National Drug Control
Policy, DEA, FDA, and the National Institute on Drug Abuse. Two
consultation meetings in July will review the impact of accreditation on
the OTP standard of care and the impact of the recommendations made in
the 2003 assessment.

***Council Discussion.*** Dr. Skipper referred to the importance and
complexity of the issue of methadone misuse and abuse, which have
resulted in more than 3,000 deaths per year. Improved training for
doctors, perhaps even mandatory training, and better surveillance of
OTPs are needed. He recommended that SAMHSA (1) support the idea of a
medical specialty designation for chronic pain management, with
oversight and standards for treatment, and (2) disseminate the findings
on the hazards of methadone misuse and abuse in the popular media. Dr.
Madrid reported that in the past 10 years the supply of heroin has
increased to the extent that what once cost \$100 per day now costs
about \$2 to \$4 per day and speedballing injection (a combination of
heroin and cocaine) has become popular. His recommendations are for more
training of clinicians, determining methadone dosing on the basis of the
extent of the addiction, training doctors about simultaneous abuse and
multiple diagnoses, revisiting the take-home concept, and examining
problems related to the purity of the substance. In response to a
question from Ms. Jackson about Florida's high death rate, Mr. DeCerchio
explained that in 2003--2004 significant increases in the prescription
of oxycontin by doctors in a number of Florida counties resulted in a
change in prescribing practices, including an increase in the use of
methadone for pain management. Methadone misuse and abuse are part of a
prescription drug problem, and deaths from prescription drugs far exceed
deaths from heroin and other illicit drugs. Mr. DeCerchio called for
mandated training by State boards of medicine for physicians prescribing
opiates. Furthermore, laws should be passed regarding prescription
fraud, and a prescription drug monitoring validation program should be
established. In addition, a public health outcry is needed from chief
medical officers in departments of health and State surgeon generals, as
well as at the national level. Ms. Jackson responded that this
information must be disseminated and discussed at conferences. Clearly,
physicians need training in prescribing long-acting pain killers. Dr.
Clark stated that SAMHSA presented on this topic at a recent conference
in New York. Some practitioners are attempting to address this issue,
but more work is needed to solve the problem of methadone misuse and
abuse.

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

Dr. Dennis Moore, a professor in the Department of Community Health at
Wright State University, briefed the Council members on issues related
to substance use disorder and persons with disabilities. Dr. Moore
described a program called Substance Abuse Resources and Disability
Issues (SARDI), which is one of the few research and demonstration
programs in the country focused on persons with disabilities and
behavioral health problems. Since 1990, SARDI has examined a number of
issues related to substance use disorder, mental illness, and other
stigmatized conditions such as HIV and hepatitis.

One SARDI program involves Rehabilitation Research and Training Centers
(RRTCs) and focuses on substance abuse, disability, and employment. A
number of projects nationwide work with vocational rehabilitation
systems to deal with these problems. The Center for Mental Health
Services (CMHS) funds or co-funds four of the RRTCs through the National
Institute on Disability and Rehabilitation Research (NIDRR). Some of the
funding that goes into RRTCs results in high-quality research.

SARDI has examined health and disability issues that adversely affect
minority populations. A program called Brothers to Brothers/Sisters to
Sisters focuses on people who are living with or who are at high risk
for HIV and/or a substance use disorder. Dr. Moore explained that a
number of people with severe disabilities do not understand that
functional impairments affect many aspects of their lives, including
their recovery. Sometimes SARDI's mission is to help people understand
the barriers they face. SARDI runs a mobile van and uses a church as a
primary outreach site in Montgomery County, Ohio. SARDI accounts for
about 25 percent of the HIV testing in the county and is now beginning
hepatitis C testing. Dr. Moore asserted that the model suggests that in
15 years hepatitis C will outstrip HIV in terms of morbidity and
mortality. The Consumer Advocacy Model (CAM) program is one of the few
programs in the country that was established to provide substance use
disorder and mental health treatment to people with disabilities.

Dr. Moore described substance use disorder treatment barriers for people
with disabilities. One barrier involves the attitude of people who lack
exposure to disability issues and tend to jump to inaccurate conclusions
about potential clients. Other barriers involve discriminatory policies
and practices and communication difficulties, in particular, involving
people who are deaf. Also, architectural barriers can compromise
accessibility to treatment venues, funding barriers affect the
acquisition of treatment, and some existing disability statutes are a
low priority for State agencies. Another problem involves the minimal
level of advocacy from the disability community itself because of the
fear of stigma.

SAMHSA has undertaken several actions over the past 15 years to address
the issue of substance abuse treatment services for people with
disabilities. It has sponsored issues forums and training, and a number
of its conference agendas have included the disability issue. Treatment
Improvement Protocol 29 involves substance use disorder treatment for
people with physical and cognitive disabilities. SAMHSA also has
required grant applications to include disability issues and has
provided States with technical assistance in mental retardation,
developmental disabilities, and deafness. In addition, an informal,
voluntary advisory group has been formed at CSAT to deal with the issue
of substance abuse treatment services for individuals with disabilities.

Regarding future directions, Dr. Moore commented that SAMHSA offers a
1-day training for staff to sensitize them to the issue. He also urged
SAMHSA to consider the National Advisory Committee's comprehensive
strategic plan and encouraged CSAT to seek out interagency partners, in
particular, NIDRR, the Administration for Children and Families (ACF),
and CDC, to help address some of the issues involved in substance use
disorders and persons with disabilities. He also urged SAMHSA to use
social marketing to generate momentum on the topic within the disability
community. Most important, SAMHSA should ensure that the data systems
within CSAT represent people with disabilities. In addition, SAMHSA
should encourage State-level compliance.

***Council Discussion.*** Ms. Jackson concurred with Dr. Moore's
statement that many substance abuse treatment center professionals do
not understand issues involving individuals with disabilities. Ms.
Bertrand asked Dr. Moore to explain his assertion about the predicted
increase in the number of individuals with hepatitis C. Dr. Moore stated
that the increase in morbidity and mortality is related to people who
acquired hepatitis C several decades ago. As these individuals age, they
progress to an acute condition. Mr. DeCerchio referred to Dr. Moore's
description of a treatment approach that involves less intensity over
longer duration. He mentioned that this approach is linked to the
problem of funding and an opportunity to use home-based treatment or
out-patient treatment instead of 24-hour residential treatment. He asked
Dr. Moore to identify models or cite his observations about substance
abuse services and less reliance on cognitive approaches. Dr. Moore
stated that out-patient treatment is the preferred modality and that
home-based treatment might be an alternative. However, for many people
with disabilities, the nexus of the problem is the home. Because other
family members create the problem or "feed the fire," home-based
treatment would have to be family based. A Medicaid waiver would allow
billing at higher than the standard Medicaid rate for persons with
physical and cognitive disabilities.

**Public Comment**

Ms. Patricia Taylor, the executive director of Faces and Voices of
Recovery, spoke about recovery-oriented systems of care. She emphasized
ways in which to raise the profile of and develop a stronger leadership
role at CSAT for creating a recovery-oriented system of care. In
addition to the report from the Recovery Summit, regional meetings have
taken place around the country and interest is mounting for a more
recovery-oriented research agenda. More information is needed for people
to achieve long-term recovery. A tremendous interest in peer-recovery
support services around the country results from the realization that a
recovery-oriented system of care is more than treatment; it includes
ongoing support services and other opportunities to sustain recovery.
CSAT can play a leadership role in this regard at the national level by
proactively creating an action agenda for the establishment of a
recovery-oriented system of care.

Mr. Walter Ginter, the project director of the Medication-Assisted
Recovery Services project in New York, spoke about methadone-related
deaths and medication-assisted recovery. He stated that the issue
involves, not control, but education. Perhaps methadone needs an X
number. Physicians should be trained before they can prescribe methadone
for addiction or pain. Regarding dosage guidelines, Mr. Ginter pointed
out that dosage guidelines lead to dosage caps and therefore should be
presented very carefully.

Ms. Martha Hottenstein, the founder of the National Diversion Department
of Helping America Reduce Methadone Deaths (HARMD), told the Council
members about her deceased son, who unsuccessfully sought treatment for
a Percocet addiction. After her son's death, Ms. Hottenstein became
involved with HARMD, where she founded the National Diversion
Department. Through HARMD's Web site, she has been informed about 20
cases of diversion deaths. Ms. Hottenstein stated that she is not
against methadone but she is against methadone deaths and methadone
abuse. Sales of take-home doses acquired through diversion from clinics
and other means must be stopped. Ms. Hottenstein called for more
education for doctors, public safety, and safety for patients.

Melissa Zuppardi, the president of HARMD (www.harmd.org), explained the
genesis of the organization. A group of parents and family members began
to communicate with one another about what they could do about methadone
deaths. Her fiancé, who was addicted to Percocet, died in his sleep at
an in-patient treatment center after being treated with methadone and
other drugs. Ms. Zuppardi addressed the assessment and monitoring at
treatment centers and clinics of individuals addicted to pain pills in
terms of the doses of methadone they are given. After recounting a
number of stories of methadone deaths, Ms. Zuppardi stated that people
who continue to abuse drugs while at clinics pose a danger to themselves
and to society as a whole. The clinic system must change in regard to
assessment, regulation, and monitoring of take-home doses and doctors
should be required to hold a special license in order to prescribe
methadone.

***Council Discussion.*** Mr. DeCerchio thanked Ms. Hottenstein and Ms.
Zuppardi for sharing their personal tragedies and for their advocacy
surrounding the issue of methadone diversion and abuse.

**Physician Health Programs: Blueprint for Lasting Recovery**

Dr. Skipper discussed pre-publication data from a national study that he
believes could be influential in improving outcomes for addiction
treatment. Drs. Robert DuPont and Tom McLellan contacted Dr. Skipper
because of their interest in studying physician health programs (PHPs).
Physicians have about the same rate of addiction in substance abuse as
the general population; therefore, looking at physician treatment
affords an opportunity to discover successful aspects of PHPs. The study
found that the concept of contingency management (CM) can be very
effective. CM entails the use of drug testing following treatment;
negative drug tests are rewarded with a positive reinforcement, and
positive drug tests are followed by a therapeutic consequence.

The objectives of the study of PHPs were to describe them and to provide
a national assessment of the treatment, monitoring, and outcomes of
substance-abusing physicians. Only two States (Nebraska and North
Dakota) do not have PHPs. The study surveyed 49 PHPs regarding their
structure and function. Much debate occurred about how to describe the
function of PHPs; most PHPs strongly resist the notion that they provide
treatment. Dr. Skipper described PHPs as doing "glorified employee
assistance program work" or long-term case management and treatment
supervision. PHPs attempt early detection, provide referrals to
evaluation and treatment, and monitor individuals' long term. PHPs have
agreements with State regulatory licensing boards. Some PHPs have legal
authority to operate, which provides immunity from liability, and most
of the programs are nonprofit foundations, with about 50 percent of
funding from regulatory boards.

The study asked the programs to provide chart reviews and paid the
programs \$20 per chart review received. A chart review instrument was
developed for 16 programs to obtain data over 5 years; 904 charts were
included in the study. Dr. Skipper described the client characteristics
derived from the charts and noted that 14 percent of the physicians in
the study had a history of injection drug use as compared with 9 percent
of the general population. Seventeen percent of the doctors had been
arrested for drug-related incidents as compared with 13 percent of the
general population. Certain specialties were overrepresented in the
study---anesthesiology, emergency medicine, psychiatry, and family
practice; other specialties were underrepresented---pediatrics, surgery,
and pathology. The most common source of referral was the regulatory
board. A high percentage (63%) of the doctors received residential
treatment; only 1 doctor of the 904 received methadone. Naltrexone was
used in 46 of the individuals as an adjunct to treatment, and 32 percent
were placed on antidepressants.

Dr. Skipper summarized the study's most important findings: 78 percent
of the participants remained totally abstinent over an average of 7.2
years of the study; there was only one report of patient harm; and the
most consistent service provided by PHPs to their participants was drug
testing (100%). Dr. Skipper pointed out that physicians in the programs
did not necessarily suffer from a milder variety of substance abuse than
the general population, and he emphasized that virtually all treatment
was abstinence based.

Dr. Skipper concluded his presentation by remarking on the potential for
transferring the positive outcomes of PHPs to other ATPs through the use
of long-term testing, case management, and contingency management.
Monitoring through drug testing, with support and consequences, might be
the key to treatment success for the public at large.

***Council Discussion.*** Dr. Mora asked about the co-occurring
psychiatric disorders seen in doctors in PHPs. Dr. Skipper explained
that the most common of the disorders was major depression. He added
that two doctors in the study were schizophrenic due to stimulant abuse.
Bipolar disorder, ADD, and narcissistic personality disorder were
prominent. Mr. DeCerchio asked about the cost of treatment. Dr. Skipper
responded that the main cost was borne by the doctors and varied
considerably depending on the length of time in treatment. The doctors
diagnosed with drug dependency received 4.1 years of monitoring on
average, and drug tests cost about \$30 each. In response to a question
from Judge White-Fish, Dr. Skipper replied that the average length of
stay for residential treatment was about 63 days and for out-patient
treatment about 4 months. The question is whether the follow-up
(required attendance at groups with drug testing) should be called
treatment. Ms. Jackson mentioned a similar treatment for impaired
lawyers and expressed an interest in the outcome data on that treatment.
In response to her question about the transferability of the treatment,
Dr. Skipper reported on a study of CM data involving teenagers, which
included depositing \$5 in an account for negative drug tests and
emptying the account for positive drug tests. This 60-day treatment
study resulted in a high success rate. The question involves what can be
used as leverage in similar programs.

**Promoting Safe and Stable Families (PSSF) Partnership Grant Programs**

Catherine M. Nolan, M.S.W., ACSW, presented information about targeted
grants to increase the well-being of and improve the permanency outcomes
for children affected by methamphetamine or other substance abuse. Ms.
Nolan explained that she is the director of the Office on Child Abuse
and Neglect within the Children's Bureau of ACF at HHS. After presenting
some of the history and describing the functions of the Children's
Bureau and her Office, in particular, Ms. Nolan's presentation focused
on the PSSF legislation, the purpose of the grants, the development and
content of the program announcement, and the review process.

The PSSF program was reauthorized in September 2006 and renamed the
Child and Family Services Improvement Act of 2006. Several major changes
occurred during the process of reauthorization. Title IV Subpart 2 PSSF
Section 437f authorized the Secretary to make competitive grants to
regional partnerships to provide, through interagency collaboration and
integration of programs and services, services and activities designed
to increase the well-being of, improve permanency outcomes for, and
enhance the safety of children who are in out-of-home placement or are
at risk of out-of-home placement as a result of a parent's or
caregiver's methamphetamine or other substance abuse. Permanency in this
context refers to the idea that every child deserves a permanent and
safe home. The legislation defines "regional partnerships," requires
that the State child welfare agency be a partner, specifies that at
least one non-tribal entity must be included in a tribal partnership,
and outlines the authority of the grant awards. The legislation also
lists the application requirements, use of funds, matching requirement,
performance indicators, reporting requirements, and required reports to
Congress.

The purpose of the grant program is to provide funds to assist regions
in building the capacity to address issues related to child permanency,
safety, and well-being occurring because of parental methamphetamine or
substance abuse. In consultation with SAMHSA and other Federal partners,
the Children's Bureau worked to implement the legislation and draft the
program announcement. Thirty people from a variety of agencies worked on
the development of the program announcement. Ms. Nolan described the
history of partnering with SAMHSA, which included the 1999 report to
Congress on substance abuse and child welfare, creation of the National
Center on Substance Abuse and Child Welfare, child welfare waiver
demonstrations, and May 2006 Conference on Methamphetamines: Child
Welfare Impact and Response. She also supplied a number of details about
the development of the program announcement, including the establishment
of subgroups to work on the performance indicators and funding
structure, creation of a conceptual framework, and writing, submittal,
and posting of the program announcement on May 4, 2007.

The key components of the projects are that the applications must
represent regional partnerships formed by a collaborative agreement and
must designate a lead agency. Ms. Nolan explained how discussion of the
possible funding schemes led to the development of four program options
with two possible Federal award amounts and two possible grant periods.
The program announcement stipulates that the partnership must select one
of the program options and justify the selection in terms of
accomplishing the project goals. The money declines over time; the \$1
million awards decline in the out years, and the \$500,000 awards remain
fixed. All awards have an increase in percentage in the match over time.

Potential applicants received technical assistance through a Webinar on
May 22. Ms. Nolan noted that grant applications are due on July 3, 2007.
A panel of experts will review and score the grant applications during
the week of July 30. In August 2007, a decision meeting will be held
with the Administration on Children, Youth and Families Commissioner,
and final grant award letters will be sent to successful applicants by
September 30, 2007.

***Council Discussion.*** Dr. Clark mentioned that Sharon Amatetti, who
works very closely on a variety of issues with the Bureau of Alcohol,
Tobacco, and Firearms, has been instrumental in helping CSAT become
involved in this new program. Ms. Jackson noted that the program
announcement bridges differences in perception between people who work
in child welfare and people who work in substance abuse. She asked about
continued work on this issue. Ms. Nolan explained that the work group
was convened specifically to write the program announcement and help
with the launch of the grant program. A series of meetings will take
place over the next 5 years with program directors, evaluators, and key
partners. Dr. Madrid commented on the program announcement's funding
options and the notion of sustainability. He asked how the Children's
Bureau is planning to take advantage of Medicaid dollars to begin
efforts for sustainability on day one. Ms. Nolan explained that the new
program is Section 437f of Title 4B Part II. Title 4E pays for cost of
care. The match must be non-Federal dollars; therefore, Medicaid cannot
be used as the match. She pointed out that Medicaid is complicated
because it is different from State to State and that the question of
sustainability and the use of Medicaid funding deserve consideration.

**Recovery Month Update**

Ivette A. Torres, M.Ed., M.S., Associate Director for Consumer Affairs
in the Office of the Director of CSAT, explained the goals of Recovery
Month, which include supporting demand reduction goals and building
momentum for holding State, regional, and national events to assist
individuals in recovery and convey the message that addiction treatment
works, recovery is possible, and funding is needed to accomplish these
goals. Ms. Torres reviewed the costs of Recovery Month (i.e., the kit,
commemorative posters and materials, PSAs, multimedia materials, and
meeting logistics) and noted that the package is relatively inexpensive
given the exposure received. She encouraged all of the Council members
to participate in the Road to Recovery series, which is televised in 27
percent of U.S. households.

Recovery Month includes 54 events. Local communities and coalitions are
encouraged to tap private sources and other resources to assist in the
observance of Recovery Month. Various events target adolescents, African
Americans, American Indians, Asian and Pacific Islanders, and Latinos.
Events include a Fun Walk at SAMHSA, Addiction Professional Day,
Recovery Rides, and numerous community events nationwide. Attendance at
these events has increased significantly since 2002, as have visits to
the Recovery Month Web site (www.recoverymonth.gov). Ms. Torres showed
two PSAs that carry the message of recovery. She noted that Nielsen
rated the 2006 campaign in the top 10 percent of national campaigns in
terms of quality and number of plays. However, Ms. Torres noted that the
campaign's success should be measured not in the awards it receives but
in the significant increase between 2002 and 2007 in the number of calls
from individuals and families to SAMHSA's national helpline.

**Partners for Recovery**

Shannon B. Taitt, M.P.A., CSAT's Office of Program Analysis and
Coordination, is the new Partners for Recovery (PFR) coordinator. PFR's
cutting-edge initiatives include a series of briefings on the outcomes
of addictions treatment and approaches to monitoring performance. PFR
developed the Know Your Rights brochure, which provides individuals in
treatment and recovery and their friends and allies with information
regarding Federal anti-discrimination law related to employment,
housing, public benefits, and other domains. The brochure is available
in English and Spanish at www.pfr.samhsa.gov. PFR activities in the area
of workforce development focus on recruitment, retention, and
professional development. The PFR initiative resulted in a report titled
Strengthening Professional Identity: Challenges of the Addictions
Treatment Workforce, which catalogues major addictions treatment and
recovery workforce challenges. PFR is currently funding activities
related to improving workforce recruitment and retention.

**Council Roundtable**

Ms. Bertrand requested that the administration of CSAT take a proactive
approach to "set the stage" for States' activities regarding a change to
a recovery-oriented system of care. Ms. Jackson suggested that the
National Advisory Council use its roundtables to discuss its priorities
for 2008--2010. A discretionary grant or a pilot might set the stage for
examining the way in which recovery applies to the medical and legal
professions. She also noted the difficulty that men have in getting
treatment and the lack of progress in increasing funding at the State
level. Perhaps the Council can set priorities and formulate policies and
ideas for the future. Mr. Kopanda noted that the budget picture has
changed since the March meeting, Dr. Fletcher's letter to Dr. Cline, and
the House and Senate markups. Restoration and even growth are now in the
picture. CSAT would value the input of the Council in the form of
comments and suggestions regarding recovery and other areas.

Dr. Mora declared that she supports recovery efforts and will follow up
with her congressional representatives regarding funding in that area.
If the Council's role is to advise on policy and priorities, one way to
do so might be in the writing of RFAs, where priorities are set and
identified. Dr. Mora asked what input the Council can have in that
process and suggested that this topic be discussed at the next meeting.
Mr. Kopanda responded that CSAT will ask the Council for suggestions on
the distribution of discretionary funds for the coming year and a
strategic framework regarding longer term priorities. Dr. Mora asked
whether a strategic plan is available that delineates the long-term
goals of CSAT and SAMHSA. Mr. Kopanda responded that SAMHSA's strategic
plan does not cover fund allocation. Dr. Mora expressed a desire to
understand the general plan and future direction. She commented that the
Council might be able to have some input in terms of targeting special
needs.

Mr. DeCerchio remarked on Dr. Clark's mention of SAMHSA's internal
discussions regarding the 2009 and 2010 budgets. He suggested that in an
upcoming session the Council could be informed of the agency's thoughts
and expresses its own thoughts in a constructive dialogue. Ms. Jackson
agreed that the Council could benefit from a guided and structured
discussion of the topic. Mr. Kopanda stated that this suggestion will be
added to the next Council agenda.

Mr. Kopanda reminded Council members that if they talk to their contacts
about the 2009 budget, they should not do so as Council members.

Mr. Kopanda remarked that a confluence of elements affects CSAT's
programs, priorities, and budgets. The Government Accountability Office
is examining the OMB's Program Assessment Rating Tool (PART) process to
determine how managers use information from evaluations and other
aspects of their programs to determine future program priorities. The
PART process was completed recently for the Access to Recovery program,
and CSAT is looking at the application of PART principles to many of its
other programs. Dr. Mora commented on the complexity of the grants and
the fact that many community-based organizations do not have the
technology, support, or resources to compete even though they have the
trust of the community. She would like to have a dialogue about this
problem. Mr. Kopanda agreed that this issue deserves attention.

Mr. DeCerchio asked about any proposed changes to the block grant
formula for 2008 or 2009. Mr. Kopanda stated that the reauthorization
process is currently under way and thus far no changes have been
proposed to the block grant formula, except for possible changes in the
minimum State allocation. The question that usually arises concerns the
relationship between the formula and the need for funding and services.
Mr. George Gilbert added that some thought is being given this year in
the reauthorization of SAMHSA to include a provision that would mandate
a study of the formula and options to change it to better reflect need.
Mr. DeCerchio commented on the tenuous nature of consensus regarding
modifications to the formula. Dr. Madrid added that on the House side as
of June 21, an additional \$35 million has been proposed for the block
grant and discussion involves how that amount will be allocated based on
the present formula.

Dr. Madrid recommended that the Council discuss border issues related to
the problem of double medication. The Federal Government spends millions
of dollars to affect the supply side of illegal drug trafficking on the
border but invests zero dollars to affect the demand side. Lowered
prices mean that more and more young boys are becoming addicted to
methadone and heroin. Dr. Madrid stated that border issues deserve
study. He suggested that in the coming year the Council discuss the
possibility of collaboration to work on the demand side problem. The
Council also could discuss a PFR national plan. Mr. Kopanda stated that
future discussions will focus on border issues.

Ms. Jackson pointed out that Congress funded ACF last year in a very
complicated system. One of the problems with match money is the
difficulty faced by agencies in matching funds. Nonprofit organizations
must survive through grants, foundations, third-party payers, and
insurance, but sustainability is impossible given the dwindling
resources from these funding sources. The Council should discuss
sustainability with an eye to the match issue. Mr. Kopanda asked whether
match requirements encourage grantees to seek outside sources of
support. SAMHSA has not conducted a systematic examination of whether
match programs are sustained at any greater rate than any other
programs. Another key issue involves the dollars in the system as a
whole. It is difficult to increase capacity when the dollars do not
increase. Ms. Bertrand pointed out that match alienates smaller
community-based organizations because they cannot match, whereas larger
hospitals, foundations, and universities can.

Mr. Gilbert returned to the issue of formulas. He reported that a
proposal in the Administration budget this year would withhold 5 percent
of the reward to a State if it failed to report using the National
Outcomes Measurement System (NOMS). The Senate has said that it will not
support this provision, but this issue could be raised in the
appropriations process. Dr. Clark stated that a key issue is the
expectation of performance data to ensure accountability. Most
jurisdictions in the substance abuse community have been responsive in
submitting data that show the money is being well spent.

Dr. Clark announced that a teleconference meeting for grant review has
been tentatively scheduled for August 23. The next face-to-face meeting
of the Council is tentatively scheduled for mid-October. He encouraged
Council members to visit the OMB Web site to learn about PART, which
will be applied to SAMHSA's entire portfolio.

There being no further business, the meeting was adjourned at 4:30 p.m.

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

[12/03/2008]{.underline}
[/s/]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

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

Chair

CSAT National Advisory Council