SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Friday,

May 20, 2005

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

P.O. Box 360833

Strongsville, Ohio 44149

Kenneth A. DeCerchio, M.S.W.

Director

Florida Department of Children and Families

Substance Abuse Program

1317 Winewood Boulevard

Tallahassee, Florida 32311

David P. Donaldson, M.A.

CEO

We Care America

44180 Riverside Parkway, Suite 201

Lansdowne, Virginia 20176

Bettye Ward Fletcher, Ph.D.

Professor

Jackson State University

1120 Andrew Chapel Road

Brandon, Mississippi 39047

IN ATTENDANCE:

Valera Jackson, M.S.

CEO

Village South/West Care Foundation, Inc.

3180 Biscayne Boulevard

Miami, Florida 33137

Chilo L. Madrid, Ph.D.

CEO

Aliviane NO-AD, Inc.

7722 North Loop Road

El Paso, Texas 79915

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

Eric A. Voth, M.D., F.A.C.P.

Assistant Medical Director

Stormont-Vail HealthCare

901 Garfield

Topeka, Kansas 66606

Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 340

Crandon, Wisconsin 54520

[Ex Officio Members]{.underline}

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders

and Psychiatric Rehabilitation

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

[C O N T E N T S]{.underline}

PAGE

Welcome

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

Director, CSAT 5

Recovery Month Update

Ivette Torres, M.S., M.Ed., Director, Consumer Affairs Office,
SAMHSA/CSAT's Office of the

Director 5

Discussion 15

International Perspective on the Harm Reduction Movement

Eric Voth, M.D.

NAC Member 18

Discussion 38

E-Therapy Update

Valera Jackson, M.S.

NAC Member 47

Sheila Harmison, D.S.W., L.C.S.W., Special

> Assistant to the Director, SAMHSA/CSAT's
>
> Office of the Director 58

Discussion 65

Community and Faith-Based Update

David Donaldson

NAC Member 71

> Jocelyn Whitfield, Senior Public Health Advisor,
>
> CSAT; Co-chair, SAMHSA Community and Faith-Based Initiative Work Group
> 79
>
> David P. Donaldson 84 55

Discussion 85

Council Roundtable 97

[P R O C E E D I N G S]{.underline} (10: 03 a.m.)

DR. CLARK: Welcome to the final open session of this meeting. Our first
presentation will be a Recovery Month Update. Ivette Torres is the
director of CSAT's Office of Consumer Affairs and will begin this
section of the meeting. Ivette manages the team responsible for
generating and disseminating substance abuse treatment information for
SAMHSA's mission-related consumers. She developed national
communications strategies and campaigns, including the observance of
National Alcohol and Drug Recovery Month celebrated each September. She
is president-elect of HHS's Hispanic Employee Organization. Her term
begins in November. As mentioned earlier, she is also a member of the
CSAT Hispanic Work Group.

MS. TORRES: Good morning. I'm going to try to be very quick, because my
esteemed colleague from our team reminds me that smaller audience,
quicker presentation. So let's see how quickly I can get through this.

Many of you know that Recovery Month essentially highlights the societal
benefits. We aim to reduce stigma, and we want to empower people in
recovery. Anita Bertrand here is one of our best examples of doing that
in a local community, because she just told me yesterday that she is
running three Recovery Month activities in September, which is
wonderful.

We also support ONDCP in their demand reduction efforts, and I'll be
more clear and let you know how we do that in a minute. We generate
momentum for holding state and local community-based events to enhance
the knowledge, improve understanding, and promote support for addiction
treatment nationwide. We publicize messages that reduce stigma,
encourage the need to get into treatment---very critical.

I want to emphasize every single year that I come before you, just to
remind you that this is not just a straight-out public education
campaign where people get messages and we expect some type of behavior
change. What we are experiencing is an average of 24,000 calls a month
to our hotline, which is significant. So if we take any of the other
CSAT programs that are serving directly people, and a program may serve
60 to 70 people, this particular effort basically helps two things. It
helps to get people information so they can address their addiction
issues. It also helps to really try and increase the number of people
who go into treatment. And some of those people in fact are going into
some of our publicly funded programs, if you've seen the latest report
from DR. Chalk's shop in terms of the number of people who are going
into publicly funded programs because of the reduction of the privately
funded resources.

What do we do? Seventy-five thousand kits, which you have in this handy
little bag that I've given you. I have a copy. We just got them
yesterday afternoon. I haven't even opened one. Yes, I did. I opened it
and it looks beautiful. The posters, which are quite nice this year.
Every year we try to do them a little bit different. These are very
rectangular and hopefully you will find room for them in your offices
and homes. No, I'm kidding. Ten thousand flyers, 20,000 giveaways. The
new jewelry that you have in the bag is also one of these Lance
Armstrong knock-offs, which is for Recovery Month.

(Laughter.)

MS. TORRES: So I want you to remember to wear them everyday.

We've won yet another award for our Web page, and I can't even remember
the name of it. It's in the monthly report that I submit to Rich. But
it's amazing! People keep giving us awards for the campaign. This one is
significant because it's not just for the Web. It's actually an award
that is for the entire campaign, in other words, not only for the
webpage and the e-government aspect of the campaign, but also for the
print materials and the activities that are conducted.

As you can see, we're nearing a million hits every month on the Web. We
have a series of webcasts called "The Road to Recovery," which I'm going
to show you a promo in a minute. We're in 149---I just counted. I have
to correct that, because it's 149 cable markets. It's probably 160 by
now, because we've got the Alliance for Community Media working with us
to increase it, and they started their work about two months ago. So
we're probably past this. But on the list that I saw yesterday, it was
149. So I'm going to tell you it's 149.

Beyond what we get, which is potentially what you're seeing here in the
149 cable markets, I looked at the number of potential subscribers.
We're potentially reaching about a million people a month with the
webcast. Beyond that we get about 12,000 or 13,000---12,900, almost
13,000---people who are coming onto the Web to look at the webcast.

And in addition to that, we are selling, for cost recuperation, the CDs
and the tapes of the webcasts, and they're being used by local
communities to train. We haven't kept track of how many people see it
through that avenue, but certainly I think that's a very significant
aspect of the campaign, because people are actually using these tools to
train people in treatment centers as well as in academic settings.

Here's the promo for "The Road to Recovery."

(Video clip played.)

MS. TORRES: And that was Maryann Fragulis, who used to be an RCSP
director, but she has graduated.

As you can see, it's a very well done production. I think that's one of
the reasons that it's really helping us to get into those local public
educational and government channels through cable.

What else can I tell you? The hits for the Web are booming. We went from
2003 to 2004; we increased unique visitors by about 232 percent, and we
see the increases each year to be exponential growth with such large
numbers. We have very high expectations for this year.

Here's the award-winning website. I encourage you to go in, because it's
really very full of information. Your whole Recovery Month kit is there.
We've got a virtual Recovery Month kit on the website. We have people
having dialogues and chats who are in recovery and posting their
stories. We have a listserv that you can sign up to, and we can let you
know exactly when these "Road to Recovery" shows are coming on or when
we have the Ask the Experts sessions that we host with one of the
panels. And the reason you saw my picture up there, by the way, is not
that I'm putting myself first; it's that I host the show. We use one of
the people who participates in the panel to actually respond to
questions from the folks who come on to the Web.

I encourage you again and again and again. We've got slots for panels
coming up. I can certainly have Cynthia and George send you what the
topics are if you're interested in participating in one of these shows
and being a panel member. We welcome you, and just let us know about
your availability. The one that we have to worry about is Mr. Curie and
Dr. Clark's schedule, and that really is what sets the production
agenda, if they're interested in doing a show. So we're not very
flexible in terms of dates when it comes to Mr. Curie and Dr. Clark. But
everyone else, if it's flexible, we'll work around your schedule.

Community events. These are the proposed sites for this year. We tried
to go this year where we haven't been before in communities that really
target rural areas as well as urban areas, where we haven't been to
before. As you can see, it's a whole host of new areas that we're going
into.

Our Major League Baseball is going very, very strong. These are the
proposed major league teams that we will be working with this year. We
may even go beyond these because some folks are already starting to work
with these and have gotten local community support already. When we go
into these cities, if that's happened, we're not going to go in there.
We're going to use our resources to go to other teams that have not yet
hosted these types of events.

MR. DeCERCHIO: (Inaudible.)

MS. TORRES: The Yankees weren't up there?

MR. DeCERCHIO: We're going to have to work on them.

MS. TORRES: Oh, yes. If you can help us, indeed.

(Inaudible.)

MS. TORRES: They need all the recovery they can get?

(Laughter.)

(Inaudible.)

MS. TORRES: All right. We've got 44 events already listed, folks, and we
haven't even distributed the kits this year. So what does that tell us?
It tells us that people out there from last year are coming onto the
Web, and even without the materials, they're already planning events and
we're absolutely thrilled. Last year, 417 events, which was 44 percent
growth from the previous years. I've said to people that I will not be
happy until this year we have about a thousand events.

I just talked to Dr. Suchinsky to see if we can get the Veterans
Volunteer Network to work with us, and right there, we'll have thousands
of events, because the veterans do have an incredible network of
volunteers nationwide.

A hundred and eleven proclamations. We went down a little bit because
there was a young man at the Governors Association who no longer was
there this year to help us, but governors do get the letters. As a
matter of fact, the president of the Governors Association essentially
signs the letter and sends it to the other governors. So we've been very
fortunate that this year we're connected and can be doing that. We also
send kits to legislators, mayors, city and county managers, and so on,
so we really spread the wealth quite a bit.

"Treat Me" and "Artist" are the two treatments for the public service
announcements this year, and I'm going to show them to you in a minute.
"Treat Me" is really about people in recovery, and "Artist" is about the
trajectory of an individual from being addicted to reaching his
recovery. We try every year to give a different focus in terms of the
people we portray in our public service announcements.

I have to tell you that with the limitations in our budget for '06,
we're either going to get rid of the webcasts---unless I can get some
support from RWJ or NIDA---or the PSAs. That's where we have to make
choices, and the planning partners have so been told, and we will see
what happens. But certainly NIDA was in one of our last webcasts that we
did on medication-assisted therapies, and they very much enjoyed
participating. So I told Dr. Vocci to go back and tell Tim Condon that
we needed some cash if they wanted to continue to participate in these.

Okay. We get tons of money coverage, and this isn't the half of it,
because we are in the matching program, as I always tell you, with
ONDCP. So our PSAs are really in prime time everywhere, nationwide. So
this is only what we generate from our effort.

Here is our first, which is our "Artist."

(Video clip played.)

MS. TORRES: And now, for Chilo's benefit, we will go to the Spanish
version.

DR. MADRID: I'll do the translation.

(Laughter.)

(Video clip played.)

MS. TORRES: And "Treat Me."

(Video clip played.)

MS. TORRES: And essentially, that's the campaign for this year. We hope
that you join us in the observance of Recovery Month by working on
events in your local community, if you're able to do so, and encouraging
others in your community and your state to get involved also and to plan
statewide events, which I think are really critical. I think those are
the ones that really bring the message to the governors, to the
legislators, about the miracle of recovery.

This would not be possible without, first of all, a host of planning
partners that are just wonderful. Many of the organizations that you're
very familiar with are involved and come about three times a year, as
well as Dr. Clark's support certainly, and the staff. Carol DeForce is
here and Stephen is waiting for 125 boxes of kits that are coming in, so
he can't be here, or he would be here. And of course the AWS phenomenon.
Michelle Westbrook is on her AWS today, and she wasn't able to be here.
But certainly the team works very, very hard each year with the
contractors to make all of this possible.

Next year, just another word about the public service announcements,
there is a campaign that is being put forward. NCADD with Mannesis
Communications started the effort about three years ago, and CSAT has
supported the campaign. So perhaps what can happen if those public
service announcements actually bear fruit and are compatible with the
Recovery Month message, we want to work in synergy with that campaign,
and hopefully then we can salvage the webcast by using those PSAs. But
it's yet to be determined.

Thank you very much for your time.

MR. DeCERCHIO: When will the PSAs be released? You always give us access
to them. When will they come out for release so we can use them?

MS. TORRES: The public service announcements, the only thing that we
have to do is code them for the hearing impaired. And as soon as that
happens, and it should be within the next two or three weeks, we will
make CDs available and have the folks send them to you.

MR. DeCERCHIO: Do you have the rural area in Florida identified, or are
you still trying to work on that? I noticed you had Florida as one of
the states. We've done events there in the past.

MS. TORRES: In Florida there are two efforts going on. I think NCADD is
trying to do something in Tampa through Sherise.

MR. DeCERCHIO: Yes. I'm surprised the Yankees aren't on board yet.

MS. TORRES: Also this year we have three new initiatives. I really
didn't get into it.

MR. DeCERCHIO: We can go offline. Just give me the cities.

MS. TORRES: Absolutely. We'll also have a motorcycle run. We're trying
to get the Sober Riders together in Florida. That will be Massachusetts,
Florida, and California. We're going to put together Sober Rides. So
that will take place in Florida as well.

But I'll talk to you during the break.

Yes, Dr. Suchinsky?

DR. SUCHINSKY: Do you have any idea of the content of the telephone
inquiries? Are these inquiries for treatment? Inquiries for information?
Do you have any sense of what people are asking about?

MS. TORRES: Well, we can tell how many are asking for materials and
being referred. That's the extent. We have to be very careful because of
privacy laws and the anonymity of the people who are calling in. So it's
hard to ask for more information. But to the best of my knowledge, we
can tell how many people are coming in for referrals and information or
just for information.

DR. MADRID: Congratulations, Ivette, for the creativity. Those Spanish
PSAs really hit on target, very, very relevant, very creative. The
"Treat Me" theme is very, very nice. It had the same impact in English
as well as in Spanish, which is unique. So congratulations for all the
work that you, your staff, and Dr. Clark have put into this campaign. I
think that it's probably one of most successful campaigns nowadays in
reference to health care, period. So I think those six awards are very,
very well deserved.

MS. TORRES: Thank you, Chilo.

DR. CLARK: Any other comments?

(No response.)

DR. CLARK: Thank you, Ivette.

(Applause.)

DR. CLARK: While we prepare for our next speaker, I thought I'd read a
little vignette out of this week's *Potomac* *Gazette.* Eric would be
interested in this. There was an article, "Community Deals with Student
Drug Arrest":

"School officials said there is no drug problem at Cabin John Middle
School after three students were charged with drug possession earlier
this month.

"Three boys, aged 11, 12, and 13, all of Potomac, were found with
marijuana on school property. Each was charged with possession of a
controlled dangerous drug. The 11-year-old was charged with possession
with intent to distribute.

"'I don't see a problem in the schools,' says Cabin John principal
Paulette Smith. 'I look at it as an unfortunate incident.'"

Eleven, 12, and 13. But there's no drug problem. The kid is arrested for
intent to distribute. To whom? I thought Eric would like that.

Obviously there's a problem in the school, and the school had to
struggle with how to deal with it. But one of the major elements in
terms of the problem is that the school has got its blinders on. One of
the issues is one of denial. How you deal with the kids is certainly
another matter, but if those in authority don't recognize that there is
a problem, then there is a problem.

DR. VOTH: That's a great segue towards maybe a future presentation on
student drug testing, if we really want to stir up the controversy.

DR. CLARK: Speaking of controversy . . .

(Laughter.)

DR. CLARK. . . . presenting on the international perspective on harm
reduction is Dr. Eric Voth. Dr. Voth is a specialist in internal
medicine and addiction at Stormont-Vail HealthCare in Topeka, Kansas.
He's chairman of the Institute on Global Drug Policy, recognized as an
international authority on drug use, and lectures nationally on drug
policy-related issues, pain management, and appropriate prescribing
practices.

He serves as an advisor on alcohol and drug-abuse issues to the Kansas
State Board of Healing Arts. He is also a consultant on a number of
international drug prevention organizations and is a clinical associate
professor of internal medicine at the University of Kansas School of
Medicine.

Dr. Voth?

DR. VOTH: It's great to be here among friends.

One of the major things that I do in the course of my personal and
professional time is chase around the world trying to stay one step
ahead of the legalization effort. It's a little bit like those of us in
prevention and treatment trying to bail the water out of the boat while
somebody else is running around drilling holes in the bottom of the
boat.

One of the areas that has surfaced is a fundamental change in what we
all recognize as harm reduction policy. Some of us are now calling it
pseudo- or so-called harm reduction. I want to go through some of that
historically so we can get a good handle on this.

Let's keep in mind that traditional drug policy, which most of us grew
up with and I believe probably most of us agree with, is a fundamental
abstinence-based type of a phenomenon---in other words, harm elimination
for treatment, primary prevention, or harm prevention, fundamental
emphasis on no drug use as our ultimate goal, even though we recognize
that's difficult to achieve, and an element of legal enforcement
underlying a lot of this policy.

Why is it so important? If you go back to the risk-focused prevention
model and think about the community risk factors, one of the fundamental
areas that underlie drug policy and risks is community laws and norMs.
And if community laws and norms change, there is a paradigm shift, and
then there's more acceptance of drug use that takes place.

Currently we're really seeing three areas show up in the drug policy
arena. I'd say most of us in the room fall into this group, which is
largely an abstinence-based type of policy orientation. There is a group
absolutely pushing for the broad, all-out legalization of drugs, and
there is a group that's more or less originated some of the original
features of the harm reduction movement, and, as you'll see through what
I'm talking about, there's been an invasion of some of the legalization
movement into the harm reduction movement and then subsequently into the
overall drug policy arena.

In general the way that harm reduction is shaking down, I think that
harm reduction policy is probably most effective only in those behaviors
that are generally legal and socially acceptable. So think, for
instance, about wearing seatbelts in a car. We know that some element of
car accidents are simply unavoidable, and we want to do things to
mitigate those.

Helmets, for those of us who drive motorcycles or ride bicycles. We know
that sooner or later there's a chance we may fall. It's an acceptable,
otherwise generally healthy, behavior. But how can we protect ourselves
and our children?

But here's the sinister side of what we're calling the pseudo- or
so-called harm reduction movement. Back in the late 1980s, there was a
group---this is quoting Peter McDermott, who is the editor of the
*International Journal on Harm Reduction,* who said, "I was part of the
Liverpool cabal who hijacked the term harm reduction and used it to
aggressively advocate for change."

Down here he's saying, "Harm reduction implied a break with the old,
unworkable dogmas, the philosophy that placed a premium on seeking to
achieve abstinence."

That old dogma sits alive and well in this room, and I think is
workable, that we want to try to seek to achieve abstinence, and there's
nothing about it being an inappropriate goal.

Another bit of sinister side of harm reduction. This is quoting Pat
O'Hare, who was at that time director of the International Harm
Reduction Society, who said, "If kids can't have fun with drugs when
they are kids, when can they?"

Another hole being drilled in the bottom of that boat. You can see we're
working on prevention, working on treatment, while some people in the
arena are actually espousing this type of policy.

Ethan Nadelman, who has served as one of the primary drivers behind the
drug legalization movement, saying, "Recognize that many, perhaps most,
drug problems in the Americas are the result not of drug use per se, but
of our prohibitionist policies."

So the new what I'm calling so-called harm reduction, or pseudo-harm
reduction, really gives up on the user and seeks more only to
encapsulate the user. It is predicated only on trying to reduce societal
harm, and it considers drug use inevitable and uses this nihilism to try
to get folks in society, and actually involved in other drug policy
arenas, to say, "Yeah, well, it's inevitable. I guess we just have to
accept that."

Andrea Barthwell and I had a long, wonderful discussion on this, and she
opened my eyes to an arena I hadn't thought about before. The harm
reduction movement, as it's panning out, really only focuses on this
segment of the drug-using world, the addict and those who are in pretty
bad shape, as far as the nonaddicted drug user population, but really
does nothing for primary prevention and does very little, if anything,
for the nonaddicted drug users. So we end up with this enormous
reservoir up here feeding the addict population almost inexorably, and
we're just standing by in that movement, saying, "Well, if they start
using their I.V. drugs, we'll do various things for them."

So what you'll be hearing from me, and clearly from the President and
Mr. Curie, etc., is that we need to look at this entire phenomenon, the
whole population, to really have effective drug policy.

So here's what we're seeing as the variance between what we'll call
traditional drug policy and maybe even where harm-reduction policy
originally intended to be, and where it's really ending up today. One is
a "responsible use" message, and, I kid you not, there are literally
movements around the country that are trying to convince parents to
teach kids to use pot responsibly, to drink responsibly. Underage kids.
Imagine those 12- and 13-year-olds drinking, using pot, responsibly.

"Medicalization." We can talk about that if we have some time. Needle
exchange, some forms of methadone. And by the way, I just give you my
hats off to all the work that Wes has done in terms of trying to get a
handle on methadone treatment and standardizing and moving it forward in
appropriate realMs. I think it's wonderful work. I never had a chance to
say that to him, so I do it in a public realm.

Heroin handouts are beginning to pop up around the world. There are
actually some cities that have been handing out "safe crack kits,"
intended, one, to move addicts away from I.V. drug use, but also to
teach them how to use crack safely. There's a great paradox in that, I
hope you're seeing, but the instructions in the safe crack kits say, "If
you have cracked or bloody lips, don't share your crack pipe." There's a
condom thrown in with it, too, and some really incredibly ridiculous
points, rather than, "Wait a minute, let's maybe try to get them away
from that behavior."

Then other forms of treatment, trying to moderate use and tossing out
the notion that abstinence is a reasonable thing.

I want to run through some of the areas where harm reduction policy has
been tried and give you some examples. We don't have near enough time to
really dig into these, and if I have some, I'd like to dig into some of
the examples where harm reduction has really caught on around the world.

First off, alcohol policy. You talk about trying to bail water out of
the boat while people are drilling holes in the bottom of it. We've done
wonderful things recently---and for years---to try to reduce underage
drinking, to try to reduce the problems associated with alcohol. But
good heavens, consider alcohol. By no question it is our biggest
addictive problem outside of tobacco, and youth are using twice as much
alcohol on a regular basis as marijuana.

Consider advertising alone. This is what we've got. We've got a legal
drug, where harm reduction things are taking place. Enormous advertising
budgets being dumped right on kids. Enormous spending on advertising.
It's gone up 148 percent in the last couple of years. Thirty million
dollars alone advertising in the top 15 teen shows.

We're bailing out the boat. Guess who's drilling holes in the bottom?

Tobacco policy. Well, we all know about tobacco, and this is singing to
the choir. But let's keep in mind that if we are going to have this
legal drug, and people say, "Let's legalize drugs and tax it and gain
all that back," we would need to be pricing tobacco at about \$40 a pack
to regain societal costs that are going down the drain. There are now
those who are beginning to try to push a responsible smoking agenda,
believe it or not.

To give you an idea of this responsible usage, there's a brand new book
that's just hitting the market called, "It's Just a Plant." It is
absolutely targeted at the pre-teen market. One of the people who wrote
a foreword in it, Marsha Rosenbaum, has been very deeply involved in the
responsible-use message. It is published by the Magic Propaganda Mill.
It says in the back, "Thanks to Ethan," of course, likely Ethan
Nadelman, George Soros, etc. And it was funded by folks who George Soros
funds, like the Marijuana Policy Project.

Its message is very clear. In fact, in one place in that book, the
little pre-teen girl who went down the hall and smelled funny smoke
coming out of Mommy and Daddy's bedroom says, "Marijuana's not so bad. I
want to grow some myself." This is the kind of message that some of
these folks are pushing.

The medical marijuana movement is my alter ego. I spend hundreds of
hours involved in this, and I have nowhere near enough time to talk
about it today. If you're ever interested, we can do that. But again,
this is another one of these diversionary tactics, trying to push a
perceived or alleged medical application or excuse for marijuana, smoked
marijuana, and the ballot initiatives have been heavily driven again by
organizations who are squarely behind the legalization movement.

Now, needle exchange programs started off with good intent. I would have
to say, though, that as they've unfolded, a lot of negative has begun to
show up. I want to make you aware of at least the negative side. Most
people have a sense that maybe there's some sort of positive behind
needle exchanges. Quite honestly, I quit referring to them as needle
exchanges, because for all intents and purposes, they're really needle
handouts.

First let's consider the average needle requirements of either heroin or
cocaine addicts. Then if you multiply that by the millions of them
floating around out there, you'll begin to realize that there is no way
we can possibly, conceivably provide enough clean needles to handle all
of the needs of addicts. And then one gets into the question of what do
we do with those needles once they're out there.

It's a little bit dated now, but an excellent look by CDC about exchange
rates. Only 62 percent of the needles in the needle exchanges in North
America that were looked at were returned. That's 7 million needles in
one year on the street. Seven million in one year on the street. That's
needle handout, folks, that's not needle exchange.

And it's not specific to North America. This just came out of Glasgow
this last December. The return rate was 54 percent, so about 400,000 in
that small city, 400,000 needles on the street.

In some areas of the world, there are so many people being stuck by
needles around these needle exchanges that people have even quit
reporting it to local health authorities, because they figure it's just
going to happen.

When you look at the research, and I know we've all heard these
statements: "There's no question needle exchange helps." We've had some
national folks in previous administrations that say, "No question we
have to support needle exchange." But here's some reality. First of all,
most of the looks at needle exchange have been very small sample sizes.
Few if any have had control groups. There's largely been a
self-selection of participants, high drop-out rates, and self-reporting
of behaviors.

There's a brand new report that's coming out of Sweden, some folks that
I work with over there that have looked very rigorously. It's not
published yet, so it's still embargoed. But they went back and looked at
143 of the studies looking at needle exchange. And if you look at the
diversity of how the studies were done, you can sift out of them that,
in fact, the randomized controlled studies really showed no difference
in benefit. There were 13 that looked at HIV primarily that showed no
difference. Three showed better HIV rates; two showed worse. The five
that focused on hepatitis showed mixed results.

As far as risk behavior, 31 found risk behavior worse, 15 better, 21
really no particular change. That's a pretty mixed bag of those studies.
Standardization is a question there.

I want to look at a couple of studies. We don't have near enough time to
go through all of them. But a couple are just interesting. In one of the
Chicago studies, and this is getting a little dated now, but it was
interesting that 39 percent of the needle exchange participants in that
study shared needles versus 38 percent of nonparticipants. And 68
percent displayed injecting high-risk behaviors.

Montreal, which really was quite a good study, and it's interesting
because subsequently, when I communicated with those researchers, they
really tried to backpedal on their own findings, because, unfortunately,
it really showed that those involved in their needle exchange had a
significantly higher risk for HIV/AIDS conversion and seroprevalence
than the nonneedle population. Their conclusion was that the risks were
substantial and consistent in all three scenarios that they looked it.
It was really not a bad study.

Hagan over in Seattle looked at hepatitis B and C. Similar kind of a
finding, particularly among the sporadic needle exchange users, that
their risks for hepatitis B conversion were 2.5 times and hepatitis C
2.6 times higher than the nonneedle exchange participants. The Seattle
conclusions were fairly similar. The highest incidence was among the
current users of the needle exchange, and the goal of elimination and
reduction of risk behaviors had not been achieved.

Puerto Rico. I'm trying to give a more international flavor with some of
these. No significant change in injection habits. Only 9 percent entered
treatment, and remember, many of the proponents of needle exchange have
been saying that this is the way we attract folks and try to get them
into treatment ultimately. Only 9 percent enter treatment, and this is
remarkable, the number of needles that were not returned. Twenty-six
percent of the needles returned were seropositive for HIV, although I
think that's a terrible way to really measure it.

India. If you look at what happened from 1996 to 2002 during
particularly their use of the needle exchange, compare from line to line
here. This is HIV, hepatitis, hepatitis C---instances were respectively
1 percent going to 2; 8 percent going to 18 percent; hepatitis C, 17
going to 66 percent prevalence.

Scandinavia is really a phenomenal area, because you've got one of the
most "liberal" parts of the world working on drug policy, but at the
same time, you're going from some of the most liberal drug policy to
some of the most conservative drug policy in the world when you move
from Denmark to Norway to Sweden. And this is really one of the best
side-by-side comparisons of societal drug policy that's been looked at.

If you look, for instance, at Denmark, and Denmark's process has been
pretty much an open needle exchange, there's really been no mandated
compliance or reporting, and counseling and testing is very lax and a
voluntary phenomenon. Through 1991 to 1996, their HIV incidence has been
pretty steady, about 1.49 per thousand.

If you look at Norway and Sweden, though, it's interesting that with
limited handouts, and here in Sweden with no handouts whatsoever, but
with aggressive reporting, aggressive counseling, aggressive
intervention, there has been a steady reduction in HIV down to the point
where here in Sweden, we're down to 0.58 and Norway 0.58. So, a third
the HIV rate as Denmark, which pretty much hands out needles and steps
back and says, "Do what you think is right for you all."

So what are the problems with needle exchanges fundamentally? Most are
essentially handouts. There are a few that have pretty good return
rates. There is not a clear reduction in HIV and hepatitis B and C. They
do really nothing to change the underlying destructive behavior of I.V.
drug use. There is clearly a sense of immunity in the drug-using
community around needle exchanges, and that then provides an atmosphere
supportive of use. There was concern that there might be a recruiting
process going on, but that really hasn't borne out in some of the
research that's been done looking at this.

I think that it's a real problem that when you start looking at needle
exchange, there's really no advantage over aggressive outreach programs
and abstinence-based programs. And it seems to me to be a waste of
limited financial resources. No one has grappled with the product
liability risks. In other words, if you get stuck by a needle walking on
the beach, or if you're an addict and something happens to your rig that
you're getting from my needle exchange, or I'm a parent and an
adolescent of mine gets tangled up in a needle exchange, and I think
that somehow they become injured, who's going to bear that product
liability risk? We're in a liability-laden society. Certainly a
significant risk for needle sticks, and let's keep in mind that most of
the deaths of those addicts is from disease or homicide, not from the
disease specific that they're hoping to stop.

I want to talk about the heroin maintenance program, because this
phenomenon is beginning to catch on around the world, and it's
worrisome. The Swiss in 1997 came up with something that typically the
Swiss would do, which is, how can we possibly keep those folks from
causing harm to the rest of us? The Swiss are kind of provincial people,
and all of my good Swiss friends would agree to that. They thought,
"Well, let's come up with a plan to look at three legs or arms of the
study, methadone, morphine, and heroin, giving this to patients."

What ended up happening is, they didn't keep their study groups pure,
and most of the patients ended up migrating to using heroin. So they
ended up with no comparison groups.

All of the outcomes were self-reported. They initially wanted to use
end-stage addicts so they could really see if there was a benefit. But
they ended up using folks in pretty good health, which kind of biased
that severity index. There was no data that was ever captured on those
who left the program.

No independent drug testing. They said, "Are you using other drugs?"

"Oh, yes. I'm not using other drugs. I'm staying sober."

There was no random drug testing. It was always agreed upon, the
schedule, by the tester and the patient. It was not witnessed. There was
no independent evaluation of HIV, no requirement for HIV testing. The
conversion rates were not measured. The criminal behavior was
self-reported. There was no look at police files whatsoever or any
contact with the police departments.

So, imagine, the addict came into these and they'd say, "Are you using
other drugs?"

"Oh, no, no, no."

"Are you involved in crime?"

"Oh, no, no, no."

Well, of course! And they get their free heroin, and away they go.

There was no systematic evaluation of employment records.

Now, the original intent, again, was to try to bring people in, get them
stabilized, maintain them for a while, move them towards abstinence and
employability.

In the last year, they reassessed this, and only 5 percent of that
population became abstinent. One of the negative things that happen is
that abstinence-based programs started finding reduction in their
numbers, because people were saying, "Wait a minute! I don't have to
quit. I just go over here and shift to the heroin maintenance program so
I can keep using."

Only 4 percent of the original group have actually stayed off heroin.
Thirty of their abstinence-based treatment centers have closed, and the
actual annual cost to maintain the addicts on this program has been
24,000 Swiss francs a year. That's pretty darn good funds for any kind
of treatment, much less something like this.

So what's really happening there now is, even though they have said this
has been a very, very successful program, the international look is very
skeptical. Actually the World Health Organization said, "Wait a minute.
The way you structured this was so terrible, we really can't draw any
kind of conclusions."

Now, we've seen areas of harm reduction in the United States. I want to
just brush across some of those.

Baltimore has had a phenomenal drug and a phenomenal drug and violence
program. They have actually been making some progress in the last few
years. Dr. Beilenson and I testified to a congressional hearing a couple
of months ago, and they are making efforts. Actually, though, he
admitted in that hearing that some of what they're doing is not just
harm reduction any more. It's mandated treatment.

He could not say that they had actually put treatment groups beside each
other, one getting the needle exchange plus all the social support
versus a research group that had all the social support and no needle
exchange. So whether needle exchange plays a positive role for them,
don't know.

They still have a phenomenal crime problem, worse than all of these
other similar-size cities, twice as high in overdose deaths as these
other major cities. So they're paddling upstream. We've all seen what a
problem they've had. It will be interesting to see how this pans out
over time.

Vancouver is another area that's a real hotbed of harm reduction policy.
One of the more recent studies has looked at the HIV incidence among
their addict population. It's phenomenal.

It's interesting here, too, when we talk about what's our net hope for
some programs, a 27 percent needle-share rate certainly shouldn't be
one. The overdose death rate was the leading cause of death in Canada
among 30-49 year olds being overdose deaths. And among the needle
exchange program participants who were on methadone, 50 percent are
sharing needles.

Wait a minute, now. We're maintaining them on methadone. We ought to be
working away from I.V. drug use, right?

The police in Canada are literally pulling their hair out. I work with
many of them up there, and they're saying that Canada, if you look at
the big picture of what's happened with this softer drug policy, Canada
is now becoming a source country and Vancouver is right at the heart of
it.

Some other little spin-offs of lenient drug policy there. Marijuana has
escalated to a billion dollar annual import. There are virtually no
marijuana fines. Border smuggling is huge. Three million needles were
handed out in 2000. They are now initiating a heroin handout program to
add insult to injury. And there have already been 109 overdose deaths in
the government-sponsored shooting galleries, where people can come and
have "safe shooting." A hundred and nine overdose deaths there.

The overall Canadian results spill over into other areas. The overall
use of marijuana is beginning to go up. Eighteen percent of users are
smoking daily. And look at that population we worry about so much, the
adolescent use.

I hate to rocket through these, but I told them I'd stay on time today.

England has seen a significant increase in marijuana since their
decriminalization plans. Now their head law enforcement officers have
said they are very concerned, and they think it was probably a mistake
to have decriminalized marijuana.

Holland, one of the hotbeds of harm reduction and actually marijuana
tolerance. Their adolescent marijuana use skyrocketed in the early
years. Their organized crime groups have skyrocketed. They've now become
a leading exporter of ecstasy. Their own people feel that their laws are
too lax.

And again the spin-off, not just marijuana use, but look at cocaine,
ecstasy, meth use among young people. So when drug policy is softened,
there is that spillover into other arenas.

And, of course, as you'd expect, HIV rates are going up, an increase in
just that period of time alone.

So where do we go from here? One of the things that I try to support on
an international basis is a broad approach, looking at prevention,
treatment, and interdiction. Harm prevention, harm elimination through
treatment, and recognizing the importance of interdiction. And I think
now it's safe to say that enough of the harm reduction movement has been
invaded that there is a significant segment of it that has jeopardized
and maybe even being an almost harm production movement.

I'm open for some questions. That was a mouthful. But I stayed on time,
didn't I?

DR. CLARK: You stayed on time. Council discussion?

MS. JACKSON: Thank you. That was a very informative presentation.

I think that the information that you gave really points out some of the
pitfalls of harm reduction. I know that just from my local point of
view, working in an agency, some of the federal agencies do talk harm
reduction and when you write grants to get money for services, you've
got to talk about harm reduction, not necessarily legalization. I don't
think I've ever applied for anything that promoted that.

However, where is the U.S. and the helping agencies---CDC, HRSA,
ACF---what is their general policy now on harm reduction?

DR. VOTH: Well, I'll speak briefly about that. I tell you that it's all
over the board. There are, within government, some very clear hotbeds of
harm reduction. One of the most recent, as it came up, is out of the
State Department. The USAID was pushing needle handouts across parts of
the country on one hand, while ONDCP and the government was saying, "No
needle handouts."

All of a sudden they realized that we're working against each other.
I've certainly dealt with folks at CDC that have pushed and supported
needle exchange. I'd like to believe that as a national policy---and I
think if you go to the White House, they'll absolutely say they do not
support harm reduction or related policy. But I think there are clearly
hotbeds of it throughout government.

I think from our standpoint, we ought to be clear that we do not support
harm reduction as a part of or the focus of any treatment-based funds.

DR. CLARK: Richard?

DR. SUCHINSKY: I'd like to pull together some aspects of presentations
at this meeting to really focus in on what the harm reduction movement
is all about. First of all, we spent an awful lot of time yesterday
talking about outcomes measurement and how we had to convince people
that our treatment was able to produce improvement.

Now there's a huge literature that has for years shown that treatment
can produce improvement. Our technology is certainly not perfect, and we
don't even approach 100 percent. But we produce significantly good
results. But there are people who perseveratively ask us to justify our
existence and say, "Well, prove that what you're doing is worthwhile."

In my experience, many of these are the same people who are now
promoting legalization and harm reduction activities, and I think that
the bottom line here is that the crucial issue is the stigmatization and
bias that is involved in the attitudes towards people who use substances
and people who treat people who use substances. So I think there is a
connection among all three of these aspects of the presentations that
we've had here at this meeting.

I think that probably the place that we have to start is at
stigmatization issue. I think we can devote ourselves endlessly to
justifying our existence, but that is not going to convince a certain
segment of the population that we have any validity, because the major
issue is how much they dislike people who use drugs.

DR. VOTH: And I would just echo that there's a real cynicism among a
segment of that harm reduction group. If you go to Canada---and I've
been up there. I'm all over the world studying these folks. And I'm
going to tell you that there's no harm reduction taking place among
those addicts that go to the shooting galleries and shoot up and go out
on the street and sleep under the bridges and things. There's a cynicism
and a sense of ostracism. Just encapsulate those people and sort of keep
them away from hurting society. It is something I think society needs to
be aware of and health professionals need to be aware of, that that is a
sinister part of this whole thing. Rather than embracing the addict and
saying, "We can help you. Let's make your lives better. Let's help you
at least try to get to abstinence,\" it's like, "Well, here's your
heroin. Just stay away from me and my folks." Harm reduction does not
help people.

DR. CLARK: Frank?

DR. McCORRY: Well, Eric, I take issue with some of your conclusions, or
what I think would be mixing a couple of different elements into a
single presentation.

Harm reduction, I think, is larger than syringe exchange programs. And
in fact, I had looked at the syringe exchange program data recently, and
I look forward to seeing that Sweden article. Perhaps you could pass it
around when it comes out, that meta-analysis of 114, whatever it was,
119 syringe exchange programs.

But the earlier data I didn't think was so bad, and certainly in a high
HIV state like New York, syringe exchange from the data showed reduced
levels of HIV among syringe exchange users. I'd be really interested in
that, because syringe exchange is a separate issue to me. While it might
be an example of harm reduction, I don't think it's the totality of harm
reduction.

I think yesterday's SBIRT presentation---SBIRT, in fact, employs a harm
reduction approach. We're looking to reduce the use of alcohol among
problem drinkers. We're not sure about diagnosis, because it wasn't put
in. But in effect we're not looking for abstinence from drinkers. We're
looking for better use, less use, less problematic use.

Harm reduction is a standard clinical technique that many individual
therapists use. You try to keep someone in treatment to retain them, so
you do not throw out them out when they use, because you know that
relapse is part of the disorder. So by keeping them in treatment, it's a
harm reduction kind of approach, rather than saying, "Well, you can't
meet abstinence, therefore you can't be in treatment."

Of course, I'm not at all addressing issues of legalization and how some
of the harm reduction movement might be co-opted, or the camel under the
nose. I think that's another whole set of issues of drug policy,
countries' drug policy.

But I'd be cautious about defining harm reduction solely or
predominantly as a syringe exchange program. That would be my first
point.

And my second point would be, I'm not sure that the data on syringe
exchange programs is as poor as you present, so I'd be interested in
further discussion about that. It certainly is an absolute question, if
the evidence does not support some reduction in nondrug-use related
behaviors. If they've been able to show that there's no increase in drug
use, they have not been able to show its decrease necessarily in drug
use based on syringe exchange. I'd be interested in knowing more about
that.

DR. VOTH: A brief comment on that.

I think part of the difficulty is the focus on what's our endpoint. Our
endpoint really isn't to reduce drug use or necessarily to reduce the
individual's drug use.

It's like smallpox. Our intent was to eliminate smallpox. We would love
to eliminate addiction, wouldn't we? I mean, that's our ultimate goal.
We recognize it's a relapsing disease. People will relapse. People we
work with are likely to continue using, but our goal ultimate goal is an
abstinence-based phenomenon.

Now we may use techniques that reduce the harm to that individual, but
to say that our ultimate focus is harm reduction, I think, is dangerous.
And in fact, they talk about that being the public health model. But the
public health model really is identify the disease, prevent the disease,
treat the disease---not just sort of accept the disease. You may have to
accept elements of it.

As far as the early research on needle exchange, I think there was some
terrible research that was heralded as being wonderful, supportive
stuff, that was poorly put together. The Bruneau and Hagan studies were
some of the best research that I've seen. I don't want to argue just
that.

I think that one might even say that an element of needle exchange in
the process of trying to get some control over addicts' situations may
be reasonable, but not as an endpoint. Do you see what I'm saying? So
I'm not saying an element of accepting harm reduction to try to work
with the addict is not appropriate. I'm just saying that an endpoint of
harm reduction focus is where we should not be.

DR. CLARK: Frank?

DR. McCORRY: I think that there's a clinical tension between---exactly
as you described it, Eric---how much you can tolerate in terms of an
individual patient's behavior without having to act on it. While you're
pushing towards abstinence, how much you're able to stay engaged with an
individual, where you don't land up by trying to keep engagement, in
fact defaulting off what the goal of the treatment is, what the
therapeutic goal is.

I like the way you described abstinence-based phenomenon, because it's
really not abstinence we're looking for---and I think SAMHSA has been
wonderful in this. We're really looking for recovery, which an
abstinence-based phenomenon, which takes in much broader aspects of life
than simply nonuse.

To look at harm reduction as a technique in the path towards recovery, I
think, is the appropriate clinical model. As you default into the
unwillingness to confront, the unwillingness to challenge, the
acceptance of a lifestyle that is really detrimental to the community as
well as individual, I agree with you. That's where it's no longer harm
reduction, but it's something less. The expectations are just not
sufficient in terms of what you're looking at therapeutically.

But I think it's equally dangerous to equate harm reduction with syringe
exchange and to lump them into a view that in fact excludes or preempts
the use of these kinds of techniques, because they're going on all the
time, every day, in our prograMs. Counselors are engaged with folks,
keeping them in treatment, because they have their eye on the right
goal, the goal of abstinence and recovery, and to do that they sometimes
must live with the tension of having to accept use while they look
towards a brighter day for that client.

DR. CLARK: Any other discussion on this matter?

(No response.)

All right. We shall move to the next issue, except for Val's not here.

I really should point out that federal dollars cannot be used to support
needle exchange programs. I just want to put that on the record. Federal
policy does not support harm reduction as a construct at this juncture
in time. I'd like for Council to be aware of that.

We promised you an e-therapy update. Sheila's handing out some
materials. I'm going to temporize, I guess, until Val returns, since
she's going to present with you.

Dr. Harmison is my special assistant. She has spearheaded CSAT's efforts
in the area of e-therapy. She's joined today by your colleague Val
Jackson. Val is the former CEO of The Village located in Miami. She has
more than twenty-five years of experience in community, state, and
national services for people with substance abuse problems. The Village
has facilities in Miami, Florida, and the U.S. Virgin Islands.

During this past year Val has changed her position to vice president of
WestCare Foundation, the umbrella organization that includes The Village
South Miami, The Village in the Virgin Islands, partners in recovery.

Sheila and Val?

MS. JACKSON: We're handicapped. Somebody help us get into the slide
show?

PARTICIPANT: Sure.

MS. JACKSON: I want to thank you, Dr. Clark and Dr. Harmison, for
allowing us to talk about e-therapy again. As you know, we did talk
about this last time a little bit. I left on the second day, and Sheila
gave a presentation, which I thought was excellent.

Since then I've had the opportunity to present at a conference and to do
some more study about this. So today, we have a little bit of repetition
just to refresh everybody where we were with the e-therapy, and then we
wanted to request a couple of items from the Council. That's sort of
where we're heading with this little thing.

So let me see if I can figure out where we page down at. If I get that,
we've got it. Okay. I'm going to flip through these pretty fast.

My husband was in the hospital recently in Las Vegas, and one of the
things that happened was that the nurse came in and said, "You know,
probably his CAT scan was read in India, transferred back over to Las
Vegas, Nevada, and then actually brought back by the doctor in his
room."

I just sort of looked at him and went, "Well, I'll bet that does
happen." But I hadn't really thought about it before.

The days of technology, and what happens in technology and in medicine,
have really come a long way from those old days when you had to wait for
the radiologist to come in and read a scan or something like that, and
then come back to your local doctor and get the information back.

I think we have to recognize that we are moving along. Just as in
medicine, we have to begin to look at how the Internet and, in fact, all
electronic kinds of therapies, may affect us. The Internet has brought
about a way to interact with a person or group without leaving your home
or your office.

I was thinking of another story. How many of us know someone, or have a
son or a daughter or a niece or a nephew or a friend, who's finding love
on the Internet? It's something that they're very comfortable with,
something that many people are very comfortable with, and it's being
used every day in many ways: Internet prescriptions, Internet records,
telehealth, education, psychiatry, counseling.

Last time, I remember, Dr. Harmison showed you a couple of the webpages
that had individuals who were advertising themselves. Some of that is
positive, and I think that we need to think of it as positive. And, of
course, some of it also may be very, very dangerous, and we need to
really look at the qualifications, at the impact and outcome, and how
this is done---which, of course, is where we're leading with this
presentation.

These are just some of the other ways that online communication formats
are coming across.

I read in the last month a lot more about doing therapy by e-mail, for
instance. Some of the advantages of that, in terms of being able to do a
diary as a patient or as a continuing care individual or even in the
engagement stage, you begin to do a diary, because you're actually
writing out this as you go, when you use the Internet.

There's ways to do it by voice, but this is talking about plain old
type-out Internet e-mails version of therapy. Besides that, if you have
a counselor or therapist just coming back to you, you have information
that you can read and reread, and you can digest.

So from a position where I was some time ago---not that long ago, maybe
only months ago---of really questioning where we could possibly go with
substance abuse prevention, treatment, and aftercare, I've begun to have
some doors opening, and I want to share those with you to think about
the possibilities.

We've all participated in webcasts. I think that the message boards, the
listservs, those kinds of things are common things. These are more
recent articles that have come out about behavioral health counseling
and the Internet and how it's worked. There are more studies being done.
I don't think we're at the end of having studies done. I think we're at
the beginning of that. But here are a couple of references for you that
we've handed out that allow you to begin to look at those.

When we think about what we might be able to do, the first thing that we
really have to admit in this society and in substance abuse and mental
health is that there simply is no way that we're going to be able to
provide residential or outpatient face-to-face treatment to all the
people in need in all of those places in need in these United States and
territories. In many areas, getting to people is virtually impossible.
Having the funds to be able to build and maintain sites and treatment
programs is really, really not something that is very, very feasible. I
think because of that, it's really important for us to take a look at
not only some of the populations, but also some of the areas that we
have to look at.

This mentions Native American communities, juveniles, rural clients. I
think some of the first things you think about are perhaps the rural
clients.

How is it in rural America? I was talking to the judge earlier today
about Native American communities, and he made a very good point, one
which I lived when I used to live in South Dakota. I used to be the
assistant state director for South Dakota. One of the grants that came
in to us, an application, was for a woman to buy her a car---not a new
one; she just wanted a used car---and she wanted enough gas so that she
could go down to the Rosebud Indian Reservation and travel from house to
house and sit at the kitchen table of those individuals who had very
difficult problems, and through that she would gain their trust, and she
was able to actually do door-to-door treatment, so to speak. It would be
what we'd technically refer to now as in-home, onsite. But in those
days, you'd go sit at the kitchen table and you'd talk and you'd get the
trust, and it works that way.

I think there's still something very, very important about that kind of
face-to-face trust, but also I think that we have to look at that there
are many, many areas where simply that's not possible.

There are populations---gay, lesbian, bisexual, and transgender
individuals---who, for whatever reason, are much more comfortable on the
Internet than they are in a face-to-face therapy group. Co-occurring
clients, women, juveniles. Juveniles, the kids that we have in treatment
today, I can tell you, and we're actually going to do this at The
Village, it is very easy for us to take a \$200 computer, teach them how
to interact with an aftercare group before they leave treatment, give
them that \$200 computer, which is pretty worthless on the street, so it
isn't a danger for sales, and then allow them to do their follow-up and
aftercare through the Internet. They're comfortable with it. It's okay
for them. They have travel problems if we ask them to come back into our
program. So there are some real opportunities, if we would begin to look
at this in an out-of-the-box sort of way.

Some patients really like the idea of computers. They're very
comfortable with it.

I won't go through all these.

One of the studies at point number 4, attrition is lower in online
treatment. Dr. Alemi, who is recognized at the bottom of your slide, has
done some studies. He is from the College of Nursing and Health Sciences
at George Mason University. I met him at a recent event, and I was
talking to him about a study that he completed.

His study showed that those people who were in a continuing care or
aftercare program---they had received treatment, outpatient treatment I
believe it was, and once they left that treatment then they joined in an
aftercare program. Their attrition was much lower coming out of
treatment if they participated in the Internet study than it was if they
were just expected to come back into groups and do that.

So from my own logical thinking, what it seems to me is that what
happens at The Village, where we are in Miami---we're in a very urban
area; we're not in a rural area---adults or women with children
particularly have transportation problems in our urban area. They have
care problems. They leave treatment with every intention of coming back
to the aftercare groups, but you know what? It's really, really hard for
them to do that. What we need to do is find a way to make it easier for
them to do that, and this Internet, whether it be telephone, Internet
talk or Internet type---and again, you have to look at the skill level
of the individual---may be something that is worth us looking into and
doing some pilots and work in the future.

I think that, as the judge and I were talking this morning, there are
some real questions. Who the heck are you counseling with when you get
on Internet therapy? How do we ever license or certify that those people
are qualified? Those are huge, huge questions that I think need to be
asked?

How do we deal with it if it's from California to Florida, or from
London to Nevada? Those kinds of things are really, really big
questions.

How do we measure any kind of effectiveness or outcomes? It's like a lot
of things on the Internet. It is really, really difficult to put any
controls on it and put it in a box where you can measure it, know that
it's doing good and not some harm. So first do no harm. We need to find
out that it's first do no harm and take it from that point.

Right now there are no minimum standards of care. Anybody who wants to
can get online, say that they can treat you. "I can make you feel
better." I hear commercials on the radio station I listen to every day
that says, "Call me. I can take care of your drinking problem. It's no
problem. If you can't stand it, go to AA, come to me."

I have no clue who that woman is. She might be the greatest thing since
sliced bread, but I have no way of knowing, or even asking to find out,
what kind of standards she would meet.

Confidentiality and privacy issues, lack of technology and expertise.
The reimbursement for services is another issue. One of the things that
I would like to suggest on that is that it's quite possible that in
reimbursement--- Ken just walked out on a telephone call. I wish he were
here, because I want him to hear this question, because he's in my
state. But I have often asked myself in Florida, we go by cost centers,
and of course counseling is a cost center, individual counseling or
group counseling, however you might like to do it. There's nothing
really in the rule or the regulation that says an hour of Internet
counseling wouldn't be as valid as an hour of any other kind of
counseling. So it would be very interesting to see how we might be able
to fit some of these services in the services that we're already
providing, either through the block grant or the state maintenance or
even through grants that we have through SAMHSA and other organizations
at this point in time. And it depends on how we want to define that. But
I think those are questions that we need to have answered---and to ask,
first---and then to get answered before we can actually go forth and be
able to take this nationwide.

Cultural issues obviously, I mentioned that a little bit with the Native
American issue, the rural issue. I think those are all relative.

The cost of e-services can be much lower than the services that we try
to perform face to face. We don't know exactly what the cost is. We
don't know where the savings would be, compared to the benefits. So we
need to look at that.

And of course, we mentioned before, the ethical and legal guidelines.

I think I'm close to getting to you, Sheila.

One of the things that I discovered, though, that I wanted to mention,
before I turn this over to Sheila is that, people say, "How can you
possibly do e-therapy when you can't see the eyes and you can't see the
body movements and you can't see the body language?"

It turns out that there have been some studies, though, that because we
have changed, we have grown comfortable with our technology. There's an
expression that basically becomes telepresence, a person can be working
in therapy with someone through the Internet and they sense that that
person is there with them, and they actually establish a bond. That's
been shown to be a benefit in this kind of therapy. And I think that the
text-based bond can lead to telepresence and illusion of being in
someone else's presence without sharing any immediate physical space.

All of us have that sense sometimes, if we're on the phone with someone,
and we get so comfortable that it's as though we're sitting on the couch
actually having that conversation with someone. We need to think about
that. How does that apply to therapy?

I think that I'm going ask Dr. Harmison to go ahead and continue on from
me with the activities that the Council has done, and then what we'd
like to do is to talk to you a little bit about a couple of requests
that we would like to ask the Council to support for e-therapy and how
we want to continue on with that.

Since Ken's walking in now, then I'll repeat my question about costs. We
were talking about paying for e-therapy, and I said in Florida---you
don't have to answer this question; I just want to pose it right
now---we go by cost centers, and the cost centers have individual
counseling, group counseling, and there is really nothing in there that
says whether it is necessarily sitting in a room face to face or through
the Internet. Would that be recognized as that, and how can we possibly
look at fitting a valid---if we choose that it's valid and find that
it's valid---Internet therapy into our existing cost centers, versus
trying to find a whole new pot of money to do that? So consider that I
have repeated that for you, and now I'm going to ask Dr. Harmison to
continue with the activities.

DR. HARMISON: Thanks.

Good morning. It's really nice to see all of you here today, and I want
to tell you, when I saw the weather outside before I came, I was
thinking, "Gosh, wouldn't it be nice if we had televideoconferencing,
and I could just do that instead of coming in today." But I made it. I
made it.

Let me just go back one piece here, because this is important. Last
month we did a presentation, which Val was a part of, and I just want to
thank you so much. Her presentation was excellent in giving an
introduction and overview of what we are trying to accomplish with
e-therapy in C-SAT, what we're looking at and what we've done so
far---which is really a lot, considering the other OPDIVs.

We did have a presentation, and Dr. Clark spoke to you about this
briefly. It was called "Not Just for Downloads: An Innovative Approach
to Treatment in Minority Communities." It was at the Lonnie Mitchell
conference in Baltimore.

The thing that was unique about this particular conference was that it
was directed towards minority students, and those who really want to get
into the field of addictions. So all the presentations were around
looking at how we could assist these students understand the issue of
e-therapy with the minorities community more, and then give them ways in
which to get into the field and work their way up.

Patrice Clark was our NAFEO intern at that time. She was the moderator.
Val was there. Stephanie Moles from Women's Heart spoke. She's from
California. Dr. Alemi from George Mason University and Angela Harg, who
is working with Dr. Alemi on many of the various studies that he does.
And Dr. Alemi has been in this field almost ten years, I'd say, just
looking at some of the research---maybe longer---and had a lot of
wonderful suggestions for us. Again, we can share those slides with you
at any time and give you an idea of where we're going when it comes to
that particular topic area.

On February 3rd, I presented at a Joint Workgroup on Telehealth at the
Appalachian Regional Commission in Washington, D.C. This is a group of
federal agencies that get together on a regular basis and discuss what
is happening when it comes to e-health, telehealth, telepsychiatry,
e-records, what have you, within the federal government. That was quite
interesting.

They were very interested in what we had presented in December, with the
conference. And, by the way, we did send around all of those slides to
you. There were about 30 PowerPoint presentations. If you didn't have
time to read all 30, you can go back to the table and look at the
newsletter that's been developed also, which is the second point. It
really does say, in a nutshell, what that particular conference had to
present and gives you some ideas of where we might want to go.

The important thing to remember about that conference and what we're
looking at within SAMHSA is that that was considering all three areas of
concern in SAMHSA, substance abuse prevention, substance abuse
treatment, as well as mental health services. And it also dealt with
medical services in primary care. There are a lot of wonderful studies
that were presented, and we did do quite a bit of literature review on
that to get to that point.

Since that conference has occurred, I've had some suggestions from the
field I wanted to present to you and tweak your innovation with. Dr.
Alemi did state that reimbursement was one thing he would consider that
needs to be addressed at this time. He felt that it was urgent that we
get those pieces looked at and worked out before we go on, because
that's what it all revolves around, actually.

If this is a type of treatment that's going to be less costly, how are
we going to fund it? What is it that we're going to do with it when it
comes to the various kinds of criteria that we need to make sure are
there?

He thinks that we could reimburse e-therapy in a way that is budget
neutral (doesn't increase the total cost of care to a population), or is
performance based (and it will pay less to firms that have worse
outcomes), and is medium neutral (that it does not mandate in-person,
visual, voice, or text connection).

If you've looked at any of these pieces, you can see that there are many
different modalities for e-therapy. We even had one presentation---I was
fascinated by it---where somebody could access their therapist and their
behavioral modification program on their Palm Pilot, and that was for
food disorders and eating disorders.

Another suggestion that I received, and this is from Carolyn Young, who
is the executive associate of the Hogg Foundation for Mental Health in
Texas. She called me and stated that the Texas Juvenile Probation
Commission is developing a proposal now to fund a pilot project to
provide mental health and substance abuse treatment through
telemedicine, and this is for the juvenile population in Texas.

They're finding a serious need for serving these children in that they
have language difficulties; they can't find the counselors that know
Spanish; and they have cultural issues that only folks who are in those
particular indigenous communities can really understand. So they want to
reach the rural populations, but they also want to treat their urban
children that are having problems, too, and they're looking at
consultation, medication management, and treatment services. I thought
it was fascinating.

One other thing that she suggested to me, and it's just a little piece
of food for thought, was that she was looking at recovery services also
in regards to faith-based communities being involved, and that somehow
they wanted to work with those particular entities.

The federal response has been---I've sent around to you, too, various
newsletters that have come out, May 11th. It just shows that the HHS
Secretary, Mr. Leavitt, is concerned and leading the charge on this. His
statement on that is that public and private collaboration is necessary
to achieve the President's vision for widespread health IT adoption.

Mr. Leavitt also issued a new report entitled "Health Information
Technology Leadership Panel: Final Report," citing that investment in
information technology is essential, and that we really do have to begin
to develop it more. He states that the information technology is pivotal
for our health care system, and that we're at a critical juncture and
need to work together with the private sector. Specifically they're
looking at fewer medical errors, lower costs, less hassle, and better
care. And I want to underline better care, because that's where we fit
in.

The panel identified two basic themes: Investment in health IT is
urgent, as we have increasing demands---we've been discussing all this.
But we do have business interests in it also, in a broader U.S. economy,
and that the potential benefits and costs of health IT must be clearly
perceived by its stakeholders.

On April 26th there was another press release, which I sent around. This
is the "Indian Health Service Is Sharing Electronic Health Record System
with NASA." This is an MOU, memorandum of understanding, between the IHS
and NASA that was signed to transfer technology from the Resources and
Patient Management System, which is a suite of applications, including
electronic health records, to NASA.

Why am I bringing this up? Because this is another example of how the
federal government can partner together to incorporate more of what is
being done in the federal government to improve not only us but also our
partners in the field.

The Indian Health Service is a pioneer in the use of computer technology
when it comes to health data, as well as doing clinical services. This
particular system, though, the RPMS, is an integrated solution for
management of clinical and administrative information in health care
facilities of various sizes and orientations.

I do have to say that our Division of Services Improvement, Mady Chalk's
division, is now looking at e-records, and Sara Wattenberg is heading up
that initiative. And I have to say that we're really taking a look at
how we can make certain that our field is represented in the e-record
movement that's occurring very, very quickly with medical records.

So we're at a point now that we are suggesting that we might want to
consider a subcommittee through the National Advisory Council for CSAT.
These are just beginning suggestions to start thinking about. That's
what this whole presentation has been about, just to get you to think
again about the usefulness, if it's something you want to consider. We
can support a comprehensive literature review. We could prioritize the
issues with that particular review, hold a kitchen cabinet meeting of
advisors and experts in the field. If you like, we could support a
preliminary needs assessment on the lack of access or capacity for
substance abuse treatment. There have been many of those. But when it
comes to locking into the e-therapy issue, not so much. And we could
also support the development of a TIP on e-therapy. Just some
suggestions.

With that, I'd like to hand it back to Val. Dr. Clark would be the one
who would handle this.

DR. CLARK: I would turn it over to Council members, and Val can start
that.

MS. JACKSON: Well, I think, as it's shown in the last side, after
talking about this and learning more, what I found is that I think that
we have crossed an issue that is really very important, something that
does warrant the National Advisory Council's attention. And by turning
it into a subcommittee of the Council, that would be the request, noting
that it also allows Council members who might want to participate in the
expert panels and in the meetings could be in that. That's my
understanding.

So help me out, Dr. Clark, if I'm saying this wrong.

And the other issue is, of course, that report-backs to the National
Advisory Council ups the priority of it and gets us moving along and
supported much better if we go this route.

Chilo?

DR. MADRID: Presently, we are working with the Juvenile Probation
Department in the development of an e-therapy program in Spanish, and a
lot of the issues that you talked about are a lot of the issues that we
are being confronted with.

The one issue that you did not touch on that I wanted to throw this on
the table, and that is, will this particular component of the agency
that I represent be able to pay for itself? So one thing that we're
looking at in a very intense way is how to "Google-ize" our website. In
other words, how are we going to advertise online so that we will be
able not just to capture the market, the probationees that need a lot of
this assistance in rural, remote, and frontier, but others that might be
interested.

We're looking also at targeting mothers, because our study is showing
that there's a lot of hits going into the Internet by mothers that are
very desperate concerning their kids. So I definitely would agree that
further study is needed, and I definitely would want to be part of this
study group, and perhaps share what we have done so far, as we've worked
with Juvenile Probation in our area there in Texas, which is about two
thirds rural, remote, and frontier.

DR. CLARK: All right. So it sounds like at least one of the Council
members is interested in this activity. And it sounds like we've got a
large jurisdiction that is actually moving forward to address this as an
element of the spectrum of approaches that they have.

The VA has actually used telemedicine as an adjunct to both psychiatry
and general health care as a way of reaching rural or remote areas. So
that dynamic is out there.

So I think the question on the floor is whether this particular Council
would like to have a subcommittee on e-therapy to move forward through
time.

MS. JACKSON: Yes, that's the question. I don't know if I'm asking
someone else to make a motion or if I'm just asking---

DR. CLARK: You can make a motion. Nothing keeps you from making that
motion.

MS. JACKSON: Thank you very much. Then I would make a motion that we
have a subcommittee of the National Advisory Council that addresses
treatment and recovery in substance abuse through the electronic
modalities and to explore that.

DR. MADRID: And I'll second that.

MS. JACKSON: Thank you.

DR. CLARK: It's been moved and seconded that there should be created,
within the Center for Substance Abuse Treatment National Advisory
Council, a subcommittee on e-therapy/telemedicine, etc. All those in
favor?

(Chorus of ayes.)

DR. CLARK: Anybody opposed?

(No response.)

DR. CLARK: So moved. Well, that was easy enough, don't you think?

And it's good to hear that Texas is doing this, since we've been
exploring this. And also it's important that we need to recognize this
is occurring in the arena of juvenile justice. So that's something else
that you raised, Val, but it's the thing that we need to continue to
flesh out and address. Co-occurring disorders is another theme.

Judge?

JUDGE WHITE-FISH: Yes, Dr. Clark. I had some questions about e-therapy
at the previous meeting. I would like to volunteer, if possible, to also
serve on that work committee.

Val, you used my exact words. She remembered very well from last meeting
my concerns. And I suppose, in order to take it further than that, if I
serve on a work committee or that committee, maybe those concerns will
be taken care of.

I told her I'll be her worst opponent in there, but she says, "No." And
that's the reason we had talked previously, because I do have some
concerns looking at the cultural aspects, as well as looking at quality
of treatment. I believe that as SAMHSA looks at quality of treatment,
that's where my biggest concerns are.

MR. DeCERCHIO: I think one of the challenges on the mental health side
in Florida, we're about to experiment with doing emergency screenings
for involuntary commitments in a rural area. But one of the challenges
from my perspective as a state, I think we need to work through this and
embrace it. I think it has a tremendous amount of promise.

This whole regulatory piece, perhaps one of the taskings might be to
look at some basic standards that we could employ, because we license
programs and how you get into licensure---if we open the door,
circumventing the licensure process, anyone in Florida could say, "Well,
we're doing e-therapy. We don't need to be licensed," or, "If I'm in
another state, you're not licensing us. You have no authority." To me
that's the biggest question, as a state officer, that we have to work
out.

Reimbursement we work out. We can do telephone counseling. We can figure
out reimbursement. But the regulatory piece and how to assure some
public confidence and how to respect the legitimacy of licensure for the
more traditional things that we do, how to reconcile all that.

Dr. CLARK: Actually, the experience of eGetGoing is that in some
jurisdictions they were not licensed and therefore could not pursue
their therapeutic schedule and therefore had to figure out how to anchor
the treatment in jurisdictions. Jurisdictions can do whatever they jolly
well please, because they're the ones who decide who can or cannot do
what within their jurisdictions. So it's less of a threat, if you will.
It is always, and remains, an issue. The question, though, for
jurisdictions, if I reimburse, then I can require that you, as a
Medicaid, need to provide certain documents. You need to be on registry,
etc., etc. You just get that flexibility.

But, we won't dwell on this. What we're going to do is focus on letting
the subcommittee deal with it and figure out what we're going to do over
time, because this, I think, will assist us in dealing with some of
these rural and remote issues, unique population issues, etc.

With that, if that's okay, we can move forward. Chilo will work with the
committee. Three names: Chilo, Val, and Eugene White-Fish.

MR. DeCERCHIO: You can add me to that.

DR. CLARK: And Ken DeCerchio. We'll make sure that your names are on
there and we'll move forward.

Did we work out our technology problems?

MR. DONALDSON: Well, we've got the first-generation version, but we'll
do our best.

DR. CLARK: All right. Very good.

During the January meeting, we had a presentation from Dave Donaldson,
chair of the faith-based subcommittee, accompanied by CSAT staff Clif
Mitchell and Jocelyn Whitfield.

Some of you expressed an interest in working with the subcommittee with
the hope to be able to carve out time during the course of this meeting
for the subcommittee to meet. However, with the schedule we were working
with, we weren't able to set aside time for the subcommittee to meet.

We suggested to Dave that he and members interested in working on the
subcommittee meet Wednesday or Thursday. It's my understanding that they
did meet last night and have a report to present to Council today.

Dave's expertise includes a strong faith-based focus, disaster response,
substance abuse and mental health, volunteer mobilization, promotion and
organizational development. He's the founder and CEO of We Care America,
an organization that helps the community of faith build a greater
capacity to serve the needy through advocacy training, resource
development, and volunteerism.

Dave?

MR. DONALDSON: Thank you, Dr. Clark. Jocelyn's going to be joining me in
a moment to talk about some of the collaborations that have emanated out
of the trainings that we have conducted across the country.

But I'm happy to announce, as you just mentioned, that we do have a
faith-based subcommittee. Bettye is on that and Anita. So I've asked
them to chime in as they want to.

Let me just say as a preface that I really feel that we are at a tipping
point as it relates to the faith community, its involvement in social
services, and also the faith community as it relates to partnering with
government.

There are two converging movements that are happening in our country.
First of all, in the faith community, churches are moving from being a
fortress to becoming what I like to call a Wal-Mart, a one-stop shop,
where people can go to for their physical, spiritual, and emotional
needs.

I was asked to speak at our church, and the pastor went up to the
podium. I thought he was going to introduce me, but instead he resigned
from the church.

(Laughter.)

MR. DONALDSON: And then he asked me to come up and speak. And to make
matters worse, my sermon title was, "Never Quit!"

(Laughter.)

MR. DONALDSON: And afterwards we had lunch, and I asked him, "Why are
you leaving this church and this community?"

He said, "There's just too many problems here."

It's exciting for me to see that the pastors of old that saw these
so-called problems now see them as opportunities for the church to be
the church that cares. So that's happening in our nation.

The second movement that is converging is that the faith community for
decades saw government as adversarial, and there's a shift that's
gradually occurring.

Ronald Reagan said in the 1980s, "If you get in the same bed with
government, you probably will not get a good night's sleep." But at
least the faith community is now keeping one eye open, and they're
looking for full partnerships with government to build healthy
communities.

I think that's happening through two primary ways, first, the government
affirming the value of faith-based organizations, especially as it
relates to treatment and recovery. I think, Ken, maybe you mentioned
this yesterday. These churches, these shopping malls of compassion, have
the greatest opportunity for providing that continuum of care---I think
one of the greatest opportunities, also, to minimize and perhaps even
eliminate the stigma attached to treatment. In many cases, it's not an
agency/client relationship. It's a deeper trust in relationship. Also,
just with the recovery management services that are already inherent in
many of these fellowships.

You add to that, as somebody who is a person of faith, the one that
nobody voted in and nobody's going to vote out, God in His power, and
you combine that with this continuum of care, and that's where it leads:
to transformation of lives, families, and communities. And we're seeing
that across our nation.

So this mission that you're looking at here, in this emerging
partnership with faith-based and government---and I mentioned this the
last time that I gave an update---the mission is not to publicly fund
proselytizing. That's not what it's about. What it is about is to
increase the capacity of faith-based organizations and community-based
to more effectively provide clients with a higher quality of treatment
and recovery services.

So we're seeing a leveling of the playing field so that both faith-based
and community-based groups can compete on a level playing field for the
funds and to become that recommended service provider. But also we are
building their capacity. The net result is that the needy, those who
have needs in our country, are going to have access to the best
services. And that's what all of us want.

SAMHSA and, more specifically, CSAT had been in the vanguard of moving
that forward. That has now permeated into other agencies of Health and
Human Services and other agencies beyond that, like Education and Labor.
But a lot has been accomplished, and a lot of it started right here. I
think we need to give ourselves a hand there.

The five Rs that we have employed as a strategy: first, building
relationships, helping the faith community find common ground with the
government agencies like CSAT. I've shared this before. I feel like ATR
is the greatest and most natural connection for the faith community
working with government.

But it's not easy. We've had these workshops around the nation, and for
many people in the faith community, working with government is like
dancing with a porcupine. They don't know exactly where to grab on to.
So we're helping them to understand how to do that.

Representation, building these coalitions. Jocelyn's going to share
about that in a moment. It's just incredible what's happening with these
coalitions. I see it as a Rubik's cube of capacity, where we're able to
galvanize these groups and then together they can apply for these
resources, where, in themselves, they probably couldn't compete.

Third is results, not just faith based, but outcome based. This is hard
for some groups who think that the only qualification is to be moved by
the spirit. We're helping them to not to eliminate that, but to build
upon that and become more sophisticated. It's neat to see that many of
them are getting licensed, getting their certification. It's happening.

Resources. Showing them ways to leverage their private resources with
public funds. Part of that is making sure that they're writing the best
possible proposals. We've done a lot of training on how to write grants,
even showing them, walking them through the process of writing a
proposal.

Before that we would get a lot of handwritten sermons. Now we're getting
some proposals. Just last year we did a sampling of the organizations
that were part of these workshops. There was more than \$18 million that
they had garnered for the first time. That's just a small sampling of
those that attended these training.

Replication. We talked about this yesterday, but multiplying these
effective models. We've got to document these models. But, as Dr. Clark
mentioned yesterday, we've got to show them how to adopt it.

Ken, Florida has incredible models as it relates to the faith-based
community working with government. I'd just love to package those and
see those replicated.

I know there's a challenge with getting these best practices adopted,
but in the faith community, we're pretty good at pirating things. Like
they say, first you quote the person. Then you say, "I heard the other
day." Then the third step is, "I've been thinking."

(Laughter.)

MR. DONALDSON: So we're pretty good at that.

The obstacles. I've already gone over some of these. I'll go through it
fast. The skepticism of government sources. Am I going to sell my soul?
Am I going to compromise my mission and values by partnering with
government? Understanding faith-based and government language barriers.

I remember one of the trainings we did in Atlanta. I asked, "How many
here even know what an RFP is?" And only half the group raised their
hands. I mentioned SSA, and one lady raised her hand. She says, "What
does this have to do with Social Security?"

(Laughter.)

MR. DONALDSON: So it's just like taking a machete to the jungle. This is
carving new territory.

And it is important. And, Dr. Clark, you put this in your presentation
the last time we met, how important it is to have these operational
definitions. Because otherwise it'll exacerbate it even more.

Limited capacity. We had a good discussion about that this morning,
Anita, and Bettye, and I. I think that's one of the greatest challenges.
And it's a tug of war, because on one hand we've got to be stewards of
the public's trust and resources. But on the other hand, you see these
well-meaning organizations that have big visions, but they have little
provision. So we've had to drill down, instead of doing the larger
venues, even though we are going to do some of those with Dr. Clark,
more of a vision casting with ATR educational forums, but we've gone to
these smaller mentoring groups to qualify which organizations truly have
the potential to garner these resources, and then to mentor them to
actually succeed.

With that, the strategy that we've employed, addressing the trainees
through organizational assessment conducted for each of these
organizations in the state. Two, we've conducted the training, as I've
mentioned, in these small mentoring groups, as opposed to the larger
audiences.

What we're trying to convey is that we're building collaborations, where
they're not just coming to hear us, but the days following, they're now
cultivating relationships with others in their own city.

With that said, Jocelyn's going to come and share with us about what's
happening with these coalitions.

MS. WHITFIELD: Could you give us a minute? It appears that our CD did
not copy, so we're going to insert. There it is, right there.

I want to show you exactly what we're doing. I know that at the last
committee meeting, what we did was talk about the coalitions that we had
developed in the communities. We told you about the technical assistance
that we have provided to these coalitions.

As of today we have 15 coalitions that were formed as a result of the TA
that has been provided by SAMHSA and CSAT. So what I want to do in a few
minutes is to showcase what we've been doing so that you'll get a little
idea of exactly---

What we're trying to do is bridge the gap to those whom we serve. We've
done that by forming coalitions in about 15 states.

This is the Institute for Therapeutic Wellness. As you can see, we have
almost every type of community service represented there, but mainly
their treatment, prevention, recovery, and mental health providers.

In each state that we have a coalition, Dr. Clark will be visiting those
states in order to educate them about ATR. This is the one in Louisiana.
We will be going to Louisiana. I think that's June 16th. And Dr. Clark
will be meeting with most of these providers that we have been training
over the past two years.

You need to know one thing about these providers. Most of them have
their 501(c)(3). They're nonprofit organizations. They've had three
years of operational experience. Many of them have been funded by other
entities. And they have the staff capacity to carry out the services in
their community. Some of them are treatment providers, and they are
certified and licensed by the state, while we have others who are
meeting the recovery standards of the state. So that is Louisiana, one
of the states where we have a coalition.

We have the Nebraska Continuum of Services. You can see all of the
service providers we have that are part of that coalition. You'll see
that most of them are recovery and treatment providers. Some of them are
community and some of them are faith based.

North Carolina and South Carolina. We have a network of providers there.
Last year the Center for Mental Health Services gave us \$350,000.

What have I done? I must have done something. Am I doing something
wrong? Oh, sorry.

Thank you, Dr. Clark. What could we do without Dr. Clark? He's my
favorite.

MR. DONALDSON: I thought I was.

(Laughter.)

MS. WHITFIELD: No, Dr. Clark is my favorite. Okay. Thank you, Dr. Clark.
You're just so precious. Okay.

We have the Institute for Therapeutic Wellness. That's a network of
providers I just showed you. You can look at all the different providers
that we've put together in this network. This is over a two-year period,
so if you go to the state, don't let the state tell you that there
aren't providers who are certified, that are credentialed, that are
licensed, that have been delivering community services for over ten
years.

One of the criteria was that basically they would have to have three
years of operating experience, that they would have had to have been
funded by some entity, that some of them would have to be licensed
providers. And you can see very well that we have a real mix there.

This is Nebraska, Continuum of Services. You'll see that it will be
community service providers as a part of that group. Most of these are
treatment and recovery providers in Nebraska, and they are all
faith-based and community-based organizations.

What we've done over the last three years, we've provided TA in
certification, showing them how to become licensed providers. We've
provided TA in infrastructure development, TA in fiscal management, TA
in grant writing and proposal writing, TA in project management. So you
see that everything that we've done in the last three years, it has paid
off.

This is North Carolina. We received \$350,000 from the Center for Mental
Health Services. We plugged in the Mental Health Associations in North
Carolina and in South Carolina, as you will see. These are our providers
in South Carolina. You can see there are homeless shelters, treatment
programs, co-occurring disorder providers, and a mix.

We contracted with the New Jersey Office of Faith-Based. What they did
was pull together a team, a network of providers called ATLAS. You can
have a good look at what they're bringing to the table.

I think that's the last one.

The other coalitions and provider networks formed are in Hartford,
Connecticut. We will be in Hartford, Connecticut, on May 25th, next
week. Dr. Clark will be hosting or one of our panel speakers, and he'll
be talking about ATR and other opportunities for faith and community
groups to partner with SAMHSA.

Dr. Clark will be in Washington State, I think it's June 7th, and will
be working with a community action coalition there that we've helped
support over the years.

Alabama; Pennsylvania; Brooklyn, New York; Bronx, New York; Baltimore,
Maryland. We're working with the Mayor's Office of Faith-Based, and we
have a coalition out of the city of Baltimore, Maryland. Then we have
Arkansas and Pine Bluff, and you can see what we're doing.

Coalition and provider networks that are in process are in Virginia,
Indiana, Ohio, and Wisconsin. So that tells you a little bit about how
much we've been doing as a faith office---what we've been doing over the
last year and a half---to show you that, basically, your money's at
work. We're doing some responsible things with it. People's services are
being improved as a result of it. They're building capacity as a result
of it. And they will be some of the ATR providers in the future.

I'm going to turn it back over to Dave. I hope this has interested you.

MR. DONALDSON: Terrific. Let's give her a hand. That was tremendous.

(Applause.)

MR. DONALDSON: Tremendous. Great pleasure to work with Clif and Jocelyn.

Very quickly, the outcomes that we're looking for: helping to develop a
strategic plan for each participating organization.

It's like that pilot. The watch tower says, "Do you know where you're
going?

He said, "No, but I'm making record time."

That's many of the groups that we're helping to really develop a path of
travel.

Equipping and mobilizing volunteers. There's gold in them there pews.

Identifying candidates with the highest potential, as we share the
501(c)(3) preparation and board development.

Sustainable funding. One thing the President has said, the last thing he
wants to see is a new welfare state called nonprofits. So we're making
sure that there is a leveraging of the private with public resources.

Helping to identify specific grant opportunities, even helping them
write the proposals, managing the grants. This is mentoring.

Documenting the models, as we've already shared, and then evaluating
these outcomes.

I just wanted to highlight another model, Full Circle Health. I'll be
with them this weekend and on Monday. This is one of these Wal-Marts
that we were referring to, but it's now become our lead agency there in
the coalition in New York. They're integrating faith and science into
practice. The provide now for 1,500 active patients. You can see the
staff, some of the different fields there. We wrote a proposal for them
through the Red Cross and got \$467,000, and now we're writing some
proposals for here for CSAT.

Let me just conclude by saying this. This is a tipping point. What has
been ordinary has become extraordinary. But if this is not adequately
funded, it's going to become a teeter-totter. I would just appeal to
this group and to the leadership of CSAT to make sure that we continue
to move this ball down the field. There's too much at stake. There's too
much momentum, and there's too much promise to stop right now. The
greatest days are ahead.

I'm happy to field any questions that you may have, or comments.

MS. BERTRAND: Thank you both for your presentation. I guess my comment
is just for the Administration and just something for us all to think
about as we move forward. I want to commend you on the work that you're
doing in Florida with Access to Recovery and being a pioneer for the
rest of the world.

I'm thinking about the language in terms of moving forward and making it
really clear to individuals that are applying for funds that we want to
be inclusive of faith-based organizations and community-based
organizations. I don't know how to say it, so I'll just say it, but just
to ensure in language, if we do have an opportunity, or the states have
an opportunity, to apply for Access to Recovery or even grants with the
recovery community, that there is language that makes it really clear
that this is a priority and that the Administration is willing to work
with the grassroots organizations that struggle with information
technology and things that underfunded organizations have that they
struggle with.

I'm thinking that my charge on the committee will be just to think of
ways to ensure that those organizations and their services, because they
are so valuable, are outlined very clearly. Another thing I'm thinking
of, in terms of when we as Council look at applications, and I know that
we just concur, and I don't think there's anyone here who works in those
departments, but that perhaps earmarks for faith-based organizations. I
know we're trying to level the playing field, and can't say we're going
to fund X number of faith-based projects out of a group of applications,
but those are the kinds of things that may help, because being an
administrator and working with other administrators, I know that
sometimes new things aren't necessarily welcomed because it's different,
and we just don't want to see a wonderful opportunity like this for the
grassroots organizations.

I know in Ohio, in the area where I'm at, I have people who cannot wait
for my recovery project to get off the ground. I haven't moved fast
enough for some of them. We have services going on every night, and we
just started in December.

I would want to urge the Council to think of some ways to ensure the
integrity of this program and work with those that are underprivileged,
who may not necessarily have the opportunity and the means to be able to
write these grants. Just because you can nail the grant to the table, it
might not necessarily mean that you can provide the services.

DR. CLARK: The beauty of ATR is that, one, the President has made it
clear and the Secretary has made it clear that the principal objective
is to expand the reach into community-based and faith-based
organizations. In fact, under the new Secretary's 500-day plan, one of
the items in that plan is expanding services to community-based and
faith-based organizations.

The beauty of ATR with regard to those objectives is that you don't have
to be a grant writer. You simply have to be able to provide competent
services and account for the money that you receive as a voucher that
you process. That's the key issue here with ATR. It's not being a grant
writer, but being able to demonstrate that you didn't take the money and
run. I think that then puts the organizations at a less complicated
level, in the sense that they're not competing for a grant.

I'm fond of saying, he who has the client has the voucher, and he who
has the voucher has the money. So if the faith-based community has a
relationship with those individuals who are adversely affected by
alcohol and drugs, in essence they become key factors in the delivery of
services. If you just want the vouchers without having a relationship
with clients or the community of people have clients, then, of course,
you have to adhere to the traditional standards, because you're
providing primary treatment, as opposed to recovery-support treatment.

Val?

MS. JACKSON: Thank you very much.

I'm sorry, David, I missed part of your presentation on an important
issue.

MR. DONALDSON: I was counting on you to be here to laugh at my jokes.

(Laughter.)

MS. JACKSON: Oh, you know what? I laughed down the hall. Didn't you hear
me?

I think that it does need to be noted that ATR is a very important
movement. And I think that one of the things, though, as we saw in the
presentation yesterday, it's certainly limited. I'll say it personally,
because it affects me, but it doesn't only affect me, it affects however
many counties there are in California, except for two, and numerous
other places across the United States, and that is that the Access to
Recovery movement, just because it's said to be in California or Florida
or some of the other states, does not mean that it is covering those
states, nor is it providing services to all of those areas. Whether it's
through discretionary grants---which I think discretionary grants are
still a lynchpin of being able to look at new and different approaches
to services---things that maybe would never happen if we just gave all
the money to the states, it's extremely important to do that. You
mentioned writing grants. If the states are the only ones that can write
grants, some of us are really, really left out.

So I hope that as we look at whether it's ATR or any of the initiatives
that we're looking at now, we look at the ability to spread that across
to those areas that are severely in need but not being covered.

DR. CLARK: Again, one of the other beauties of ATR is consumer choice.
So, as I mentioned earlier, he who has the client has the voucher. He
who has the voucher has the money.

You're right in terms of jurisdictional limitations at this juncture in
time, but those programs within the jurisdictional reach of ATR that are
able to demonstrate that they're accountable, that clients do well, that
recovery is supported over time, will probably do better than those
programs that don't.

Innovative programs should not suffer under ATR. It offers them an
opportunity to apply the models that they use.

We talked about incentive therapy. Ostensibly an ATR program that's
offered incentive therapy would do better, at least according to the
preliminary research, than one that did not, and they would have the
data to support that.

Chilo?

DR. MADRID: I wanted to thank Mr. Donaldson for representing this
Council in excellent fashion and certainly the faith community of this
country. So thank you very, very much. And certainly Jocelyn and Mr.
Mitchell. Mr. Mitchell's not here, and the rest of the staff has been
doing an excellent job. And also take the opportunity of inviting you
all again to our international conference, faith-based, partially funded
by CSAT, where we're going to be addressing a lot of the ATR issues.
We've invited our ATR director from Texas. The governor of Texas, as
well as the governor of Chihuahua, will be there. We're expecting about
50 faith-based organizations that are wanting to work with us as far as
ATR, so all of you all are invited. We'll even put you up in my house,
if you go there.

(Laughter.)

DR. MADRID: It's an open invitation.

MR. CLARK: Bettye?

DR. FLETCHER: I, too, would like to add my thanks to Dave as well as to
Clif and Jocelyn for the work that you are doing in this area.

One of my observations is that I don't know if it was listed as an
outcome, but one of the outcomes of this whole area is building the
indigenous capacity within the community. I have created a term called
"projectized," and some of our communities have been projectized to
death, to the extent that you come in with some dollars and you have a
project, and when the project is over, the capability, the capacity, and
the project are gone, and the community is left with nothing.

In this instance, building this indigenous capacity in the community is
probably the penultimate of sustainability, because you're creating the
capacity within the community, and I see that as one of really the
values of this particular effort.

I also think that as we go down this road, it's important to recognize
the reciprocal process, the reciprocal learning that can take place.
Because there's a tremendous amount of social ministry or social
entrepreneurship that is happening in these communities. But what they
need is the best practice to go along with it. And they've been doing it
for many, many, many years in many of the communities that we are
exposed to. But here's an opportunity to reinforce what they're already
doing and provide them with the resources to really carry out that work
that is driven strictly by their passion in many instances.

So I think we have an opportunity here that really we can do more than
maybe what appears on the surface in terms of advancing the social
entrepreneurship that exists in our communities.

My last comment would be---and Jocelyn, I know that you all have done
some work with some of the institutions of higher learning---but again
the bridging with institutions of higher learning and the communities'
faith community represents again an opportunity that has not been
maximized at this point.

How do we get our institutions to leave the ivory towers, where I spent
30 years, and come into the communities and do some serious work with
communities in terms of building the capacity for them to sustain their
efforts in community building?

MS. WHITFIELD: Can I just say one thing? I think what we've done over
the last three or four years has really been tremendous. And I know that
we have a lot of work to do in the future. But one of the things that
Clif and I have really focused on in the last couple of years is
building these communities and building the capacities in these
communities among the grassroots faith and community organizations.

We know that after our federal dollar leaves that area that they need
some capacity to sustain their services over time. So that's what we're
doing. And as many states as we are allowed to do, we're going into
those states and we're trying really to build capacities in those
communities.

I can tell you one thing. We're trying to do a little in Mississippi.
You know that we've been working in Mississippi for the last two years,
trying to establish a place were people can come to the table and learn
about grantsmanship, learn how to build infrastructure. That's exactly
what we've been doing the last three or four years.

MR. CLARK: Ken?

MR. DeCERCHIO: One of the other things we've learned is that the
connectivity of relationships between the faith-based community and
traditional delivery systems and state agencies, the motivation for
bringing that together can't be funding. We had the good fortune of
having two years of discussion about how our systems need to connect for
the purpose of enhancing folks' access to recovery services. It was
never a conversation around dollars.

And Access to Recovery came on the table, and by that time, the
conversation was real easy. But if the conversation starts out about
dollars, it's very easy to get (inaudible). And the feedback with our
faith partners at the state level has been, "You know, it was a lot
easier because when we got together, no one was talking about there's
money on the table. Now we have to figure this out."

It was, we've been out here for years providing addiction services and
support services. How can we connect and benefit from clinical
treatment, how can we connect and how can you provide more access to
training and the kinds of support that the faith community needs?

We return people from treatment back into the community without adequate
support except for AA and NA, how can we do that? Faith community, how
can we support ministers who have people with addiction, and what do
they do? How do we support that?

So it was those kinds of dialogues and discussions that made it a lot
easier. I lamented on an ATR visit a couple of months ago that if ATR is
the focus for the initial discussions between the faith community and
our systems, that's a tough discussion when you're putting money on the
table, and then we've got to figure that out. So the opportunities
around the rest of the other 54 states and territories that aren't
getting ATR to have the dialogues, to connect on some layer, that's what
needs to be happening now, not waiting for the dollars. Because the
sustainability is going to be the partnerships. And I'm convinced that
it's the partnerships and the commitments and the soul of this that will
continue long after our little bit of seed money or your little bit of
seed money goes away, frankly.

DR. CLARK: Frank?

DR. McCORRY: Thanks, Westley.

Thank you, David and Jocelyn. I really enjoyed your presentation, and I
enjoyed hearing these updates on the faith-based initiative. It really
stimulates my thinking on perhaps how to do more in my work back in New
York.

I definitely want to get the names of the folks from Full Circle and the
coalition in the Bronx.

What struck me when I was thinking as you were presenting was yesterday
we heard about SBIRT. I had made a comment about how primary care is
this continuous health relationship, and that treatment is like an
episode within the continuous health relationship. On the front end and
on the back end of that treatment experience, health care fits. If you
can empower the primary care physician to have a place to both identify
people in need as well as to return people after their finished with our
system.

Of course, what strikes me is how much the faith-based initiative is
exactly that, too, to identify people in need, both the ability on the
front end of identifying people in need and this continuous relationship
that's often not just individual but familial and community based, so
that the same paradigm that we talk about in terms of health care really
can fit in terms of faith-based organizations.

It struck me in your presentation how powerful that could be. I enjoyed
hearing about it. It helps me think through some of those kinds of
issues. So, thank you.

DR. CLARK: All right. Well, we appear to be about to wrap things up.

We did promise you time for additional roundtable discussion, so
roundtable is open.

Val?

MS. JACKSON: Thank you very much. I really enjoyed the presentations
that we had in the last two days. I think they were very relevant and
also informative in terms of my world.

There's something that came up this morning in a discussion that I had
with Randy Muck, who runs your adolescent services, I believe. We were
talking about best practices and evidence-based practices.

I am a tremendous fan of evidence-based practice. No doubt about it. One
of the issues that we have run into as---first of all, we're in the
Clinical Trials Network, and second of all, any grant almost or
application that we put in now is for evidence-based practices. One of
the things that we're finding, and I won't mention names, some of them
are my friends, but unfortunately the pricing of the training and the
requirements of the training for evidence-based practices is extremely
expensive.

DR. CLARK: Let me interrupt. You mean NREPP?

MS. JACKSON: Excuse me?

DR. CLARK: NREPP-driven evidence-based practices?

MS. JACKSON: I can mention in-home, onsite--a very wonderful in-home,
onsite program that was all developed by public funds, and I have no
problem with people needing to get funds to train those folks, but
somehow, if we're ever going to get the evidence-based practice to the
streets, we have to make it affordable. And \$120,000 for most agencies
isn't affordable, or six months of training to a therapist who probably
then moves on, because they've got more training. "I'm gone."

I think it's a very real problem that SAMSHA faces, not so much NIDA,
because they train evidence-based practices, but SAMHSA has to carry
those on and sustain them. I wanted to bring that up as an issue.
Perhaps we need to hear more on it later. But it's certainly a problem
for us, and we know that two of three studies that we're doing now will
not be sustained in our agency---are highly likely not to be sustained
in our agency---simply because of the cost.

DR. CLARK: I'd like to echo that we do have some concerns about the
issue of the privatizing of public sector-driven knowledge, because what
happens is that the cost becomes prohibitive, and therefore the
knowledge is not transferred, which means, basically, the cost functions
as a barrier.

We don't have any answers for that, but it is a concern, because others
have raised it.

NREPP-validated strategies have often become associated with high price
tags, and that, of course, means it is not available. What we need to do
is to keep monitoring these things as we push for evidence-based
practices, so that we can address the downside of that effort.

We believe that since we don't do research, some of our best practices
have been understood as research driven, and in fact they're not. As
you've noticed, our best practices budget has declined. What we've used
the best practices budget for is to in fact translate the research
developed by the research enterprises into digestible components so that
the delivery system can afford to acquire the new knowledge. If it sits
in books and sits on the desk, it doesn't help, no matter what we do.

I'm fond of citing the laser eye surgery community. The manufacturers of
the devices and the trade organizations got together and they've
essentially revitalized ophthalmology over a ten-year period.

The actual price of the laser eye surgery has plummeted because of
increased efficiency and greater availability of services. It didn't go
up; it went down dramatically.

I cite that as an example of how, in fact, you can privatize without
creating fiscal barriers. If you create fiscal barriers, you're right
back where you started from. So we just need to keep monitoring this.

Frank?

DR. McCORRY: I'd just like to echo Val's comments. I think there are
some issues around copyright here as well. The whole research endeavor
might be with the public dollar, and somehow the training is taken
offline and is copyrighted as a private enterprise, and I'm not sure,
they might still be on the public dollar of some sort, but there's an
assertion of a right to ownership that I don't know whether it exists.
But I wonder about it.

As you said, Westley, the monitoring of it is something we should
continue to explore, like how these things get so darn expensive, when
it seems all along they were being paid for by the taxpayers.

DR. CLARK: Well, we cannot bring in the community-based and faith-based
activities. In fact when we do that, we're erecting all these barriers
and then expect the community-based and faith-based organizations to use
"evidence-based practices"---but, oh, by the way, we're going to make
sure you can't afford them. We cannot create that paradox. We'll just
have to keep monitoring and see how we proceed with that.

All right, anybody else with any other topic for the Council discussion?

MR. DeCERCHIO: I just want to thank you and thank the staff for making
this a productive day and a half. We take a lot back with us. We learn a
lot and it's very helpful. It's value added, and we appreciate that. And
thank colleagues on the Council who took the time to present. I know how
busy all of you are and how much time and extra work that requires to
come before and present. I want to tell you how much I appreciate that.

DR. CLARK. Very good. Thank you very much for your comments.

I want to remind you that we have a September 14 and 15 meeting of
Council, remind you that we also hope to convene a teleconference on
September 7 to review any grants that are remaining. The September 14
and 15 meeting will not be a grant review meeting. Nevertheless, if you
have agenda topics that you'd like to present, would you please bring
that to Cynthia's notice so that what we'll be doing then is discussing
topics of your interest and topics that we believe that you might find
interesting.

Any further discussion?

(No response.)

DR. CLARK: I will entertain a motion to adjourn.

PARTICIPANT: So moved.

PARTICIPANT: Second.

DR. CLARK: All those in favor?

(Chorus of ayes.)

DR. CLARK: This meeting is adjourned. Thank you. There is no further
business, and moving on.

(Whereupon, at 12: 34 p.m., the meeting was adjourned.)