SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Thursday,

June 28, 2007

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

3746 Prospect Avenue

Cleveland, Ohio 44115

Kenneth A. DeCerchio, M.S.W.

Assistant Secretary for Substance

Abuse and Mental Health

Florida Department of Children and Families

1317 Winewood Boulevard, Building 1, Room 207

Tallahassee, Florida 32311

Bettye Ward Fletcher, Ph.D.

President and CEO

Professional Associates, Inc.

P.O. Box 5711

Brandon, Mississippi 39047

Valera Jackson, M.S.

Executive Director

New Century Institute (NCI) Systems, Inc.

4500 Island Road

Miami, Florida 33137

IN ATTENDANCE:

Chilo L. Madrid, Ph.D.

CEO

Aliviane NO-AD, Inc.

7722 North Loop Road

El Paso, Texas 79915

Juana Mora, Ph.D.

Professor

California State University, Northridge

Chicana/o Studies Department

18111 Nordhoff Street

Northridge, California 91330-8246

Gregory E. Skipper, M.D., FASAM

Medical Director

Alabama Physician Health Program and

Alabama Veterinary Professionals Wellness Program

19 South Jackson Street

Montgomery, Alabama 36104

Judge Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 340

Crandon, Wisconsin 54520

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

PAGE

Call to Order and Welcome

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

Director, CSAT

Chair, CSAT National Advisory Council 6

Consideration of March 21, 2007

Council Minutes 6

Member Introductions and Activity Updates 7

Director\'s Report

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 16

Discussion 26

Methadone Misuse/Abuse/Mortality

Robert Lubran, M.P.A., M.S.

Director

Division of Pharmacologic Therapies

CSAT/SAMHSA 29, 40

Kenneth Hoffman, M.D.

Division of Pharmacologic Therapies

CSAT/SAMHSA 32

Discussion 45

Substance Abuse Treatment Services for

Individuals with Disabilities

Dennis Moore, Ed.D.

Professor

Department of Community Health

Wright State University, Kettering, Ohio 54

Discussion 72

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

PAGE

Public Comment 76

Physician Health Programs:

Blueprint for Lasting Recovery

Gregory E. Skipper, M.D., FASAM

Medical Director

Alabama Physician Health Program and

Alabama Veterinary Professionals Wellness Program

Member, CSAT National Advisory Council 93

Discussion 107

Promoting Safe and Stable Families (PSSF)

Partnership Grant Programs

Catherine M. Nolan, M.S.W., A.C.S.W.

Director

Office on Child Abuse and Neglect

(OCAN), Children\'s Bureau

Administration for Children and Families (ACF)

Department of Health and Human Services 112

Discussion 136

Recovery Month

Ivette A. Torres, M.Ed., M.S.

Associate Director for Consumer Affairs

OD/CSAT/SAMHSA 143

Partners for Recovery

Shannon B. Taitt, M.P.A.

Public Health Analyst

OPAC/CSAT/SAMHSA 151

Discussion 158

Council Roundtable 162

[P R O C E E D I N G S]{.underline} (10:00 a.m.)

DR. CLARK: Good morning. I\'d like to call this meeting to order. I
welcome you to the 50th meeting of the CSAT National Advisory Council.

In opening this public session, I want to acknowledge for the record
what I said at the end of our closed session earlier this morning to
review grant applications, and that is, I can never say enough about how
much I appreciate the service of council members. It\'s a very important
council. We pay close attention to your feedback and your opinions, and
I really thank you for your commitment to the field and the service you
provide to this council. And I can say this on and on and on again and
take up the whole day with accolades and praises, but we have an agenda.

(Laughter.)

DR. CLARK: So our very first item of business on the agenda is to vote
on the minutes from the March 21st meeting. The minutes were forwarded
to you electronically for your review and input. Hopefully, you had time
to review the minutes and give Cynthia your input.

I will now entertain a motion to adopt the minutes. Is there any
discussion?

PARTICIPANT: Move to adopt.

PARTICIPANT: Second.

DR. CLARK: Any discussion?

(No response.)

DR. CLARK: All those in favor?

(Chorus of ayes.)

DR. CLARK: Those opposed?

(No response.)

DR. CLARK: The minutes have been adopted as presented. I thank you for
that.

It\'s become customary that we set aside time for our members to briefly
introduce themselves and to hear from them about what they\'ve been
involved in since we last met.

However, before we turn the floor over to members, we want to formally
welcome Dr. Juana Mora, Professor at California State University,
Northridge, and the Chicana/Chicano Studies Department at Northridge,
California. As I mentioned in the closed session, Dr. Mora is no
stranger to SAMHSA. She served on the CSAT National Advisory Council.
She\'s recognized as a national expert and scholar on culturally focused
Latina substance abuse treatment and prevention issues and has developed
and taught courses on Latino families and women. She\'s also active in
public health policy and advocacy.

Welcome, Dr. Mora. I\'m sure you\'ll be able to expand on my brief bio
and introduction. Do you want to say anything?

DR. MORA: Just that I\'m very happy to be here, and I\'m very impressed
with the level of organization of the council since I was last a council
member with CSAT. It\'s just wonderful to be here and I look forward to
the rest of the day. Thank you.

DR. CLARK: By the way, on the handout table is a bio document which
contains each member\'s bio, along with each presenter\'s bio, and I
encourage you to pick up a copy of this document if you\'ve not already
done so.

We\'re also grateful to have Dr. Chilo Madrid back with us. Chilo is a
faithful member of the council and has been a strong supporter of
SAMHSA. Chilo was unable to be with us in March. He had undergone major
surgery. He looks like the picture of health. I was talking to him at
the break, and he\'s running two to three miles a day and he\'s eating
better and he\'s finding out how to keep his health up. He\'s lost a
little weight, appropriately. So welcome back, Chilo.

DR. MADRID: Thank you all very much for your prayers. I feel real, real
good. My doctor said I\'ll be ready for the next marathon in about 30
days. It\'s more like 60 days to me, but anyway, thank you all for your
prayers and it\'s real nice to be back.

DR. CLARK: So I want to take a couple minutes to allow council members
to introduce themselves and to let us know of new and existing projects
they\'re working on. We\'ll begin with Chilo and proceed around the
table.

DR. MADRID: Other than my bypass, I was very involved in our legislative
session in Texas as the legislative chair of our state association. We
pushed a lot of real nice legislative bills, funding bills especially
for people that are addicted and are very, very enmeshed with the
criminal justice system. We passed some bills concerning counselor
licensure. We relaxed some of the requirements from 60 CEUs to 24 in two
years. So I was very involved with that during the month of January.

February is when I got my new heart on Valentine\'s Day. So I laid off
for about a month. Then I came back in March-April and a little bit in
May, and the session was over in May. So that\'s all I\'ve been doing
the last several months.

DR. CLARK: Anita?

MS. BERTRAND: Good morning. My name is Anita Bertrand, and I\'m the
Executive Director of the Northern Ohio Recovery Association. And we
develop peer recovery support services in three counties in Ohio,
Cuyahoga, which is Cleveland; Summit County, Akron; and Lorain and
Lorain City. We just recently signed our third lease to open up a
resource center in Akron, Ohio, and I\'ve been working very closely with
the local funding bodies and their executive directors to make sure that
recovery support services are linked to the professional treatment
services in those counties.

DR. CLARK: Judge?

JUDGE WHITE-FISH: Good morning, everyone. I\'m Eugene White-Fish. I\'m
the Chief Judge for Forest County Potawatomi, as well as the President
for the National American Indian Court Judges Association.

One of the things in the judicial body that the Native Americans are
looking at, as well as the legislature, is the meth problem across
Indian Country. A lot of the presidents of national associations of
Native Americans are getting together looking at the impact that it\'s
having across Indian Country. They\'re trying to identify resources on a
holistic basis in order to take care of the issues.

And the court systems are starting to get overloaded in some of our
court systems in our Native American courts and tribal courts. The
funding there is difficult. Some of the tribes aren\'t as fortunate to
have revenue in order to support their court systems. Wisconsin tribal
courts ‑‑ I want to say some of them don\'t have the funding. There are
other areas that don\'t have the funding in order to handle the problem
that\'s hitting Indian Country such as meth.

For some reason, the people are targeting Indian Country with meth
because they think they can stay away from the judicial jurisdiction of
the outside law. That\'s exactly what we\'re trying to do. The courts
are also allowing ‑‑ because Public Law 280 allows concurrent
jurisdiction, but in some, they have their own sole jurisdiction. So the
discussion amongst the judges nationwide are trying to handle exactly
jurisdictional questions such as that, as well as working with state
court judges and federal court judges so that we are able to handle that
problem. Judges talking to judges, as we call it, so that these issues
do not continue in Indian Country or any other jurisdiction.

Thank you.

DR. CLARK: Val?

MS. JACKSON: Good morning. I want to thank you. I actually was
officially through with my term some time ago, but I continue to be on
so long as you don\'t appoint someone else. And I enjoy being here, so I
appreciate that. So as long as you don\'t appoint anybody, I\'ll just
continue on. It\'s good stuff.

I am the Executive Director for NCI Systems. NCI Systems is an
interesting collaborative of six of the largest and perhaps most known
human resource agencies in Florida that are now working to impact not
only Florida but the U.S. The centers are the Center for Drug-Free
Living in Orlando, Disc Village in Tallahassee, Gateway Community
Services in Jacksonville, Stewart Marchman Center in Daytona Beach,
Operation PAR in St. Petersburg, and Concept House in Miami, Florida.

It\'s a new endeavor in that these are not-for-profits, but they have
invested in me, a one-person staff, although I get to contract with
people every once in a while, to come up with innovative ways for
not-for-profits to find lines of business that can then turn around and
put money back into the not-for-profits so that we can have better and
more quality services.

So as an example, one of the things that we do is a lot of teaching and
training and assisting other organizations in best practices, which
you\'re all familiar with, evidence-based practices and/or helping
grassroots organizations to build. And we consult to do that. That money
then turns around, outside of the money that I need for expenses, and
goes back into endeavors within the agencies to try to go back to help
put more services and more attention into the communities.

So we\'re hoping in the future this will be a way, besides all of the
struggles of the grants and the communities and the governments, to be
able to bring not only more knowledge and awareness of but more
financial security and so on to not-for-profit organizations.

Thank you.

Oh, I want to say one more thing. I have two weddings and a birth this
year. One wedding is over. One wedding is coming, and the birth is
coming in September.

DR. CLARK: Thank you.

Greg?

DR. SKIPPER: I\'m Greg Skipper, Medical Director of the Alabama
Physician Health Program.

I guess I\'m going to talk this afternoon about some interesting stuff
I\'m doing. The other thing is I\'m working internationally trying to
promote physician health, and Switzerland and Austria have invited me to
come and help them get a physician health program started, which is kind
of neat.

DR. FLETCHER: I\'m Bettye Ward Fletcher. I serve as President and CEO of
Professional Associates, Inc. That is a research and evaluation firm
located in Jackson, Mississippi. Most of our work is with foundations
where we help them to evaluate large initiatives, as well as in some
instances design initiatives, particularly those that work with
nonprofit organizations. We have also been asked to work with the local
treatment program in strengthening its outcome evaluation for the
services that they provide in their homeless shelter, as well as their
treatment program focused on women. So we continue to do work in that
area.

MR. DeCERCHIO: Good morning. I\'m Ken DeCerchio from Florida and the
Assistant Secretary for Substance Abuse and Mental Health.

Our legislative session ended in the beginning of May. One of the, I
think, pieces of legislation that I\'m real excited about is called The
Substance Abuse and Mental Health Criminal Justice Reinvestment Act that
creates a grant program for local communities to come together to plan
strategies to divert individuals with mental illness and substance abuse
from the criminal justice system. That\'s something that was really just
an idea that we modeled after the Bureau of Justice assistance grants up
here and came together in less than a year with funding in a very tight
budget year.

In substance abuse, we\'re excited to be implementing a Brief
Intervention, Referral, and Treatment CSAT grant for older adults. It\'s
called BRITE. It\'s called Brief Referral, Intervention, and Treatment
for Elders. We\'re initiating that in 14 sites to do that initiative for
older adults. It\'s certainly long overdue in Florida.

Then the third thing. Actually this is my last week in my current
position. I resigned my position as Assistant Secretary, and September
1, I\'ll be working with the National Center for Substance Abuse and
Child Welfare, which is run by a company called Children and Family
Futures out of California, working on methamphetamine and other
substance abuse issues in communities that are working to connect
substance abuse services, prevention, and treatment for children and
adults in the child welfare system.

Thank you.

DR. MORA: Hi. As a professor, one of my major tasks and activities is to
mentor young people. So I work with a lot of new, young scholars in
various areas. In fact, I\'m having dinner tonight with a Chica, a
Latina student, who is doing an internship in D.C. and is very homesick.
So I\'m going to spend some time with her tonight.

What else? In the last five-eight years, I\'ve also been very interested
in doing participatory action research, community-based research. I\'ve
changed my focus to doing research with communities and not on
communities because it helps me understand what\'s going on in the
grassroots level because I still see a huge divide between what\'s going
on with our communities and what takes place in meetings like this, for
example.

So I just finished a three-year project working with low income
immigrant communities in Los Angeles trying to identify what research
issues they want to explore, and three issues came up: violence,
substance abuse, and environmental health. So I just finished that
project. I\'m working on publishing some of those results right now.
I\'m continually fascinated and I learned so much from community groups
and try to bring their voices to meetings like this.

I\'m also just possibly beginning a new initiative on substance abuse
issues along the border.

Thank you.

DR. CLARK: Thank you. Again, I want to thank you for adjusting your
schedule to attend this meeting.

I\'d also like to recognize that we have had staff that joined CSAT
since council\'s last meeting. If the new staff will stand up. We have
some interns. We have Robert and interns. Donna. So another graduate
materializing. You\'re popping up. Okay. They\'re all bashful and shy.
You don\'t have to be bashful and shy. Thank you very much. Hopefully
you will take the opportunity to introduce yourselves to council.
Welcome aboard.

I\'d like to move to the Director\'s report. I\'m delighted to have this
opportunity to address you today.

Before proceeding, I\'d like to apologize to those members who may have
experienced delays in your reimbursement. The Department made a change
to a new accounting system which caused some delays. Not only did the
switch affect you, it also affected staff. I can vouch for that. For a
moment there, I felt I was subsidizing the federal government. That\'s a
tremendous burden. We hope that the kinks have been worked out, and I
invite you to let us know if you continue to experience any kind of
problems. I want you to rest assured that we will continue to do
whatever we can to expedite your reimbursement. We appreciate your
patience and understanding as management resolves these issues.

CSAT has had a very productive and active quarter. I\'d like to take
this moment to bring some, though not all, of our areas of activity to
your attention.

Fiscal year 2007 started with a series of continuing resolutions.
Ultimately, President Bush signed a yearlong continuing resolution on
February 15, 2007. CSAT continued to fund grant and contract
continuations throughout this period of uncertainty. Now, as we move
into the last quarter of the fiscal year, new grant opportunities are
being prepared for award. These include a new round of Access to
Recovery grants, Targeted Capacity Expansion grants, Targeted Capacity
Expansion-HIV, which you\'ve already addressed, and Addiction Technology
Transfer Centers, to name a few.

At the last council meeting, members expressed some significant concern
about cuts proposed in the PRNS spending category for CSAT in the
administration\'s FY 2008 budget request to Congress. I\'d like to take
a few minutes to update you on where things currently stand.

At this point, both the House appropriations subcommittee and the Senate
appropriations full committee have completed markups of the President\'s
request that restore the cuts that were made. As you know, this is not
yet final. We\'re beginning to get a feel for the direction in which
Congress is headed, and I\'m sure the Congress will negotiate with the
President on the final budget.

The House report language is not yet available, but we do have a draft
Senate report which directs that Science to Services programs such as
Recovery Month, Minority Fellowship, and KAP programs, and others be
restored to 2007 levels. In fact, all PRNS activities will be restored
to 2007 levels except PPW, which is increased. That\'s Pregnant and
Postpartum Women, increased to \$20 million in the Senate language, and
the requested increase of \$13.7 million for criminal justice, the drug
courts, is also endorsed by the Senate. The Senate even includes an
additional PRNS increase of \$26.7 million. The Senate straight-lines
the block grant, but the House increases it to \$35 million.

So the process is going on, and it\'s clear that both the executive and
the legislative branches will negotiate at the end. The President has
expressed a genuine concern about not disrupting the budget. He\'s very
much interested in a balanced budget. Obviously, because we have a
difference of opinion, the executive branch and the legislative branch
will resolve these matters in due course.

All this information is included in the budget section of my written
report, but I wanted to highlight it to you. So I\'ll remind you again
that this whole discussion between the legislature and the President is
not yet final, and we\'ll keep you posted as things progress.

We\'ll be moving on to fiscal year 2009. The first is SAMHSA\'s budget
proposal has been submitted to HHS. That is still closed. So I\'m not at
liberty to discuss this now that we\'re in this particular phase, but
the point is that, again, we\'re already moving into the out years,
which raises questions, in order to invite participation, we should be
thinking in terms of 2010. What do you see 2010 entailing in terms of
activities?

SAMHSA Administrator Dr. Terry Cline will present the FY 2009 request to
the budget council on July 11th. Other center directors and I will
accompany the Administrator to assist in responding to questions, and
after the final markup by the Department, the budget will be revised and
be submitted to OMB in early September.

Moving on to administrative matters, the center underwent a
reorganization of two of its divisions, the Division of Services
Improvement and the Division of State and Community Assistance. DSI is
now comprised of three branches: Health Systems, Targeted Populations,
and Quality Improvement and Workforce Development. DSCA\'s
reorganization was designed to consolidate CSAT data collection,
reporting, and analysis of grantee and state block grant data into one
organizational unit, the Performance Measurement Branch. There are three
open positions in the new branch which are expected to be advertised
shortly: Branch Chief, Lead Public Health Analyst, and Public Health
Analyst.

I\'d like to really stress this issue of having adequate data to justify
what it is that we\'re doing. Questions are always being asked about how
are individual grants performing, but they also want to know how
programs are performing. Increasingly you have to justify how is this
program performing, what is the philosophy of the program, what kind of
accountability mechanisms you have structured in the program, and where
does this program go in terms of sustainability and in terms of it being
adapted and adopted by states, tribes, cities and counties, and local
jurisdictions.

I would like to bring to your attention other program areas. Our ATR
grantees are now in the third and final year of the three-year grant
period, and CSAT has been conducting a series of sustainability
trainings for ATR providers to help them sustain their program efforts
after this particular phase ends. To date, eight trainings have been
conducted in Washington, D.C., Baton Rouge, Orlando, Los Angeles,
Sacramento, Hartford, Connecticut, Houston, and Vancouver, Washington.

Additionally, the 2007 request for applications for ATR programs was
posted on March 23rd and closed on June 7th. We anticipate up to \$96
million will be available, including our expectation that some \$25
million will be spent to address the methamphetamine issue. We
anticipate approximately 18 grantees will be awarded.

On April 24th, I represented CSAT in a cross-cutting breakout session on
methamphetamine abuse in the Department of Health and Human Services\'
Ninth Annual Tribal Budget Consultation Session. The Department has been
conducting regional tribal budget consultation sessions. The purpose of
these sessions is to discuss issues important to tribal members and
involve multiple HHS operating divisions. I spoke of SAMHSA\'s programs
and CSAT\'s programs specifically and encouraged leaders to apply for
grants. I also emphasized SAMHSA\'s continued commitment to creating
healthier tribal environments.

We continue to make progress in our efforts with electronic health
records. A SAMHSA-wide strategy for EHR has been developed and improved.
In fact, is Sarah Wattenberg out there? Rich Thoreson? We have two CSAT
staff actively involved at the SAMHSA level on EHR, Sarah Wattenberg and
Rich Thoreson, neither of whom are here, but they\'re actively involved.

New activities related to development of privacy, security, and other
relevant health information technology standards will begin over the
summer, the first being a joint SAMHSA/CDC work group on HIV and
methamphetamine was held in Atlanta, in conjunction with a TCE/HIV
grantee meeting. A steering committee of community leaders, researchers,
program administrators, and federal partners were identified to
determine the utility of a summit to address the needs of lesbian, gay,
bisexual, and transgender populations affected by methamphetamine use.

The new NREPP website for the National Registry of Evidence-Based
Programs and Practices was launched on March 1st. Four substance abuse
treatment interventions posted on the searchable database included three
adult interventions and one women and children\'s intervention.

The Recovery Community Services Program convened a planning meeting in
Washington on May 30th to address organizational infrastructure, peer
practice, ethical framework, and guidelines for peer practice and
evaluation of peer recovery services. The results of the work group
plans will be presented during the annual RCSP grantee meeting in
August.

The 2007 RFA for TCE grants was posted on March 29th and closed May
25th. Projects to be funded have been categorized into four major areas:
Native American/Alaska Native and Asian American/Pacific Islander
populations, E‑therapy, grassroots partnerships, and other
populations/emerging substance abuse issues. We anticipate the total
available funding to be \$8 million, with up to 16 grants expected to be
funded.

CSAT is particularly pleased with the success that we\'ve experienced in
our training initiatives among our faith-based community. Nationwide,
over 400 community- and faith-based providers and organizations have
received capacity building and sustainability training and technical
assistance, including our ATR treatment and recovery support providers.
As a result, many of the participants have developed program
sustainability plans and been able to market their program services to
potential donors effectively. We\'ve successfully held 13 meetings
across the country, with the remaining to be completed before August of
this year.

I\'d also like to highlight our Partners for Recovery Initiative. As you
know, the PFR Initiative is a collaboration of communities and
organizations mobilized to help individuals and families achieve
recovery. In a concerted effort to promote and support the mission goals
and objectives of the agency, PFR continues its efforts through the
Partners for Recovery website, the PFR planning and implementing
recovery-oriented systems of care regional meetings, performance
measurement training, and the NASADAD annual meeting, and then the
PFR/ATTC Leadership Institutes.

I\'d like to commend our staff in Consumer Affairs for their excellent
on \"New Morning\" and \"Labyrinth,\" two public service announcements
which won the Gold Omni Awards for spring in 2007. Omni Awards
recipients are chosen by their peers for outstanding media productions
that engage, empower, and enlighten.

The 2006 \"Road to Recovery\" webcast series won two awards, including
the 2006 Gold Aurora Award, which recognized the webcast \"Addiction &
Family: Healing & Recovery,\" in the social issues/report/documentary
category. The Aurora Award is an independent film and video competition
for commercial, cable programming, documentaries, and other videos.
You\'ll be hearing more about CSAT\'s Consumer Affairs and PFR
activities this afternoon.

I\'m very pleased with the successes and achievements of CSAT\'s staff,
our contractors, and associates, as they have performed very well over
this past quarter. Later in today\'s program, the Director of the
Division of Pharmacologic Therapies, Robert Lubran will address an issue
to which we\'re giving much attention, that is, the issue of misuse of
methadone and mortality associated with methadone.

I\'m looking forward to hearing from Dennis Moore of the Department of
Community Health at Wright State University in Ohio, who will be
speaking to us about substance use disorder services for individuals
with disabilities.

NAC member Dr. Greg Skipper will be presenting with Dr. Robert DuPont,
President of the Institute of Behavior and Health, for our afternoon
discussions on physician health programs.

I\'m also pleased to welcome this afternoon Catherine Nolan of the
Office of Child Abuse and Neglect of the Children\'s Bureau, who will
speak to us about promotion of Safe and Stable Families Partnership
Grants.

Finally, as always, we have reserved time for council input throughout
the day, including a council roundtable. We have a long, productive day
ahead of us.

I thank you for being here today.

I think we need to move forward to the next order of business. I\'d like
to give you a few minutes for a general discussion, and then move to the
issue of methadone abuse and mortality. The floor is open for questions
and comments you may have pertaining to my report.

Judge?

JUDGE WHITE-FISH: I want to say thank you from the Native American
communities for participating in the tribal consultation sessions. I
noticed also in your report for the American Indian and Alaska Native,
that you\'re also working with them. Comments are out there, and I
don\'t want to expand your head too good. But they asked what SAMHSA is
doing in Indian Country a lot more. And I said it\'s a good thing. It\'s
positive. Don\'t question them. So thank you.

DR. CLARK: Thank you.

We want to make it clear that our role is not to preempt the activities
of IHS or the Bureau of Indian Affairs. We see ourselves as subject
matter experts on mental health and substance use at SAMHSA, and the
other entities have turned to us. We really welcome the fact that tribes
and tribal organizations are also turning to us in the area of substance
abuse and mental health, not just as consultants and providing
resources, but so that we can facilitate a resolution to some of these
problems.

DR. MADRID: I wanted to comment on something that you mentioned that I
think CSAT needs to be commended on, and that is the whole issue of
sustainability. One of the things that is so important is when we look
at three- and five-year projects, what are we going to do on that last
day? Some of your staff I think have done excellent work, especially in
the PPW area, Linda White-Young. I don\'t know if she\'s here or not.

But anyway, the concept here is that sustainability starts on day one,
not on the third year or the fifth year. I think that we\'ve done
something good and I think we need to augment that because I think
service providers need more direction, more assistance in this whole
issue of sustainability. So I want to commend you for giving it that
attention in your report, and certainly Linda White-Young for giving ‑‑
I believe there was a conference. Some of my staff attended. They were
very impressed with the ideas that CSAT presented and hopefully we can
put some of those into practice because I think that that\'s something
that we cannot overlook.

DR. CLARK: Indeed, part of the question that the Office of Management
and Budget would have when we\'re dealing with some of these issues and
dealing with some of our programs is what happens at the end of the
program, as you stated. So we want our discretionary portfolio to deal
with acute issues but also to help prime the pump so that some of these
efforts, hopefully with new technologies, are adopted by local
communities, cities, counties, and tribes and states so that, indeed, we
can facilitate service delivery.

Anyone else?

(No response.)

DR. CLARK: Then that puts us back on schedule.

According to the National Center for Health Statistics, the number of
overdose deaths associated with methadone has risen dramatically in the
past five years. SAMHSA is interested in knowing how practices regulated
opioid treatment programs are a factor or may be contributing to this
public health concern.

In addition, we are concerned about the abuse of or dependence on
methadone prescribed or dispensed for pain.

To discuss this important issue is Bob Lubran, the Director of CSAT\'s
Office of Pharmacologic Therapies. He\'s accompanied by Dr. Kenneth
Hoffman, Medical Director of the Office of Pharmacologic Therapies. Is
Tod or Nick Reuter also going to be with you and your group?

MR. LUBRAN: We\'ll have staff available for comments.

DR. CLARK: All right. Bob and Ken.

MR. LUBRAN: I\'ve asked Ken Hoffman to join me. Ken is our medical
officer here working on this issue, and we\'re going to sort of do this
as a team and then we\'ll be available for comments, as well as other
staff.

Let\'s start back in 2003. SAMHSA recognized that there was a concern
about overdose deaths and mortality associated with methadone. We
conducted an assessment almost four years ago, May of 2003. A copy is
back on the table for your review. And we were concerned because in 2001
we had transferred authority from FDA to SAMHSA for responsibility and
oversight and regulation of methadone treatment in the United States,
and there was some question whether or not the new regulations that were
implemented in 2001 had an effect on this change in mortality with
methadone. Alan Trachtenberg at the time was the medical officer and was
the medical editor of that report.

Here are the findings that came from the report.

Number one, all narcotics, including methadone, were increasingly
associated with diversion, abuse, and mortality.

Respiratory depressant effects and/or cardiovascular effects at high
doses of narcotics can be fatal.

Methadone treatment has a proven safety record, and for this population
who are addicted to heroin, particularly injection drug users, methadone
actually is very effective at reducing mortality.

There were three scenarios that came out from the report.

Number one, that accumulation of toxic levels of methadone during the
early induction period could be dangerous for some people because of
their tolerance and the pharmacologic properties of methadone.

Secondly, diverted methadone into the community used by individuals with
little or no opiate tolerance was also a factor.

And then there\'s the synergistic effect of methadone together with
alcohol, benzodiazepines, and other prescribed medications that would
exacerbate its effect.

We learned that methadone was increasingly being prescribed for pain,
therefore, more available in the community.

There was no comprehensive database of deaths associated with narcotics,
including methadone.

Coroners and medical examiners did not have a uniform case definition so
that somebody who was in an automobile accident, upon examination was
found to have had methadone, could have been classified as a
methadone-related death when there may have not really been strong
evidence that methadone contributed to the cause of death.

And because of the increased availability of methadone for pain, there
was not much of an increase seen in mortality in narcotic treatment
programs, or we refer to them as opioid treatment programs, and the
increased deaths were not likely to have been affected at all by changes
in SAMHSA regulations.

Now, scroll four years later. The problem continues to be a serious one
because of misuse, diversion, and abuse of methadone. There are
significant numbers of deaths being reported, and we\'re going to go
into that in more detail. And deaths associated with methadone are in
many communities, or certainly in some areas of the country, outpacing
those of other narcotics, and we believe that this requires a concerted
effort on the part of the whole public health system at the federal,
state, and local level to begin addressing what we can do.

Just briefly, methadone is a Schedule II controlled substance. There is
a quota on production that\'s set by DEA. And from \'98 to 2006, that
quota has increased over 250 percent. That\'s based on the demand that
the companies project for the use of the drug. The increase is largely
attributed to expanded use of methadone for pain. The level of increase
for methadone going to opiate treatment programs is fairly steady, and
the number of prescriptions has increased 700 percent since 1998, which
is very significant.

Ken, I\'m going to ask you to come up and walk us through some of the
data that we\'ve been gathering from primarily CDC and also our own
SAMHSA DAWN system.

DR. HOFFMAN: And to try to keep us on track, I\'ll go through some of
the slides fairly quickly, but what I want to highlight a bit is what
we\'ve had in the DAWN, the Drug Abuse Warning Network, system, as well
as what the CDC has more recently published, some of which has been
referenced already, some of the data that comes from the medical
examiner\'s office in Florida, as well as one of the actually nice and
key studies on methadone program causes of death among patients that was
published also in the past year.

From the DAWN, clearly we see methadone ranking third among the opioid
analgesics, this nice big bar over there. It is a problem. One of the
things that is on the back table there is a handout, some initiatives
that we sponsored the development by the California Medical Association
for a course, and they\'re now requiring their prescribers in the state
to have additional training in use of opioids in treatment beyond just
the methadone program, but just in general. One of the things, having
been through medical school myself, is that while the demand has been to
please prescribe more opiates for people in pain, the basic training
really isn\'t there, and that\'s something which has to be developing or
reestablished within the basic training. But the California Medical
Association at least is starting to tip in with a requirement for those
holding state licenses to at least have some hours of training.

This is just showing some of the age distributions of methadone
mentions. Now, DAWN will pick up the total emergency room visits that
will mention methadone and then the non-medical ones will relate to
issues such as overmedication or if there\'s actually a specific mention
of drug abuse. And what one is noticing, I think, is there\'s an
increase. In the older population, there\'s an issue probably related to
the overmedication issue but there\'s also an abuse possibility going
on, and the younger population is also affected. So this is across the
board. It compares always to hydrodocone, which has been always the drug
that\'s mentioned with far greater frequency, but as you see, methadone
is catching up.

The methadone-related deaths. This is a fairly busy slide, but it
summarizes what was in the articles. I think I\'ll go through some of
the slides that graphically illustrate that. But what the CDC has and
the National Centers for Health Statistics is access to all the death
certificates that are submitted through the states. On the death
certificates, you do have causes of death and antecedent causes of death
as perceived by the medical examiners or coroner.

Clearly, the problem ‑‑ you know, sometimes dissecting this, they\'ll
get coded to basically ICD-10 codes, which is a very nice descriptor of
poisoning type deaths and it could be either through suicide or
unintentional. Right now the suicide rate is about a quarter of the
unintended overdose deaths. You see here basically the take-home for
methadone is from 786 that were in the death certificates in 1999 to
3,849 in 2004.

This is just again graphically showing the all poisoning deaths and the
poisonings related to methadone going from that 786 or so to 3,800 over
the course of time. So the slope is slightly greater for that.

In terms of the age group affected, you see the faster slope going on in
this 25- to 34-year-old age group.

In terms of the lethality ‑‑ and part of this is when one looks at the
FDA labeling changes, as well as the alert that went out this last
December, there\'s a half-life difference between how long the drug
stays in the system and how long it gives pain relief. In general, the
pain relief is a lot shorter than the half-life of the drug. So in
methadone treatment programs, it is less of a problem because you\'re
giving it because of its long half-life, whereas for pain management,
you\'re giving it because of its pain relief, but the pain relief is
going to go about 4 to 6 hours, whereas the half-life of the drug is
going to be 9 to 51 hours. So if you\'re trying to dose the pain relief,
you can rapidly overdose on the drug.

In terms of percentage, that\'s reflected here.

The other thing is in terms of related to the pricing of oxycodone or
other such opiates, methadone is actually very inexpensive, and so one
of the issues that\'s been mentioned anecdotally among seniors is that
when you hit the donut hole and you have to pay medication out of your
own pocket, this is a much cheaper drug that becomes affordable.

This is basically saying the same thing, looking at the percent
increase.

Then just to mention, what the CDC does rank ‑‑ you see the number of
deaths, some of the tables that have been published. This is really the
top 10 states. Now, what\'s not in here actually is the percent of the
population treated, but if you just look at all states total, what
you\'ll see here is mostly in the rural states, there\'s been a very
dramatic increase. New York, for example, isn\'t here because it\'s been
fairly steady over time, but these are the states where you have the
highest increase and the ones that certainly we\'re on the phone an
awful lot with at this point.

Just to complete the information here is the fact that in 1999, there
were a few states that actually had no deaths reported in 1999, and over
the time to 2004, there have been some with certified methadone
programs. You see Maryland, the District of Columbia, and Nebraska. And
then without methadone programs, you have these states over here. So
there have been deaths reported in those states.

I think one of the things to remember with Maryland and the District of
Columbia is that Maryland certainly has had one of the longest-standing
opioid treatment programs and with the medical schools, I think they\'ve
been very much in tune with how to train the physicians in the
appropriate use of methadone and other opiates.

Moving to the Florida data, the medical examiners, which do a fantastic
job in going into the different causes of death, I think given that
drugs are found in the system, that the highlight here is that you have
‑‑ where heroin has been attributed directly as the cause of death,
which is the pie here ‑‑ you have other drugs like cocaine,
propoxyphene, hydrocodone, and oxycodone ‑‑ it can be in the system, but
not necessarily considered the cause of death. But when you look at
heroin and methadone, if it\'s been attributed to the poisoning or the
death of the individual, it\'s also likely to be considered the cause of
death of that individual.

Now, getting into this, actually it turns out to be a I think nice
standard, but what Jane Maxwell did in Texas ‑‑ she\'s part of the NIDA
Community Epidemiologic Work Group, and she\'s been very interested in
methadone deaths in Texas. They accumulated all the records, about 766
people between 1994 and 2002 who had died ‑‑ this is a reportable event
to the Texas Department of Health ‑‑ of the 13,264 patients that had
been in methadone treatment.

What you find here is that most people in methadone programs will not
die from the methadone, but people come into methadone programs fairly
ill with other medical conditions. That actually does get reflected.
They found liver disease, cardiovascular, but overdose is still a
significant issue, and most of this is going to be happening kind of in
that induction point, those first weeks in treatment when you\'re trying
to stabilize the patient. But then you have these other causes of death:
cancer, motor vehicle accidents, respiratory, suicide, AIDS, homicide,
and then just all other causes.

Now, if you look at standardized mortality ratios, for those who have
done health risk appraisals and other things, it\'s a very good way of
comparing. Given I\'m part of this population, what\'s my risk of death
compared to everybody else in the world. So if you take the distribution
of age and gender and match it to the general population for the state
and you know how they died, you can generate basically this is what
really happened in terms of the population. There were 105 overdose
deaths. You can calculate what would be the expected number of overdose
deaths in a similar type population.

So this is a standardized mortality ratio, 4.6. So this is a higher than
expected value. This is higher than expected, and you go liver disease,
respiratory, homicide, AIDS. And then actually the other thing that
happens, given that this is a group that died of something, how did the
other causes, cardiovascular, motor vehicle ‑‑ the risk is actually less
in that population, or the mortality ratio becomes less in that
population. That becomes reasons for investigation or looking deeper
into it.

The other thing that Jane did is comparing the private and public OTPs.
There\'s a different group that come into OTPs, and I think there\'s a
marked similarity in terms of the age coming into a private or public,
days dosed, months, and gender, but when you get into the ethnicity,
white, African American, Hispanic, you start to see some marked
differences in who\'s going into the programs. Actually the conditions
in which people come into the programs will also differ. So when you
look at causes of death between the public and the private, you also see
differences in cardiovascular, liver, overdose deaths differentially
between the private and the public programs.

This is kind of the quick summary, that patients in opioid treatment, if
they die ‑‑ most people are being treated effectively, but you have the
overdoses, liver disease, respiratory disease, homicides and AIDS among
people in opioid treatment that are more likely to suffer deaths from
those causes, but less likely to die from cardiovascular disease, motor
vehicle accidents, suicides, cancer, and other causes of death.

Then you have the cohort characteristics, the age of the population. If
you were in treatment longer, more take-homes, higher doses. These were
the people that were older in the programs, and they died more
frequently from chronic disease. The younger cohorts died more
frequently from drug overdose and trauma, which would be your motor
vehicle accidents. The conclusion of that paper is that the scope of
services should include on-site treatment for other medical conditions.
Obviously, the physicians in the program become kind of a key focus of
attention at this point of the competency and skills and what the
programs could be offering. Then the staff is able to counsel concerning
risk of death to new patients, and you might get into also a level of
care type of issue in terms of what is the best range of services and
the intensity needed for patients coming into treatment.

And I\'ll turn this back over to Bob.

MR. LUBRAN: Well, what does all that mean for CSAT? I think that we\'ve
been certainly evaluating what we\'ve been doing up till now and what
may be needed in the future, and so I want to talk just briefly about
some of the initiatives that are underway.

First of all, we\'ve been working for quite some time to develop revised
accreditation guidelines, and those guidelines are very well into the
process. We hope to get that out of SAMHSA certainly in the next few
months.

Just some highlights on the guidelines.

We want to increase emphasis on ability to provide comprehensive
medical, psychological, and preventive services within OTPs. I think if
you heard Ken\'s comment about the summary of the Texas report, I think
that\'s reflective in some of the changes we\'d like to see.

We\'d certainly like to see improved case management capability within
the community so that these medical conditions of chronic diseases that
we\'re talking about, cardiovascular, AIDS, hepatitis, and so on, that
the programs have a network of providers, if they can\'t provide the
medical care themselves, that patients have a place to go to get the
kind of services that are going to reduce mortality in those chronic
conditions.

We are holding next month two meetings of a consultative nature. July
19th, we are meeting with people specifically around opioid treatment
programs and what kinds of opportunities are out there for making some
improvements over the next several years that we might be able to
propose to the field and that the field themselves may want to engage in
adopting some new practices.

And then the next day, which is Friday, the 20th, we\'re going to have a
reassessment following what we did in 2003. We\'re inviting back federal
agencies, leaders in the field of addiction treatment, pain management,
medical oversight through state medical boards, law enforcement, the
medical community, cardiology and other aspects of medical care to take
another look at the data, take a look at some of the initiatives that
have occurred since 2003 at FDA, at SAMHSA, DEA, and elsewhere and again
come up with some findings that we can then go back to Dr. Clark and
advise him as to what that means in terms of our programming, our
regulatory oversight, our training, need for medical education, and so
on.

We also want to take a look at the need for perhaps some better data
collection on our part so that we have a better understanding of what is
happening with regard to the deaths. As you saw from one of the slides,
the top 10 states have a tremendous amount of the numbers of overdose
deaths, and there are some other states where the numbers are very low.
So we want to better understand what is going on in Florida, Tennessee,
Ohio, West Virginia, and that may require some special studies too.

We do think that education of medical staff in OTPs is a priority that
we\'ve worked for a number of years now with the medical community
around buprenorphine, and we\'ve developed, I think, some excellent
programming and support of the medical education of physicians. Now
we\'re starting to take a look at perhaps the similar need for
physicians coming to work in this field since there is so little
education that the medical colleges provide and very little continuing
education for people working in this field.

You heard earlier about the grant program of physician clinical support
systems out there for buprenorphine doctors, and we also have a project
aimed at helping to educate patients in methadone treatment,
buprenorphine treatment through reduction of stigma, through better
knowledge, education of what is methadone and what is recovery, and how
can people working at recovery do a better job and achieve their goals
as well.

We\'ve also been working with the medical community around education of
pain. There is a lack of education in the medical world about the use of
opiates, and Ken Hoffman has been very actively engaged with not just
the American Society of Addiction Medicine, but the American pain
management community that we\'re very concerned about. As Ken mentioned,
there\'s a collaboration with the California Medical Association on a
course that\'s now being held around the country. Online courses are in
development. And we\'re having a lot of interaction. The Federation of
State Medical Boards adopted a resolution at their meeting in May to
support medical education around substance abuse and use of pain
medication. AMA is also considering similar kinds of resolutions.

So we\'re having a lot of dialogue with the medical groups, with the
pharmacy companies, and obviously, we\'re coordinating our efforts
within the federal government.

So let me just summarize saying that methadone-related deaths continue
to escalate. Current data suggests that medication that is intended for
treatment of pain is the most likely source of illicit use or misuse of
methadone. However, we need to do more surveillance and more review of
how that\'s happening and what effect, if any, OTPs through diversion or
misuse are contributing to that.

The prescribers of methadone are practitioners with very little training
particularly in the use of methadone. And there\'s very little training
going on through the medical education system, and we\'re going to
continue working to help improve that.

The two meetings we\'re having next month ‑‑ Dr. Clark is going to be
chairing both those meetings ‑‑ as a way to hear from the field, hear
from the community about what are some of the opportunities that the
field in general and CSAT for sure can learn about and then try and
implement.

(Applause.)

DR. CLARK: I want to thank Bob and Ken for that succinct but
comprehensive overview of the issue.

We should take a break, and when we return, we will have discussion.

(Recess.)

DR. CLARK: Council members, please make your way back to the table. I
appreciate it. We\'re running about 15 minutes behind.

You heard Dr. Hoffman and Mr. Lubran present on the issue of methadone
misuse, abuse, mortality. Does anybody on council want to discuss this
issue? Dr. Skipper?

DR. SKIPPER: Well, first, I want to commend Dr. Hoffman and Bob Lubran
for a good presentation and their work in this area and commend CSAT and
particularly Dr. Clark for bringing these organizations together last
time and the plan to bring them together again to look at this issue. I
think it\'s a very important issue and it\'s a very complex issue.

But one thing I wanted to point out is if a new drug came out today,
say, an antibiotic, and you had a few people die per 100,000 due to some
adverse reaction, the drug would probably be pulled off the market. But
we have drugs out there that are killing people. It\'s amazing that
3,000-plus per year die from methadone deaths and not more is done.

I\'m not saying it should be pulled off the market. What I\'m saying is
we should take these actions. It\'s an important drug. We need it for
treatment of addiction and the action to improve training for doctors to
know how and possibly encourage requirement of training because I\'m a
little concerned that if we offer training, it often seems that the
doctors who really need the training don\'t volunteer for it. That\'s a
concern I have.

And then the other thing that\'s critically important is that we do
better surveillance of the OTPs to protect the OTPs. We need them to
stay, and I do not think, as they mentioned, that the increased deaths
have anything to do with opiate treatment programs.

There are two other things I\'d like to recommend. One is that we
support in some way specialty designation for pain management and for
addiction medicine, for that matter. It\'s just still weird to me that
addiction is such a prominent problem in our society. There\'s medicines
for treatment of it. Doctors are important in the treatment of it. It is
a complex specialty, and yet it\'s not recognized by the ABMS as a
legitimate medical specialty. It\'s just weird. And chronic pain
management needs some kind of specialty oversight as well to encourage
them to have standards and do proper treatment. And that\'s where
training could come from if we saw that happen.

The other thing is when we do this conference in July, as in 2003, I
think it would be good if SAMHSA popularized the findings more in the
popular media. I don\'t know if that\'s forbidden or not, but I\'d like
to see Dr. Clark on \"Oprah\" or something talking about the hazards
because I think a big part of the problem here is the public needs to
know that this is going on and kids that are going to steal from
medicine cabinets or people that are going to leave their methadone in
an improper place where it can be stolen, and even the doctors who are
not smart on this, I think if the public knew and we had a little bit
more of a push to make this public awareness, I think we could reduce
the number of deaths because families that I\'ve known who have lost
someone were just not aware that this could happen. I think popularizing
this would be good.

Thank you.

DR. CLARK: Chilo?

DR. MADRID: Very fast, I\'d like to say that I\'ve worked with opiate
addicts for about 30 years and I\'ve run a methadone program for about
20 years. Ten years ago, one-quarter of a gram of heroin, which is about
the dose that most heroin addicts use at one time, was \$100 a day, and
now it\'s \$4 a day and in some places \$2 for a quarter of a gram. So
what does that tell you? That the supply is really out there on the
streets.

We\'re seeing more heroin addicts at the high school level now.

The other thing is that 10 years ago it was heroin injecting. Now we
have speedballing injecting, which is a combination of heroin and
cocaine at the same time. So I think that as we proceed, we need to take
into consideration these types of facts.

And I want to thank certainly Bob and Dr. Hoffman for their excellent
presentation, and I have just several recommendations in that I concur
that we need more training especially with our clinicians.

The recommendations that I would like to present at this time is we need
to look at methadone dosing based on the extent of the addiction. In
other words, our medical doctors have a real hard time deciding how much
methadone our addicts are going to be administered.

Also, we need to train our doctors about simultaneous abuse, and that
is, are addicts doing heroin at the same time, methadone, and cocaine?
Multiple diagnoses. We have a lot of addicts coming in with many other
diagnoses, including mental health, a lot of cardiovascular problems
because of the cocaine and the speedballing that I mentioned. We need to
train our doctors insofar as the take-home concept. How much should
people take home and what should be the protocol there? We need to
revisit that. There are a lot of doctors that are doing private
methadone versus public.

And then the cutting of the heroin ‑‑ that\'s very important in a
methadone clinic. The heroin that is being used by the patient coming in
‑‑ what is it being cut with? That has a lot of medical ramifications.

Then, of course, the old situation of the purity of the heroin. There
are times when the purity is really, really high, and we get a lot of
overdoses. There are times when it\'s really, really low and then we
tend to overmedicate with methadone. Every addict that I\'ve seen comes
into the methadone clinic saying I do 10 grams of heroin a day when in
reality they probably do three-fourths of a gram because they want more
because of the pain.

So I think that all those things need to be discussed as we move forward
to teach and to train our clinicians so that we can curb what is being
done.

But, again, I commend Bob and certainly Dr. Hoffman and the whole CSAT
staff that put on such an elaborate presentation.

DR. CLARK: Val?

MS. JACKSON: Well, I\'m just going to appear ignorant and ask the
question. I didn\'t understand Florida. Ken you must understand. But it
stuck out like a sore thumb. So can somebody explain to me why in
Florida evidently the incidence of death is so much higher than all of
the other states?

MR. DeCERCHIO: In part, yes. We looked at this issue back in \'03 and
\'04 when it first hit. What happened back in \'03 and \'04 when it
first hit, there were ‑‑ if you look at the ARCOS data, which is the
data on pharmaceutical prescribing, we had tremendous increases in
hydrocodone, OxyContin prescriptions. We had about three or four doctors
who were arrested. We had small numbers of doctors in Broward County,
Palm Beach, Dade County doing a high volume of prescriptions. Some of
those of doctors were busted.

And all of a sudden, after those real high profile busts, Pensacola,
Palm Beach, Broward to a lesser extent, the prescribing practices
changed. So you saw a major increase in the use of methadone coupled
with a lot of press around OxyContin and associated deaths around
OxyContin. So you saw a switch. Then the data indicated the switch to
the use of methadone, not in addiction treatment programs, but for pain
management in other physician settings.

The numbers are worse now. The \'06 numbers are over 700.

In my opinion, this is part of a prescription drug problem. We can chase
individual drugs. We do that very well both in terms of treatment, as
well as prevention, but this is part of a larger ‑‑ in Florida alone,
prescription drug deaths ‑‑ we take alcohol off the table ‑‑ far exceed
deaths from heroin and other illicit drugs. All the deaths associated
with prescription drugs, excluding alcohol, are much greater than
illicit drugs.

I\'ve come to a couple conclusions. I think we\'ve got to have mandated
training by the Board of Medicine in states for physicians in
prescribing. We had made that recommendation to the Board of Medicine in
Florida, and they looked at it as a voluntary piece. But there\'s
mandated training for HIV/AIDS. I think there\'s mandated training for
domestic violence, for CMEs. There\'s got to be mandated training for
the use of opiates and prescribing practices associated with general
practice.

We haven\'t had a major increase in the number of methadone treatment
programs in Florida. You can count them on probably two hands in the
last five or six years, nowhere near associated with the increases in
methadone deaths. And I believe that\'s what\'s going on, and it\'s
going to take a lot of work in the public health sector and through the
regulatory bodies for physicians I believe, as well as the guilds,
coming together to figure this out.

We kind of took a more voluntary, proactive approach with some of the
work in the \'03 committee. We did that in Florida, passed some laws
around prescription fraud, but we were not able to pass a prescription
validation program. This past session there was movement. There\'s an
e-prescribing bill that was passed that mines existing databases, but
we\'re still far short of a statewide prescription drug
monitoring/validation program.

So I think it\'s got to be mandatory education and there\'s got to be
kind of a public health outcry from both chief medical officers and
departments of health, i.e., state surgeons general. And we haven\'t
seen the public health outcry at the national level either from either
the Surgeon General or related public health officials.

MS. JACKSON: Well, if I could just respond to that as someone in the
field in Florida. And certainly I do a lot of reading. I watch the
newspapers. I live in Miami-Dade, the most populous county in Florida,
and we do know about the drug busts ‑‑ I\'m sorry ‑‑ those physicians
and some things that are misprescribing.

However, when I go to conferences ‑‑ and I don\'t know how it is across
the country, and I do go to some national ones. But I\'m speaking now
perhaps of the Florida ones ‑‑ it seems like we definitely have a need
to get that information out. It\'s not really being discussed. It\'s not
really being pointed out. The last conference I went to with a very
credible person giving statistics, we were busy talking about
methamphetamine, which is, if you look at it, quite a minor problem
percentage-wise at least or per capita-wise in Florida and in many
states compared to what we were just looking at.

So, Chilo, I think you mentioned the fact that we somehow perhaps need
to get to our state SSAs, somehow get to our folks that we get some
alerts out here because I will tell you, as a person in the field, I
knew that methadone was causing a problem. We have talked about it at
these meetings.

And I thought Dr. Skipper had one of the best suggestions, and that was
on long-acting pain killers and the prescriptions of such, particularly
without having any kind of training and that sort of thing. The
attention needs to at least get to some of the agencies and those people
who are professionals, and I don\'t think it\'s getting out there. I
really don\'t.

DR. CLARK: Any other council members?

I\'d like to say before we move to the next topic that we\'re probably
going to have some further discussion in the public comment period. So
that will be after our next presentation.

SAMHSA did present on this topic to the pain community this past weekend
up in New York. So there are practitioners who are attempting to address
this issue. Obviously, a lot more needs to be done.

So we\'ll move then to Dennis Moore on substance abuse treatment
services for individuals with disabilities.

DR. MOORE: Good morning. My name is Dennis Moore. I\'m a professor in
the Department of Community Health at the Boonshoft School of Medicine
at Wright State University in Dayton, Ohio.

I\'m here today to brief you about some emerging issues related to
substance use disorder and persons with disabilities. I\'m going to go
rather quickly through the presentation this morning. It will be more
focused on policy and some of the high points rather than actually
looking at data because I really don\'t think we can do both in the time
that we have.

I come from a program called SARDI. SARDI is one of the few research and
demonstration programs in the country focused on persons with
disabilities and the intersection of behavioral health issues. Since
1990 we have looked at a number of things related to substance use
disorder, mental illness, and increasingly other often stigmatized
conditions such as HIV and hepatitis.

We have several programs in SARDI, and I\'m going to tell you about them
very briefly because I think it\'s an important thing to illustrate how
some of these connections are made.

We have an RRTC, which stands for rehabilitation, research, and training
center, that\'s focused on substance abuse, disability, and employment.
We have a number of projects that are nationwide, working primarily with
vocational rehabilitation systems, looking at this issue.

The reason I mention this is that CMHS funds or co-funds four of the
RRTCs that are funded through the National Institute on Disability and
Rehabilitation Research. This is possibly one model that other branches
of SAMHSA might want to look at, especially as NREPP kicks into high
gear because some of the funding that goes to these RRTCs ends up in
some very high quality research.

Increasingly, we\'ve also been looking at health and disability issues
that adversely impact minority populations, and in our area that is
primarily African Americans. We have a program called Brothers to
Brothers Sisters to Sisters that focuses on people who are living with
or at high risk for HIV and/or a substance use disorder. This has been a
really exciting, incredibly challenging new area for SARDI. Some of the
things we\'re doing are just fascinating. I\'m really enjoying this work
a great deal.

I brought a description of our program and a handout. If anyone on the
advisory council is interested, I\'ll leave them with Cynthia.

One of the things that we\'ve discovered in our work is that a number of
people who have pretty severe disabilities don\'t recognize that, and
they don\'t understand that functional impairments get in the way of
everything they do in life, including their recovery. So sometimes it\'s
our mission to help people understand what some of the barriers are for
them.

We also run a mobile van and we have a church involved as our primary
outreach site in Montgomery County.

By the way, we account for over 25 percent of all of the HIV testing in
our county. Our program was responsible for bringing rapid testing to
our county, and we are now beginning hepatitis C screening, which is
really taking on quite an issue. I don\'t know if you are aware of it,
but in 15 years, the model suggests that hepatitis C will outstrip HIV
in terms of morbidity and mortality and the total costs. And when we\'re
talking about hepatitis C, we\'re quite often talking about IV drug
users. So it\'s a major issue.

The CAM program is one of the few programs in the country that was
particularly established to provide substance use disorder and mental
health treatment to people with disabilities. CAM has a census of about
350 consumers. The majority of people in that population are persons who
would qualify probably more than once for having a disability. Over half
of the consumers have a diagnosis of mental illness or some mental
health concern, and about a third of the consumers have a traumatic
brain injury. About half of the traumatic brain injuries were never
diagnosed, which is actually a fairly common problem.

Our treatment model is different than most SUD treatment providers, and
I mention this because I think this is a way we need to think about
treatment for people with severe coexisting conditions. We operate on a
principle of less intensity, longer duration. That\'s the only way it
works. To begin with, people with multiple disabilities, especially when
they involve cognitive impairments, can\'t tolerate a typical treatment
regimen. We just had a discussion with my staff last week about the fact
that our consumers can\'t sit through a two-hour group process. It\'s
just too long for them, and yet, that\'s what our billing segment
requires. So some of those issues come up on a regular basis.

The other thing we do is we integrate medical-somatic services a great
deal because, as came out in the previous discussion, people with
multiple substance abuse problems quite often have medical issues, quite
often are seeing more than one physician, and there are many
opportunities for inappropriate prescriptions to be written or for
people to be using their prescriptions in a non-prescribed manner and we
really have to pay attention to that.

By the way, CAM was mentioned in a SAMHSA-funded study that the National
Association for State Mental Health Program Directors and NASADAD
conducted several years ago looking at exemplary models for funding
co-occurring treatment disorder programs.

So what about people with disabilities? What do we know? We don\'t know
a great deal about use with disabilities and their substance use
patterns. We have managed to conduct one study based on nationally
representative data. The National Educational Longitudinal Study was
conducted for approximately 12 years. It had a large cohort of kids
involved in it, and we were able to differentiate the youth with
disabilities in that study.

What we found is that youth with disabilities had slightly higher
alcohol and cocaine use rates than their non-disabled peers and they had
comparable marijuana use rates by the 12th grade. They also had
significantly higher cigarette use and dropout rates than their
non-disabled peers in high school, and not surprisingly, their substance
use patterns correlated with their dropout rates.

One of the other things that\'s emerging for youth with disabilities is
the percentage of youth with disabilities who are involved in juvenile
justice. A number of kids involved in juvenile justice, if they\'re
given the opportunity for an assessment, are found to have attention
deficit disorder, learning problems, or a number of other conditions. In
fact, this is a particular challenge for juvenile justice programs.

Defining adults with disabilities is not an easy task. In the Washington
area alone, there are 50 functional definitions for disability right
now. So I\'m going to talk about 10 million people. How\'s that for a
number? That\'s less than the 60 million people that claim to be
Americans with disabilities, but our estimates are a conservative
figure, that 10 million Americans who qualify for disability services
also have an active substance use disorder. Some day I would love to get
the money to really study that and go after it because I think that
would be an interesting thing to tie down.

A number of groups of people with disabilities actually do have higher
prevalence rates for substance use disorders, in particular, individuals
with mental illness and individuals with traumatically generated
disabilities, such as traumatic brain injury, spinal cord injury.
However, some other subgroups we wouldn\'t expect also have been
measured to have higher rates, such as people with multiple sclerosis.
Applicants to state-based vocational rehabilitation programs appear to
have a very high rate for substance abuse. Now, that\'s about 600,000
people in the United States per year who apply to those programs, and
because of their disability, they would like assistance in finding
employment.

Our latest findings from a year ago, in doing a validation study on a
substance abuse screener, found a prevalence rate of 22 percent active
substance use disorders among applicants in Ohio and Illinois. We have
that paper under review right now. That figure has been fairly
consistent now for about five or six years.

We also know from historical perspectives, as well as recent data, that
the Medicaid, Medicare, and Social Security ranks are overrepresented by
people with substance use disorders, and if we consider those
populations, the public health impact and the total dollar impact of the
substance use disorder with people on those benefits is extremely high.
It represents a very large expenditure every year.

Even with people who have a disability that might have a lower
prevalence of substance use disorder, the consequences of substance
abuse are much more severe for them, and that would include people with
mental retardation, developmental disability, cerebral palsy, cystic
fibrosis, and people who are deaf. I include people who are deaf in that
category simply because we don\'t have enough data about what the real
prevalence is for people who are deaf. There are a number of studies
that speculate that the prevalence is much higher. However, there are
some studies that suggest that it\'s about the same as the general
population.

Compounding this whole picture, people with disabilities are the group
in the United States who are the least employed ‑‑ the least employed ‑‑
of any minority or subpopulation. They\'re the people who most often
live in poverty. Many of the populations we work with and study,
including people attending our treatment program, come from families
where the household family income is less than \$10,000 a year. That
changes the picture in terms of how we go about providing services and
think about rehabilitation.

Another problem for people with disabilities is quite often it remains
hidden. If that individual walks into a doctor\'s office or a clinic or
a voc rehab program or a counselor in a community college, those
individuals are going to look at the disability and look at those issues
and not really look deeper at why the individual might be failing or
might not be in a situation that they want to be in.

An interesting study on that is looking at the national prevalence of
drunk driving arrests for people who are deaf. We did that locally a
while back and we found that the prevalence was about one-tenth what it
should be. Essentially what happens, if you have a disability, is people
tend to defer to your situation and think that it\'s too much trouble to
really deal with it. So the more severe an individual\'s disability, the
more they have to get into some serious trouble before interventions are
done.

If we have to talk about the one probably most common barrier to people
with disabilities in accessing substance abuse treatment, I would group
it under the label of cognitive barriers. A number of people with
disabilities, including individuals with mental illness, traumatic brain
injury, even other disabilities, have memory problems and judgment
issues that are a direct function of their physical functioning. Either
they have a cognitive impairment directly or simply how tiring their day
is to them places them in a fatigue situation in many cases, and
they\'re just not up to the normal speed. An individual with a spinal
cord injury who has to use public transportation to get to our program
probably burns more calories and puts more energy into just getting to
our program than most of our consumers who have been there the whole day
and have left. So that individual comes into the program tired already,
and that kind of thing also needs to be built into treatment.

And then compounding this issue is there are a number of policy
inconsistencies across states in terms of how they make treatment
accessible to people with disabilities, and that\'s both supply and
demand issues. For example, I\'m doing a nationwide study now of
policies in state-based vocational rehabilitation programs, and there\'s
tremendous variation in what they do about or for people with a
substance use disorder that might coexist with another disability. The
range in those policies goes from, oh, if you have a substance use
disorder, you can\'t apply here, you have to come back and prove to use
you\'ve been sober for six months, all the way to some state-based voc
rehab programs run their own inpatient substance use disorder treatment
programs. So there\'s a tremendous variation there.

If we grouped the barriers to treatment for people with disabilities, I
think the common categories would be attitudinal. A lot of people in
substance use disorder settings simply don\'t have the background or the
exposure to disability issues and they tend to jump to conclusions that
may not be accurate. We run into that on a regular basis.

We also run into discriminatory policies and practices, communication
barriers. Obviously, people who are deaf are prototypic of that, but
there are other communication barriers as well. Some people have a very
difficult time understanding a cognitive-behavioral recovery model,
which is the most prevalent one used in the United States today.

And even now, 15 or 16 years after the signing of the ADA, a number of
treatment programs, especially older facilities or residential
facilities, are not architecturally accessible. Or even for programs
that are architecturally accessible, treatment personnel in those
facilities feel that they can\'t take people who require attendant care
or some of the other conditions that are related to this.

There are most certainly funding barriers. Every alcohol and drug state
agency has a list of mandates and a pile of money, and the two don\'t
match already. And when we start talking about people with disabilities,
when we start talking about who is going to pay the \$40,000 for the
interpreting costs for one treatment episode for the sign language
interpreter, you can see we run into some conundrums there, and it\'s
not easy.

Some of the disability statutes that have been passed already are not a
high priority for alcohol and drug treatment agencies. When we did a
recent survey of who in your agency is responsible for ADA compliance,
we asked all of the alcohol and drug directors in the country, including
a gentleman here on the panel who has done several very important things
in this area. I presented in Florida several years ago at, I thought, a
groundbreaking conference and dialogue between a state agency and people
with disabilities.

But when we asked the state agencies who was in charge of your ADA
policy, the range was everybody from somebody in human resources to most
often somebody who wears six hats and this is one of the six hats and,
of course, four of the other six hats are mandated funding priorities.
So you kind of get the picture there. It\'s a difficult thing to
address.

Then another problem, and Dr. Clark and I have talked about this a
number of times in the past, the level of advocacy from the disability
community has been minimal because they are, frankly, very ambivalent
about addressing this issue. They don\'t want it coming to the public\'s
attention, and there are articles going all the way back to the 1970s
talking about how people who are deaf will not talk about drinking
problems because of the stigma associated with it. There are historical
roots that literally go back all the way to beginning of the 20th
century when institutions were formed and people with mental retardation
were sent to institutions. And that attitude prevails today.

If you\'re in a wheelchair and you\'re told that you can\'t enter a
restaurant or can\'t go into a ball park because it\'s not accessible,
you can imagine the kind of reaction you\'d get. If you\'re in
wheelchair and you\'re told you can\'t go to this treatment program, the
consumer says, whew, dodged that bullet. Okay, well, I\'ll keep looking,
no problem. It\'s a different issue altogether. So it\'s sometimes a
tricky one to address.

Just a couple of stories. I\'m going to give you four very short
stories. These are actual cases that have happened to me since we\'ve
been running our treatment program.

A person with a seizure disorder and a coexisting mental illness and
substance use disorder was forced to change anticonvulsant medication
before entering an inpatient residential treatment. He was taking
phenobarbital at the time. He had been taking it for many years. He did
change the medication. He entered treatment. He had two seizures while
in treatment and he was discharged for being medically unstable because
of the seizures. He also incurred another head injury when he hit the
floor during one of the seizures in the treatment program.

Two residential treatment providers told us that an individual with
blindness and a service animal would not be able to enter their
treatment program in one case because the individual couldn\'t find the
exits during a fire drill. Real. That\'s what they said. And the other
one was that obviously the person wouldn\'t benefit from their mandatory
vocational training component in their program. Again, this is a
complete misunderstanding of what this stuff is about.

We had another individual that we had worked with for several years, a
very difficult case in several respects. This is an individual with
probably borderline mental functioning and a traumatic brain injury. We
worked very closely with a treatment program to get him into residential
treatment which he needed, and they agreed. They also agreed to work
with our case manager and have the case manager visit the program and
assist them.

Unfortunately, they didn\'t tell us when he was going into treatment,
and within three hours of entering treatment, they discharged him for
being noncompliant because he became agitated. He thought he had
forgotten his toothbrush. And literally all they would have had to do
was walk him over to his suitcase and that would have been taken care
of. They simply didn\'t understand his situation and we really tried to
get somebody there to help out, but in that case, it didn\'t work.

We had another individual with lower extremity paralysis who was denied
residential treatment because he would need assistance in transferring
from his bed at night, and they said, no, we can\'t provide that type of
assistance. And we said, okay, we will. We\'ll locate somebody to come
in. And the treatment program said, no, that would make us an ICF
facility and we\'re not certified at that level. We\'re not an
intermediate care facility. Then a policy was developed where apparently
this line of rationale could be used at any of the residential programs
in our county for a while. So it was an interesting challenge.

The other reason they denied this person is he could not do the
required, mandatory housework that was in the agency.

The interesting thing to me is we got a hold of New York State data.
OASAS has some of the most complete disability data within their
treatment system in the country. They also serve a lot of people. And we
took a look at some specific disabilities, most recently people who are
hearing impaired or deaf, and I expected to see lower completion rates.
We didn\'t. We saw equal or higher completion rates, in part because
people who are deaf and hard of hearing tend to be in that better
demographic of they\'re older and, in some respects, a little more
mature. But in any case, if we can get people into treatment from the
data that we have available now, they at least make it to the other end
and successfully graduate.

The concern that I have for people with disabilities is they need a
longer period of recovery and sustained sobriety support in order to
really make some of those jumps that they need to make.

SAMHSA has done several things in the past to really address this issue,
going all the way back to 1990. There have been issues forums,
trainings. A number of conferences have included the disability issue
over the years. Myself and a number of other people worked on TIP #29
which looks at substance use disorder treatment for people with physical
and cognitive disabilities. They have increased the verbiage in the
grant requirements and application procedures so that all applicants for
grant funding in SAMHSA have to address disability issues. And they
provided state technical assistance to a number of states. I\'ve been
involved in several in the MR/DD area, mental retardation/developmental
disability. There have also been some in the deafness area, and I
believe some for traumatic brain injury. In fact, there may be others as
well.

By the way, Ohio has just submitted a TA request to create a statewide
system for addressing the needs of people who are deaf, and we\'ve got a
convergence in Ohio now of some resources that I think will be pretty
exciting. We\'re going to use telerehabilitation as one of the ways that
we\'re going to address the needs of people who are deaf. So there are
some things happening that are pretty cool.

The other thing that\'s happening right now is there is an informal,
voluntary advisory committee, chaired by Ms. Neville. Ruby has done a
superb job of this, by the way. She\'s had a lot of experience in
working in SAMHSA and so I think she has a very good sense of what can
be accomplished in the short term and in the long term and the whole
process has been going quite well.

In terms of future directions that I would recommend for SAMHSA, we\'ve
already got a plan in place now to do a one-day training ‑‑ it probably
will be several hours ‑‑ for SAMHSA staff to address this issue. Many of
the people that we trained or provided information to in the past have
since moved on, and it\'s probably time to do that again.

The advisory committee has come up with a strategic plan and at this
point in time has not been considered by SAMHSA. It\'s simply offered as
a starting point. Again, I have copies in the back of the room for
observers and I have copies for the advisory committee. I am really
excited about this strategic plan. I think it\'s accomplishable. I think
it\'s comprehensive, and it addresses a number of issues that are most
important. So I would strongly encourage SAMHSA to consider and CSAT to
consider that.

One of the other things that is clear is when I was first funded by
NIDRR to look at substance abuse as a disability issue, they had an
intense debate internally about whether substance abuse was a legitimate
disability issue that NIDRR should be funding. In fact, they decided,
no, it shouldn\'t be. So I was funded for three years and then they
planned to send me away and I wasn\'t going to get any more funding.
Well, in three years, we generated data to show that their state-based
voc rehab programs are in a world of hurt because of this issue, and
we\'ve been funded for 15 years now and we\'re continuing to do work in
this area. So it is important.

But along the way, we\'ve discovered that it very much is a
multi-agency, interagency issue, and so I encourage CSAT, I encourage
SAMHSA to seek out partners in other federal agencies to address some of
these issues. In particular, I think NIDRR, the Administration for
Children and Families, and CDC are potentially good partners in that
area.

Going back to not enough advocacy within the disability community, I
think this needs to be a two-way street, and perhaps SAMHSA could do
some social marketing to the disability community and disability
advocates to generate a little more momentum on this.

Perhaps most important of all of these, as we go to GPRA, as we go to
accountability standards, as we go to effectiveness measures, we have to
have data, and right now the data systems within CSAT don\'t represent
people with disabilities to the degree that they could. In particular,
the TEDS data system, the Treatment Episodes Data Set, and also the
National Survey of Drug Use and Health could ask really just literally
two or three more questions and get a great deal of information about
people with disabilities and their substance use patterns.

Then, of course, as things are transitioning to state plans, anything
CSAT can do and SAMHSA can do to encourage state-level compliance with
this would, obviously, be a great benefit.

With that, I am done, and thank you very much.

(Applause.)

DR. CLARK: Thank you, Dr. Moore.

Council questions, discussion on this matter? Val?

MS. JACKSON: I just wanted to really thank you for that presentation.
Having been in this field for many, many years, I think it\'s something
that, for reasons that you pointed out, is very hard to get it into the
main stream. Having run a treatment organization for a number of years,
we did take in some people with impairments, and we attempted that. But
what you said about many of our people who are professionals who have
all the empathy and care in the world also just simply do not understand
or they feel like, no, I can\'t take care of that. It\'s impossible for
me to do that.

So I really appreciated your comments and wanted to thank you and hope
that we can find better ways because I agree with you that the incidence
is probably something like 1 in 6, if maybe not more, and something
needs to be done. So thank you.

DR. CLARK: Anita?

MS. BERTRAND: I have a question. Can you talk a little bit about why you
think over the next couple of years there will be an increase in the
number of individuals with hepatitis? I just know personally a lot of
people are beginning to say that they have it.

DR. MOORE: Sure. To begin with, I am not an expert on hepatitis, and I
am just learning this area myself. It\'s my understanding that the
increase in morbidity and mortality is actually related to people who
acquired the condition many decades ago, starting in the \'70s. And
what\'s happening is as they\'re aging, more and more people are
progressing to a chronic and acute condition which kills them.

We had a meeting in Dayton with a SAMHSA-funded project last week, and
the leading physician in Dayton who is an HIV specialist said my
patients don\'t die from HIV anymore. They die from hep C. And that\'s
what the projection is. The cost in human lives and in dollars in about
15 years will be greater from hepatitis C from people who already have
the condition now.

MR. DeCERCHIO: Dr. Moore, in terms of treatment approaches, your
recommendation for lesser intensity over longer duration really links to
what I think is one of the major barriers, and that\'s funding. And if
we start talking about residential programming and the examples that you
gave around the associated costs, I mean, it\'s a major barrier. But the
idea of doing more less intensive either in home settings or in
non-24-hour settings, more natural types of treatment, which is we\'ve
been trying to do with substance abuse treatment ‑‑ I mean, the
opportunity I think is there as opposed to building ‑‑ the physical
modifications I think are relatively minor and probably have been
overcome compared to the other types of modifications that you
referenced.

DR. MOORE: I agree.

MR. DeCERCHIO: It\'s a bad word to use, but accommodation, you know.

So could you speak to either models or what your observation is about
outpatients and/or in-home types of substance abuse services and less
reliance on cognitive approaches?

DR. MOORE: Okay. Agree, and I\'ll do it very quickly. I\'ll cover a lot
of ground very quickly.

Yes, we need to go to less intensity for treatment, outpatient as a
preferred modality.

Home-based treatment might be an alternative, but for many people with
disabilities, the nexus of the problem is the home. Other family members
are creating the problem or feeding the fire. So it would have to be
family-based treatment if it were done that way.

One of the issues that we need to address certainly in Ohio and probably
in other states is some kind of Medicaid waiver that will allow us to
bill slightly more than the standard Medicaid rate because our amount of
individual counseling and case management and other costly things is
greater than the treatment episode for someone without a disability. And
that\'s one of the things we need to look down the road toward. It\'s
somewhat difficult now because every state has their own standard for
that.

DR. CLARK: All right. Thank you, Dr. Moore. We need to move to our next
segment. That\'s the public comment. We have four individuals from the
public who have expressed a wish to comment. We\'d like to keep that to
no more than five minutes per person.

Pat Taylor from FAVOR?

MS. TAYLOR: Hi. I\'m Pat Taylor, the Executive Director of Faces and
Voices of Recovery.

Dr. Clark and council members, I really appreciate this opportunity to
talk with you for just a couple of minutes about the focus on a
recovery-oriented system of care. There\'s tremendous interest around
the country from local recovery community organizations, treatment
providers, and others, and we were very excited to receive from you, Dr.
Clark, the report from the 2005 Recovery Summit last month. What I\'d
like to talk with you about is how can we raise the profile and pull
together at CSAT and develop a stronger leadership role in terms of
thinking about developing a recovery-oriented system of care.

As I said, there\'s a lot of interest around the country and there a lot
of different things happening here at CSAT and also outside of the
agency. So in addition to the report from the Recovery Summit, there are
these regional meetings that were described in the report. These are
follow-up meetings to the Recovery Summit. We\'ve received phone calls
from recovery advocates around the country who are wondering about what
are these regional meetings about, how does that fit into developing a
recovery-oriented system of care, and how can I participate in these
kinds of regional meetings. So those are kind of two things that are
going on.

There\'s a great interest in having more of a recovery-oriented research
agenda. We had meetings about two years ago talking about the fact that
we don\'t know how many people are in long-term recovery in this
country. We don\'t know how they got there. We don\'t know what made it
possible for them to achieve long-term recovery and to sustain their
recovery and the barriers that they faced. We don\'t have the kind of
information that we really could use to make it possible for more people
to achieve long-term recovery.

And there\'s tremendous interest in the recovery community, among
recovery community organizations and faith-based organizations as well,
in providing peer recovery support services. Hundreds of organizations
have applied for seven or eight grants as part of the RCSP program. That
tremendous interest in peer recovery support services I think really
comes from the fact that there\'s a greater understanding that a
recovery-oriented system of care is more than treatment. It\'s making
treatment beyond treatment work and many people do get into recovery
without formal treatment and they need ongoing recovery support services
and other kinds of opportunities to sustain their recovery.

We have a situation right now where states are defining what peer
recovery support services are. Insurance companies now are defining what
peer recovery support services are. And there are real opportunities for
CSAT and SAMHSA to play a leadership role in terms of bringing together
this interest in this activity and this desire to develop a
recovery-oriented system of care and raising its profile at the national
level and also, likewise, engaging the public policy makers and others
in moving forward to develop a recovery-oriented system of care.

So we were recently contacted about a recovery definition that a
consensus panel has put together at the Betty Ford Institute about what
is recovery, defining recovery for research purposes. Those kinds of
activities are going on outside of SAMHSA and CSAT, and I think it
indicates that people are trying to get involved and get engaged in
making this recovery-oriented system of care work.

What I\'m here for and want to talk with you about is I think it\'s
really important for SAMHSA and CSAT to pull together all of the various
strands that are going on within the agency, but also bring in outside
folks and organizations to put together an action agenda of what SAMHSA
and CSAT want to see happen to make a recovery-oriented system of care
happen, who the people should be there to lay out what that agenda would
look like and then move forward and aggressively and proactively say we
are behind developing a recovery-oriented system of care. These are the
things that we know need to happen, and this is a time line that we as
an agency are going to follow to make sure that those activities are
carried out.

So I thank you very much for this opportunity. I know there\'s a lot
going on within the agency and within the general public, and we need to
pull that together, be very much more proactive in terms of getting that
message out.

DR. CLARK: Thank you, Pat.

The next person is Walter Ginter.

MR. GINTER: Hi. My name is Walter Ginter. I\'m Project Director of the
MARS Project in New York.

Like Pat, I\'d like to talk about recovery services for a long time, but
unfortunately I can\'t because that\'s not what I\'m here for. But I do
want to say I do agree with Pat, and as a FAVOR Board member ‑‑ FAVOR, I
want to repeat, is kind of an umbrella group for all of us in recovery
in the United States, a whole lot of organizations, and Pat speaks for
pretty much most of the recovery community. So we\'re all very much
concerned.

I know that she mentioned the Betty Ford definition of recovery. Well,
to those of us in medicated assisted recovery, that was actually an
offensive definition of recovery. So I think as Pat said, it\'s perhaps
time for CSAT and SAMHSA to step in and coordinate some of these things.

As I said, I\'d like to talk about recovery, especially medicated
assisted recovery, but unfortunately, I can\'t. That\'s not what I\'m
here for.

I\'m here to talk about the methadone-related mortalities. I\'m with the
National Alliance of Methadone Advocates. I\'m a methadone patient for
more than 25 years. What I wanted to say is that 4,000 deaths from
methadone is just a horrendous thing. As an OTP patient, my initial
inclination is always to say, yes, yes, it was the other guy. See, it
didn\'t come from us. But that\'s pointless. What difference does it
make where it comes. There are 4,000 people who are dead from the use of
a medication, when used correctly, shouldn\'t be hurting anybody.

We all know that opiate medications are dangerous. The issue is not a
control issue. It\'s an education issue. We put X numbers on
buprenorphine for treatment and we made the doctors get an X number
before they could prescribe buprenorphine. Perhaps methadone needs an X
number. Perhaps we need training of physicians before they can prescribe
methadone and giving them a number the way we did for buprenorphine.

This is a very powerful question. I think that we really need to handle
it as an education issue.

One other thing. Dr. Madrid made a statement before which kind of caught
my attention. He was mentioning dosage guidelines for people in
addiction treatment. As a methadone advocate, that always raised the
hair on the back of our necks because the next step from dosage
guidelines is dosing caps. And we know that a lot of doctors, when they
see guidelines, they read \"caps.\"

New York State a while back wanted to put into their regulations saying
that any dose over a certain level, that the doctor would notify the
agency. They didn\'t have to ask permission. They just had to notify the
agency. Well, within about five minutes, every doctor in the state said,
well, if New York State wants me to go over that amount, they wouldn\'t
have me notify them, so nobody went over that amount. And that\'s where
I\'m afraid dosing guidelines may go. So I think although dosing
guidelines might be important from a physician\'s standpoint, I\'d like
to make sure that it\'s presented very, very carefully.

I think that\'s all I really have to say, but I hope that the council
and CSAT will consider some kind of a training program for physicians
prescribing methadone for addiction and for pain. Thank you.

DR. CLARK: Thank you, Mr. Ginter.

The next public commenter is Martha Hottenstein.

MS. HOTTENSTEIN: Hello. My name is Marti Hottenstein. I\'m the founder
of the National Diversion Department for HARMD.

My son went in to try to receive help. He came to me in September. And I
don\'t want to stay on the issue of my son because this is more than my
son. He came to me in September and told me that he had a Percocet
addiction. The hospital wouldn\'t help him. He was assessed. They told
him ‑‑ he didn\'t get the help he needed.

On October 22nd, I went into my son\'s apartment. This is my child. And
I found him dead. I\'d like you to look at this picture. I found him
dead laying there, blood coming out of his mouth, purple. I couldn\'t
believe my eyes.

I got his toxicology report and he didn\'t receive the help, and this is
how I became a National Diversion person for HARMD specialist.

I mourned for about four months, and with not good intentions for myself
to get better, I laid around, and then I decided I would inform the
public about methadone. Then I started to do some research, and I got
involved with HARMD. I believe it was March that I found the National
Diversion Department. Without any marketing, only on our website, I\'ve
had 20 cases of diversion from clinics and from clinic deaths, 20 cases.
And I don\'t have any articles in newspapers.

I have a kid here who died. His name is Matt Conger. He died. I have a
picture of the liquid methadone bottle they found at the scene. They
closed the case. They sent this in. I\'d like to pass that around too.

I have another young boy from North Carolina, Aron Streppa. The father
knows who sold him the dose. He came from a clinic. I called North
Carolina and let them know just for protection because I know with the
federal regulations, when it comes to diversion and public safety we are
allowed to be involved. So nothing was done. He reported it to the
police. There\'s an eyewitness who saw this boy take some kid\'s liquid
take-home dose and the police have done nothing. His name is Aron
Streppa. He\'s dead.

I want to make it very, very clear. I am not anti-methadone. However, I
am anti-methadone deaths and I am anti-methadone abuse. I\'m not here
just to blame clinics. I know that I will be at other places, other than
clinic diversion. I will also be going to places for MMT and also giving
speeches to doctors. I just want to let you know that I don\'t want to
do the blame game. I want us to be aware this is happening. One death is
too many and thousands is outrageous. As a mother and as a citizen that
lost her child, I am not going to sit back. I\'m not going to go away.

I am for methadone. However, there are people who wait in line to get in
a clinic and if someone is abusing that and someone really wants
recovery and they can\'t get in that spot because someone else is
abusing it, that is not fair to the person who really wants to recover
and who doesn\'t want to abuse it.

I have one more issue I would like to bring up. We had an arrest. Matt
Schalck who sold six take-home doses in my town. He sold it to the
undercover police in Warminster three times. He was arrested. I have the
article right here. And I have a letter from a father who he sold his
methadone to. And also, they found him slumped over in a car, and if
they wouldn\'t have found him, he probably would have died.

We cannot turn our back on diversion from clinics. That\'s nonsense. But
we can\'t just say it\'s clinics. What I want is more education to the
doctors. I want public safety, and I want public safety and I want
safety for the patients.

I had a case that came into me last night. A boy went into the clinic.
He tested positive for cocaine. There was no opiates on the system. They
gave him the methadone. They didn\'t even wait for the results to come
back. He died in four days.

We have a serious problem. And I\'m sorry to address it this way.
Hardcore. But guess what. I can\'t go away. My son died and I stand here
today to be the voice of many children who died from this. I\'m finding
out a lot of young boys are dying, and I\'m really wondering if the
doctors from the methadone clinics really educated. Are the doctors out
there educated? Are the MMT doctors educated?

And Melissa has a case that came in. I just got the toxicology report,
which she\'ll share with you. But let me show you these documents of the
rest.

But what really gets me is as this boy is arrested for selling six
take-home doses, he is still welcomed into a Pennsylvania methadone
clinic, which I find outrageous. And that\'s the kind of regulation I
would like to see changed. I would like to see anyone abusing methadone
‑‑ obviously, if you\'re selling it, it\'s not working.

Thank you.

DR. CLARK: Thank you. I want to make it clear that the whole purpose of
public comment is to, indeed, get your input. So you don\'t have to
apologize for your thoughts on this matter. These are obviously very
important, particularly since SAMHSA does regulate opioid treatment
programs.

So the next speaker, I guess, is Melissa Zuppardi. Is that how I
pronounce your last name?

MS. ZUPPARDI: Yes. My name is Melissa Zuppardi.

I am the President of HARMD. We\'ve only been an organization ‑‑ it\'s
very new. We started in February. It\'s kind of accidental how it
happened. Just a bunch of parents, a bunch of family members, a bunch of
loved ones just started communicating with each other and saying, what
can we do? What can we do? We have pain patients dying. We have people
going to clinics, doing the right thing, trying to get help, and
they\'re dying.

I\'m actually going to read you two quick stories from two mothers.

My story is a little bit different. I know some of you already know my
story. My fiance went into treatment for a Percocet addiction. He went
into a detox center that was apparently not licensed to dispense
methadone for opiate addiction, and he died on his fourth day inpatient
in this facility. He had no opiates in his system when he checked in. He
was already starting to experience withdrawal from the Percocet, and he
started out on 60 milligrams of methadone, along with valium, Clonopin,
and Restoril. And he died in his sleep, was left for dead for about 10
hours while inpatient. He obviously wasn\'t monitored correctly.

That\'s what I want to address, more of the monitoring and the
assessment of these patients. Because they\'re seeing such an influx of
pain pill addicts coming into the facilities or into the clinics, I
don\'t know how much of a tolerance that they have to be able to
withstand the methadone doses or at least starting out on the 30
milligrams and being raised, many of them, within the fourth day,
double-dosed. A lot of them are coming in with other medications already
in their system, such as antidepressants and benzodiazepines.

This is one person\'s story. This is from Carla Moore. Her son, Justin
Harriage, developed a pain pill addiction in 2004 after his appendix
ruptured. He spent 10 days in the hospital and became addicted to the
Vicodin that he was given for the pain upon leaving.

He heard of a methadone clinic that would treat opiate addictions, and
being the trusting person he was, he entered the program. He advised
them that he had been on Zoloft. He went five days, during which time
they doubled his dosage. During the five days, he was nodding off during
the day, falling asleep at the wheel, and indicated he was not receiving
the proper amount.

On January 12th, 2005, he went and received his morning dose of
methadone. On the way home, he became very sleepy and briefly fell
asleep but woke back up, a danger of a lot of people on methadone.
She\'s mentioning the driving. He made it to our house and passed out.
Oh, he made it to their alley and passed out, ran into the neighbor\'s
fence, and woke up. With his car he ran into the fence. Woke up. Backed
up. Came into the house. He made a phone call and then laid down and
went to sleep. She returned home that night from a business trip around
9:00 p.m. and found him. That\'s one story.

I have another one here. This has to do with somebody requesting a
hardship clause to go to another clinic because he wanted to continue
using benzodiazepines, and the clinics in his state didn\'t allow that.
His mother is a registered nurse, and she says, I regret to say that I
was unaware of the danger and the lethal abilities of this drug. My son
died June 20th, 2006. My son was on vacation in South Carolina at the
time of his death. I spoke with the coroner, Tamara Wallard, and she
told me the amount of methadone that was in his possession should be
investigated. The cause of death was a drug-induced cardiac arrhythmia.

I requested his files and found that he and his friends had been
traveling to Rossville, Georgia so they could file exception or hardship
clause that would allow them six days of take-home medications. This was
my son\'s first time to register with a treatment center. His friends
had been going to Knoxville prior to this and discovered if they had a
prescription for Xanax in Georgia that they could legally take both
drugs. According to the lab work sent to me, my son was only clean one
month before he was allowed six days of take-home medications.

I had a lawyer review the medical files and she thought the clinic had
misrepresented Colt\'s case to the state in order to obtain a grant of
hardship clause. She stated in November of 2005, he continued to test
positive for benzoids. However, the clinic continued to file for an
exception clause to permit more take-home doses.

I spoke with Todd Rosendale from CSAT and he told me that he granted the
hardship clause due to travel and employment. The paperwork they
accepted for proof of residence was a light bill with a balance of over
\$1,000. They also accepted for proof of job status a copy of a personal
check for \$150. When I questioned Todd Rosendale about why they didn\'t
check the job status, he said this would deter employment. This
explanation was not acceptable to me. If you\'re going to allow people
to travel and grant hardships, you should be concerned about why you
granted this clause.

I was also told the counselor that was seeing my son was in training,
that he was seldom seen by a doctor. I called the clinic here in our
town and they informed me that many people travel to these clinics in
Georgia due to lenient practices.

Then she goes on to just discuss more about the clinic and different
things that go on at the clinics and how they\'ve been selling and
trading their methadone.

But I think what we need to look at is the people that are continuing to
abuse drugs while on the clinic are posing not only a danger to
themselves but they\'re posing a danger to the society as a whole when
they get into cars and drive away. I mean, we know that relapse is part
of addiction. We know that. But to give them a lethal drug mixed with
other drugs that they may be taking I think is irresponsible. These are
the things that we think that need to be changed within the clinic
system.

As Marti said, there\'s a lot of changes that need to be made with the
doctors, and I agree with the training. I think that they should have a
special license, just like they do with buprenorphine, in order to
prescribe methadone. But the clinics need to do better assessment,
regulations. They need to monitor their take-home doses. This is just
outrageous how many deaths I have directly attributed to clinics and
clinic diversion.

This is Eric Kramer. He died. He was a heroin addict. He\'s actually
only one of very few of my heroin addicts that have died from methadone.
He went to the clinic four days. He was started on methadone and his
dose was doubled within the four days. He had nothing ‑‑ nothing at all
‑‑ in his system, when we was found dead, besides methadone. So he was
taking it exactly as prescribed. He didn\'t abuse any other drugs. He
just was not monitored and assessed correctly.

I don\'t want to take up any more of your time, but I hope that
everybody can see some of these faces. If you want to see my website,
you\'ll see a whole lot more people. It\'s www.harmd.org. It\'s very
sad. About 50 percent of the people listed on the website and in our ‑‑
we have over 400 families right now, and we have some methadone
survivors as well, which I\'m really happy to say that we have
survivors. Some people have survived with brain damage, but they are
survivors. About 50 percent of the people were legally taking it and
taking it as prescribed that died. So I think that that needs to be
taken into consideration.

Thank you very much.

DR. CLARK: Thank you.

Comments by council members?

MR. DeCERCHIO: I just appreciate you all coming forward and sharing your
personal tragedies, if you will, as well as your advocacy in helping us
look at this issue.

DR. CLARK: Any other comments?

(No response.)

DR. CLARK: With that, again, I want to thank the public for being here.
Room is provided on the agenda to make sure that we have a wide range of
input.

It\'s time for us, at this point, to adjourn for lunch, and we will
break for lunch and resume the meeting at 1:30-ish. Thank you.

(Whereupon, at 12:34 p.m., the meeting was recessed for lunch, to
reconvene at 1:30 p.m.)

[AFTERNOON SESSION]{.underline} (2:08 p.m.)

DR. CLARK: I\'m going to have to excuse myself, and Rich Kopanda, my
deputy, is going to chair the meeting in my absence. We have a few
council members who are out.

I\'ve also been informed that Dr. DuPont is not going to be here.

So, Rich, it\'s all yours.

MR. KOPANDA: Good afternoon. For the SAMHSA employees, and particularly
the CSAT employees, I think we\'ve decided that in the future we\'re
going to submit waivers for having food in the building at council
meetings after today\'s experience. We do have this as a new option for
us.

I guess we\'d just like to go right into your presentation.

DR. SKIPPER: So I am Greg Skipper, and I do regret that, because we ran
over, Dr. DuPont had a 2:30 appointment, so he informed me he could not
stay. But I am delighted to have the chance, and I thank very much
Cynthia, Dr. Clark, Rich Kopanda, and others for giving me this chance.

I might say that this is an influential thing to do and that\'s why I
wanted to do it, is to get some information on the public record which
happens when you speak at these things. This is pre-publication data. It
will be published probably later this summer or early fall. It\'s
regarding a study that we\'ve done that I think contains some
information, and Dr. DuPont and Dr. McLellan, who were co-authors in the
study, believe could really be influential in improving outcomes for
addiction treatment.

Let me just tell you about this and we\'ll get through it pretty fast I
hope. What happened was I was approached by Dr. DuPont and Dr. McLellan.
DuPont is a former chief of NIDA and the first Drug Czar in the United
States. Tom McLellan is kind of the dean of addiction treatment outcome
research in Philadelphia at the Treatment Research Institute. And they
approached me because they were interested in studying physician health
programs.

Physicians have about the same rate of addiction and substance abuse as
the general population. At some point, they thought it was even higher
than the general public, but it\'s no lower.

Looking at physician treatment is a chance to see how good treatment can
be because you have an excellent population with a lot of resources, a
lot of caring about what happens, and so they felt like let\'s look at
this treatment for physicians and see what\'s in it, see if it\'s as
good as people say because there\'s really been no national study, and
then see if we can get out of it something useful for everybody, and
instead of just saying doctors do well because they\'re doctors, to see
if there\'s something in this process that can help all patients. And I
think we\'ve found an important thing that was right there probably.
Like many things that are important, they\'re kind of right there in
front of us, and we didn\'t think about it.

So I\'ll tell you the punch line at the beginning and then go through
this. The punch line is that what we\'ve discovered in looking at this
model and at this concept of contingency management that\'s already in
the addiction literature, we really think that that\'s what makes this
work. Contingency management has been done in little ways here and
there, and what it means is drug testing somebody following treatment
and reinforcing negative drug tests with a positive reinforcement and
having a negative consequence or a therapeutic consequence, if you will,
some kind of consequence for relapse, but doing this in a longitudinal
way. And there have been lots of studies under this concept of
contingency management ‑‑ I\'m going to call it CM for short ‑‑ which
have been very effective in children and with amphetamines, with
marijuana. There\'s lots of data.

But it\'s not caught on because it\'s really not been long-term, and the
types of reinforcements they\'ve used have been deposits to an account
that would build that they\'ll eventually get access to some money, or
I\'ll take that away if they have a positive. And that\'s really been
kind of hard for people to swallow, paying addicts for doing well.

Well, in this model, we\'ve got a long-term CM and we\'re using
employment, the right to continue to work in your profession as a
positive reinforcer and as a negative consequence ‑‑ and it really
isn\'t negative, but it\'s an appropriate consequence ‑‑ is further
evaluation, treatment, and possibly losing your profession.

So I\'m going to run through the data real quick.

Well, first of all, let me just run through this real quick. This is Tom
McLellan\'s little thing about the current state of addiction treatment
not for physicians but for everybody. And I don\'t know if you all have
seen some of his stuff, but it\'s pretty eye-opening.

There are over 13,000 addiction treatment programs in the U.S.A.
Thirty-one percent treat less than 200 patients per year. So there are a
lot of small ones, mostly government-funded.

Criminal justice has become the most common referral source to
treatment. It used to be other sources, families and other sources.
It\'s never been that hospitals and physicians have referred to
addiction treatment, a very low source for referrals.

It\'s shifted from mostly residential in the \'70s to mostly outpatient.
Methadone treatment has stayed pretty level, 9 percent up to 12 percent
over 30 years.

Mostly what people get in addiction treatment is group counseling, and
look at the bottom one. Nine percent of people get more than one drug
test throughout their treatment. Most people get a drug test when they
enter treatment and that\'s it.

There\'s a huge turnover in counselors in addiction treatment and
directors of programs. This couldn\'t be good.

There\'s very little actual physician input. Fifty-four percent of
programs had no physician involved. Thirty-four percent had a part-time.
Nurses were involved somewhat, social workers. Mainly it\'s counselors,
which is okay, but it would be nice to have more higher level
involvement.

And outcomes are bad. Fifty percent of patients drop out within a month,
and then 50 to 60 percent use drugs within six months.

What about private addiction treatment? Is it any better? The answer is
no. And they looked at people of \"means and prominence,\" people with
lots of money in some of these programs like Betty Ford and Hazelden.
They get more residential and they get more individual counseling. No
more urine tests, though. They get the same very few post-treatment
testing. And they have a 40 to 60 percent relapse rate in six months.

What about drug courts? They do better, and they all get drug testing.
They all get more than one drug test. And they still get the main other
types of treatment, group counseling. They have a higher retention and a
higher completion, but once they\'re out of the drug court system, they
do a have a higher rate of relapse.

So the reason to study doctor programs is to see how good it can get,
see what they do. Is it really that good?

And we did two phases. One was to see what physician health programs
are. What are these things? And we found that 48 states and the District
of Columbia have a physician health program. Two states, Nebraska and
North Dakota, do not have physician health programs. We surveyed all of
them and 41 participated. So we had a high rate of participation. We
wanted to see how they were organized and about their services in the
phase one.

This was a huge debate. It\'s like what are these things. They don\'t
provide treatment. What do they do? Well, what they do they have a hard
time describing and I run one of them, by the way, in Alabama, and I
have a hard time describing it. But really, it\'s sort of glorified EAP
work or case management, long-term case management, treatment
supervision. And I\'m going to make a strong plug for us to think about
whether that can be inputted into the public model. Could we have
somebody that oversees treatment long-term and does case management?

What they basically do is they try to get early detection, and then they
do interventions, and they refer to evaluation and treatment and they
oversee that process. And then they monitor people long-term. That\'s
really what they do.

They all have agreements with the licensing boards. They all have some
kind of agreement where the regulatory board that oversees the licensing
of doctors says, okay, you can do this and we support you.

Some have legal authority. Of those that have legal authority, most have
specific state laws that created the right of these programs to
intervene in these doctors\' lives. So the program says we want these
people to do well. We give you the right and we give you some immunity
from liability. And that\'s going to be important probably in the
long-term if we ever want to get this model going for the public, is to
have some kind of immunity for the people that do this work because if
you take away somebody\'s right to work, they could sue you. So as a
director of a program that oversees doctors, I have immunity as long as
I\'m operating in good faith trying to help the public basically.

Most of the programs are nonprofit foundations.

It costs about \$23 per licensee nationally per year to fund these
programs. So, again, thinking in a sense of trying to move this out of
just elite professionals, could we rebolster an EAP movement that gets
funding to do case management for work places? About half the people
addicted in this country are employed. Could we key off of that, and are
there other things we could do to form long-term case management
agencies that are funded to follow people long-term?

About 50 percent of the overall funding comes from the regulatory
boards, and then they charge the participants some fee, hospitals,
malpractice companies, other people that care about this person\'s
health.

I\'m going to skip over a couple of things here just because we don\'t
have time.

There\'s quite a bit of coercion that is involved in getting doctors
that have trouble into these things. About 31 percent are required.
They\'re mandated by some authority. Only 16 percent actually like come
forward and say I need help. It\'s amazing that it\'s that high. Then
there are sort of intermediate forms of coercion. You know, you either
go in or we\'re reporting you and stuff like that. So we tried to
measure that.

Alcohol is the main drug, as it is with the public, as far as causing
addiction. But unlike the public, opioids are second in a prominent way.
I think there\'s more stimulant abuse, marijuana abuse in the public
sector. But with doctors it\'s alcohol and opioids.

There\'s a pretty high rate of co-occurring psychiatric disorders. Over
a third have a diagnosis of psychiatric disorder.

I\'m just going to kind of zip through this a little bit. These are the
things that these programs want doctors to do. They use 12-step support
groups. Very few use agonist therapy. Very few use methadone. Fourteen
of 36 programs said they had at least one doctor, but when we contacted
them, it was usually a doctor that was unemployed and it was usually one
or two. And you\'ll see from the phase II, there are very few that
actually get methadone. So mostly it\'s abstinence therapy. All of them
get drug testing.

Again, I\'m going to kind of speed through here a little bit.

They\'re careful about selecting the evaluation and treatment programs.
They monitor how well what they do what they do, and they stop referring
to the ones that don\'t do well. So they really keep an eye on trying to
get good outcomes.

They do report to the licensing board if somebody really messes up and
is not safe or refuses to cooperate. Then they report them. Ninety-two
percent of programs had reported one doctor in the past year.

They mostly use urine for testing, though hair is gaining a little bit.
They\'re starting to use some hair testing for monitoring. And breath
and saliva are used to a more limited degree.

They use sophisticated panels. Instead of just doing a NIDA 5, they use
these more complex panels of looking at the benzos. You don\'t pick this
up on a NIDA 5. You get more expanded panels with the opioids and other
drugs that they use.

And they get a lot of drug tests. It\'s about every two weeks, and it\'s
shifting to month to month after a year or so.

They use EtG which monitors for alcohol use and every program requires
doctors to not drink. So unlike drug courts which say it\'s okay to
drink, just don\'t use cocaine, they really believe in abstinence as a
more complete form of ideology for that.

Phase II. We asked all these programs to do a chart review, and we had a
chart review instrument to complete. And we gave them \$20 per chart
review to try to get as many doctor charts sequentially as we could. So
we asked them to start five years ago, which was in 2001. We did this
last year. So we had them start looking at charts in 2001 and do no
skipping of charts, do consecutive charts going back in time because we
wanted at least five years of outcome data on these doctors.

We were able to get 16 programs scattered around the whole country to
participate, and we were able to get 908 charts. We had to exclude four
because they were out of sequence. They weren\'t consecutive, and we
wanted them to be consecutive so there wouldn\'t be any bias. We wanted
every chart in a row. So we had 904 charts reviewed.

There was underinvolvement with women. Twenty-five percent of women were
physicians in 2001, and only 14 percent of women were represented here.
So like the general public, women have less trouble from addiction
overall.

The average age was 44 years.

Here\'s an interesting one. Fourteen percent used IV and only 9 percent
of the general population, according to SAMHSA\'s data from 2001, used
IV.

And also the arrest history ‑‑ 17 percent had been arrested for a
drug-related incident, and the general population is 13 percent. And 9
percent had been convicted of a DUI or some kind of more significant
crime. So we\'re not talking about necessarily a milder form of
addiction in doctors. They have a serious form of addiction.

Certain specialties are overrepresented. Anesthesiology, emergency
medicine, psychiatry, family practice were overrepresented. Peds,
surgery, and pathology were underrepresented.

The most common source of referral was actually the regulatory board. So
if somebody would report a doctor for something ‑‑ you know, alcohol on
the breath was the most common thing, 22 percent, but other sources were
here seen.

A high percentage got residential treatment, 63 percent of this 904
doctors.

Only 1 doctor out of the 904 was on methadone. Naltrexone was used in 46
of the 904, and quite a few got antidepressants, 32 percent.

Now, there was a huge number of drug tests done. The average doctor got
83 drug tests. That\'s one every two weeks for five years. It actually
was a 7.2 year average follow-up because we started at 5 and went back.
And the rate of positives was only .26 percent of the 73,942 drug tests
on these 904 physicians. That is a very low positive rate. It\'s
definitely lower than the general public. The lowest group we could find
was the nuclear regulatory area, and they have a .31 percent positive
rate. And that\'s everybody. But his group of doctors, all of whom had
problems, had a very low positive rate. They get a lot of tests.
Twenty-two percent of them did relapse over the 7.2 years average.
Twenty-two percent was the rate of relapse.

These are things that they did, and AA was prominent. They required AA
in 92 percent of the cases. They required group attendance long-term and
other things, but nothing really stands out as real prominent except for
drug testing. A hundred percent got drug testing.

The relapse rate, like I said, was 22 percent. Six percent was in the
setting actually around patients, and the other 16 percent was like off
duty. And then that 15 percent at the top is when they stopped doing
things but didn\'t have a positive drug test. They stopped going to
their groups or they lied about going to AA or things like that. They
called that a certain level of relapse before there was even a positive
drug test, which I think is an interesting concept.

There were two suicides, five malpractice suits, and only one episode of
patient harm was reported. I don\'t have that on the slide right here,
but it will show up in a minute. Four percent lost their medical
license. So not a large number. But there were other actions taken,
suspension and so forth and so on.

So important points. Seventy-eight percent remained abstinent for an
average of 7.2 years. So a great outcome.

There was a single report of patient harm, which is pretty incredible to
me and suggests to me that the boards are very harsh with doctors, you
know, maybe rightfully so, but they act like this is a source of great
patient harm and it may not be in this day and age. I think people get
reported pretty early and they don\'t actually cause a lot of harm.
There may be harm from accidents. There\'s evidence that patients are
harmed by medical mistakes, but I\'m not sure they come from recovering
doctors or addicted doctors.

So the most significant services they provide are drug testing, 100
percent; supervised group therapy; AA attendance; and residential
treatment. So out of all that, it looks to me like the drug testing is
the unusual thing.

Rate of revocation of license was low. They didn\'t have a milder form
of addiction, and certain specialties had a higher rate. Alcohol was the
most common drug. Virtually all treatment was abstinence-based.

So the point of this and what we\'re thinking about is the good outcome
may be transferable if we can figure out a way to do it, and that is, to
do more long-term testing, do more long-term case management, treat this
like a chronic illness like diabetes where you want somebody to follow
that person long-term, and have some built-in contingency management. So
monitoring with the drug testing, support, and consequences may be the
key.

That\'s it. Any questions or comments?

MR. KOPANDA: Thank you, Dr. Skipper. Be sure to thank Dr. DuPont as
well.

Does the council have any questions?

DR. MORA: I have a quick question. You mentioned that there was a high
rate of co-occurring psychiatric disorders?

DR. SKIPPER: Yes.

DR. MORA: What were some of those?

DR. SKIPPER: The most common was major depression, and then it went all
the way through. There were two that were schizophrenic but that was due
to stimulant abuse at the time. Bipolar disorder was prominent, and ADD,
the things you would guess. And personality disorders. We counted those
too when they diagnosed them. Most common was narcissistic personality
disorder.

(Laughter.)

MR. DeCERCHIO: Do we know what the cost to treat was outside of the PHP?

DR. SKIPPER: Good question because the main cost of treatment was borne
by the doctors.

MR. DeCERCHIO: Right.

DR. SKIPPER: And it varied a lot because some went to outpatient, the
length of time was varied a lot, but when they went to residential, it
was high.

The cost for drug testing is not trivial either. They got an average of
7.2 years. Or this was 7.2 years of follow-up. Most people that were
diagnosed with chemical dependence got, I think it was, 4.1 years of
monitoring. It was average. And they got an average of one drug test
every two weeks. But the cost of that is not huge when you do it in
bulk. It was \$30 that was the average cost for a drug test. That\'s
every two weeks. That\'s \$60 a month, \$700 a year.

MR. DeCERCHIO: The other thing that\'s interesting is the scatter of
type of drug and referral. High alcohol is not inconsistent with the
public system but low stimulant is. So you got alcohol and opioids, both
central nervous depressives, and 32 percent being treated with
antidepressants. So there\'s some stuff going on there with physicians
who are not happy about their outlook on life.

DR. SKIPPER: That\'s right. And if they\'re self-medicating, they\'re
using the wrong drugs.

Judge?

JUDGE WHITE-FISH: How long was the average stay of treatment?

DR. SKIPPER: I don\'t have that right in my head actually, but I\'m
going to guess. We do have the data. For residential, it was like 63
days or something like that and for outpatient, it turned out to be more
like four months, and it reduced from like the intensive outpatient to
once a week, and we counted all that. We have data on both. So that was
the formal treatment.

But there was a question whether you call the rest of what they got as
treatment, which is required attendance at groups and almost five years
of drug testing and groups. So really that could be called treatment.
They didn\'t like to call it that. These programs don\'t like to see
what they do as treatment, but it probably is.

Yes.

MS. JACKSON: Well, I think there is a similar treatment for impaired
lawyers.

DR. SKIPPER: There is.

MS. JACKSON: And it would be very interesting to see the same kind of
outcome data on that because that is one transference certainly.

The other question that I would have then, though, is of course, each of
these professions, the medical profession ‑‑ and I don\'t know whether
you go below, say, nurses for somebody who has had at least four years
of college invested in their careers, that sort of thing. But generally
speaking, you\'re talking about somebody who has a high investment in
their life career. I\'d just like to hear your comments on the
transference because the key to me it really does seem to work, and I
personally have someone in my family who this has worked for and I\'m
very grateful for that. My question is in the general public ‑‑

DR. SKIPPER: How to transfer it.

MS. JACKSON: Yes. How does it transfer?

DR. SKIPPER: Well, I\'m optimistic that it could be transferred because
of the CM data that Nancy Petri and others have published where just \$5
deposited in an account for a negative drug test with the provision in
the contract with the person that they would test weekly ‑‑ and these
were mainly teenagers. So maybe it means more to them to have \$5, but
still, that\'s not a huge positive. And in the contract, if they had a
positive drug test, it would wipe out the whole account to zero, and
they\'d have to start over. It led to twice the success rate. Over 60
days is all they went during treatment.

But how much does it take and what can you use? Can you use employment?
Can you use issues around relationships and stuff? You know, you can
stay at home and live here if you do well, but otherwise you have to
move out. We know of things like that that matter. So could that be
formalized and followed and more people get drug tests? The question
remains can it work and what can you use as leverage. But I think it
would be good to look into what we can use and try to do this more.

Thanks very much.

MR. KOPANDA: Thank you. That was fascinating.

Our next presenter is Catherine Nolan from the Administration for
Children and Families. She\'s going to assess their new program,
Promoting Safe and Stable Families, the Partnership Grant Program.

Before you begin your presentation to the council, I want to thank you
and ACF on behalf of SAMHSA and CSAT for reaching out to us to
collaborate with you in the development and announcement of these
grants. We appreciate the opportunity to share our expertise on the
treatment of substance abuse disorders, particularly with regard to
enhancing treatment for families involved in the child welfare system
due to parental substance abuse. This cooperation and coordination at
the federal level models the kind of partnerships these grants seek to
promote at the state, local, and regional levels to improve services and
outcomes for children and families.

I also want to thank you for agreeing to increase to \$1.5 million your
contribution to the National Center on Substance Abuse and Child
Welfare, jointly funded by SAMHSA and ACF. This increased funding will
support critical technical assistance to these new grants and we are
extremely pleased to be able to partner with you in these efforts.

MS. NOLAN: Great. Thanks very much. I appreciate that.

Well, good afternoon, everyone, and thanks to Westley and to Sharon
Amatetti for inviting me to address you this afternoon. I was very
pleased to be able to take the invitation, and I appreciate what you
just said. Everything is right on target there. We have a long history
with SAMHSA and I\'ll go into that in a few minutes, but we\'re very
pleased with the collaboration and with the evolution of the
relationship over the years.

I\'m sure none of you know me, so I\'ll just take a couple minutes to
tell you who I am and why I\'m able to talk with you today. I\'m
Catherine Nolan, the Director of the Office on Child Abuse and Neglect,
which is a small office within the Children\'s Bureau in the
Administration on Children and Families within HHS.

The Children\'s Bureau has a wonderful history. We were first formed in
1913 and we were housed within the Department of Labor because the main
reason that the bureau was formed ‑‑ and my understanding from looking
at the Children\'s Bureau history is that it was a very, very
contentious and highly debated move as to whether or not we should have
a Children\'s Bureau within the federal government. But the advocates
won, and the initial areas of concern that the Children\'s Bureau
addressed, as you might guess, were child labor issues and adoption.

So over the years, the bureau has moved to the Department of Health and
Human Services, and today, when you look at the work that we do, we
really reflect the spectrum of child welfare services. We really have
the lead in this country on up-front prevention of child abuse and
neglect, the child protective services aspect, which is the immediate
sort of response to allegations of child abuse and neglect, and then
when children cannot be maintained safely in their home, sort of the
next step is placement in foster care, and the bulk of the budget that
we manage goes into foster care payments to the states. When children
cannot be safely reunited with their families and the parental rights
are terminated, the children are then placed in adoption. And so we have
a whole adoption assistance program. And then for the children who age
out of care, as a result of the work of Senator Chafee from Rhode Island
a few years back, we now have a very successful independent living
program, which is money that goes to the states to help support the kids
when they age out of foster care.

So basically my role is a very small role within the Children\'s Bureau,
which is managing the Office on Child Abuse and Neglect. And the main
areas that my office covers are the managing of the prevention programs.
We have the Children\'s Justice Act, which is \$17 million a year that
we get from Justice for systems improvement in child protective services
around reducing trauma to child victims of sexual abuse, improving the
rate of prosecution in child sexual abuse cases and improving the
handling of abuse-related fatalities.

We also are the focal point for the Department on issues of child abuse
and neglect. We have special initiatives. Under the our legislation,
under the CAPTA legislation, we\'re required to be the point of
collaboration and coordination across federal agencies relate to abuse
and neglect. So that\'s why this is a great opportunity today. I take
that responsibility very seriously, as does everyone in my office. So
this is a nice example of being able to carry that out today.

Then we have some technical assistance work that we do. We have a
National Center on Child Protective Services. We co-fund the National
Center on Substance Abuse and Child Welfare with SAMHSA. We have a
national conference on child abuse and neglect every two years, which
usually brings together about 2,000 people in the field,
multidisciplinary. We were just in Portland, Oregon the week of April
16th. We had a great week.

So those are some of the kinds of things that my office does.

But let me just get to what I really want to focus on today. And you\'ll
see the overview of my talk right here. I want to talk with you a little
bit about the Promoting Safe and Stable ‑‑ oh, I just noticed a typo
here. \"Sage\" is good, though.

(Laughter.)

MS. NOLAN: Safe and Stable Families Legislation. Are you familiar with
the Social Security Title IV, Subpart 2? That\'s what this is. But
anyway, I\'ll talk a little bit about the reauthorization and the
creation of this new program, the purpose of the grants, the development
and the content of the program announcement itself, and then the review
process.

So basically Title IV-B, Subpart 2, used to be called the Promoting Safe
and Stable Families Program. It was reauthorized at the end of September
2006, and named the Child and Family Services Improvement Act of 2006.

As you know, in the legislative process, whenever laws are reauthorized,
there are usually some changes that take place in the reauthorization.
In this instance, I would say there were several major changes. If you
look through the entire piece of legislation, there were some very major
changes.

The one, obviously, that we\'re focusing on today is section 437f. That
was the section that authorized the Secretary to make competitive grants
to regional partnerships to provide integration of programs and services
or to create new programs and services, all with the sort of end goal of
increasing the well-being of and to improve the permanency outcomes, and
enhance the safety of children who are either in out-of-home placement
or at risk of out-of-home placement because of their parent\'s or
caretaker\'s methamphetamine or other substance abuse.

Just for those of you who are not in the child welfare field,
\"permanency\" can be a strange word. Basically what it means is that
whenever children come into the child welfare system our goal is always
to get them back home as soon as we can, as long as it\'s safe. So the
notion of permanency refers to the philosophy that the Children\'s
Bureau has which is that every child deserves a permanent and safe home,
be that their natural family, a foster family, adoptive family,
relatives, whatever. But the notion around permanency is that every
child really deserves and has a right to a permanent home.

I don\'t know if any of you here have had a chance to actually look at
the legislation itself, but if you do, you\'ll see that it\'s very
prescriptive in some ways and broad in others. But it really lays out
what they mean by regional partnerships. It notes that the child welfare
agency must be a partner unless it\'s a tribal partnership, and then if
it\'s a tribal partnership, the child welfare agency does not have to be
involved, but there needs to be at least one non-tribal entity in a
tribal partnership.

And then the language outlines the authority of the grant awards. So,
for example, it specifies that for fiscal years 2007 to \'11, the grants
cannot be less than \$500,000 and not more than \$1 million per grant
per fiscal year. And it specifies the time period. The grants cannot be
less than two years or more than five fiscal years.

It lists the application requirements, use of funds. There\'s a matching
requirement that\'s very complicated. I don\'t know if any of you apply
for grants, but for those of you who do, generally speaking there\'s
just either no match requirement at all or a standard, stable match
requirement each year. Congress\' intent was to have communities that
get this money increase the amount of investment that they have in the
project over time, leading ultimately, hopefully, to community
sustainability. So there\'s an odd fiscal arrangement in terms of
decreasing funding over the five years and increasing match on the part
of the grantee.

The law also has very specific language around requiring that we create
performance indicators in consultation with the grantees and with our
partners around benchmarks that the projects can follow or use over time
to measure their progress toward their goals. There are specific
reporting requirements and then there are an initial report to Congress
on the prevention indicators themselves and then annual progress reports
to Congress.

So let\'s go back a little bit. What is the purpose of this grant
program? Basically the idea behind the grant program is that we give
funds to assist regions in building their capacity to address the issues
related to the outcomes, permanency, safety, and well-being of kids
because of their parental substance abuse, methamphetamine use.

So what happened was this law was passed at the end of September.
October 10th, we convened a working group. I basically just sent out an
email to our colleagues in the Children\'s Bureau and partners in ASPE,
our Office of Policy, Research, and Evaluation, SAMHSA, a few other
folks, and just said we have this new grant program that we have to
develop. Any of you who are interested, come and join us. And it was
fabulous. We got a great response, and we had about 30 people from all
of those agencies working together on actually walking through the
legislation and really trying to analyze it well and respond well to all
the requirements that were laid out in the legislation. As I say, we
literally immediately, within 10 days, had engaged our partners in the
beginning of this process.

I mentioned in my opening remarks that we have a long history with
SAMHSA. On this slide, you\'ll see what are some of the activities that
we\'ve been involved in over the years.

This first began with the passage of ASFA in 1997. There was a
requirement that the Department submit a report to Congress on barriers
to collaboration across the child welfare system and the substance abuse
treatment system. So I was relatively new to the Department at that
time. So I was assigned to work on this project with some of our other
colleagues. And the end result was that working with folks from CSAT and
from the SAMHSA Office of the Administrator at that time and from ASPE,
we developed this report to Congress. It went through a lot of
iterations, and we had a lot of consultation and focus groups, but we
were very pleased with the ultimate result.

What we laid out was five basic areas, five areas of recommendations,
and under each recommendation what would the federal responsibility be,
what would the state responsibility be, and what would the local
responsibility be. At the federal level, we gave ourselves a number of
tasks, and I\'m happy to say 10 years later that we\'ve actually done
pretty well on carrying out the tasks that we assigned to ourselves.

So one of them was convening regional teams, multidisciplinary teams, to
talk more fully about this report and to really get the communication
going in the different states across the agencies. So we spent about two
years doing that with SAMHSA.

Then one of the issues that really became very clear was that we really
needed to have a standing sort of technical assistance provider around
child welfare and substance abuse issues. So really, I\'d say thanks to
Sharon really pushing for this and some of the folks on my staff and
myself, but really Sharon was our leader, I think, in this. We were able
to create the National Center on Substance Abuse and Child Welfare. We
have co-funded that for five years now, and we\'re in the process of
recompeting for another five years. We\'ve been very fortunate with the
organization that won the competition. They\'ve been doing a fabulous
job and hard, hard work with the states on trying to improve this
collaboration across the systems.

In the Children\'s Bureau, we have the child welfare waiver
demonstrations, and some of those do include looking at this whole issue
of substance abuse and child welfare since there is such a connection
there.

Last May we had a conference jointly sponsored on the impact of meth on
children in the child welfare system that was very well received. So you
see that we\'ve really kind of been working together on a number of
exciting activities over the years.

Sharon and I were just talking and kind of reminiscing about some of
this, but we think part of why we\'ve been able to maintain the
continuity is that several of us who worked on the initial report are
still in our same positions. So we have those relationships. We\'ve
brought different people on at different times, and certainly my staff
has been very involved in this work. But it\'s nice to see the
continuity.

Just to give you the details on the development of the program
announcement itself, we formed the work group in October. As I say, we
really looked at it very carefully. We realized that because of the
requirements to have performance indicators and because of the unusual
funding structure in the law, that we really needed to develop some
subgroups to really look at that a lot more intensely. So we did that.
We had two subgroups, and they were fabulous.

We had one woman, the Assistant Secretary for Planning and Evaluation.
She was great on really helping us with the performance indicators and
the conceptual framework. I don\'t know if you see on the last page of
your handout with the slides, the very last page is the conceptual
framework that the group developed to help lead our thinking on the
actual development of the indicators, but also to really help the
applicants. We included this in the program announcement so that the
applicants could have a start, you know, maybe have this jump start
their thinking about how they might want to go about developing some
kind of a program with this money.

And also the funding structure. We had another woman who volunteered
from ASRT, and she was fabulous in terms of helping us to really look at
different funding scenarios. Again, because the money is so odd, the
amount of money in the first year that we have available to give out is
\$40 million, and then the next year it goes down to \$35 million, and
then \$30 million, \$25 million, \$20 million. So we start out with \$40
million and by the end we only have \$20 million. So for any of you who
give out money, it\'s very tricky to figure out how to do that equitably
over time. This woman Sara was wonderful with helping us with that.

So at any rate, the subgroups did their work. I had an emerging leader
on my staff at that time, Miguel Vieyra, who was a great writer, and he
was wonderful with taking all the different pieces that people had
written and really putting that together in one document for us. Then we
had lots of discussion and debate and review and had several iterations.

Then finally, when we felt we had a really good product, we briefed our
Children\'s Bureau leadership and then we did submit a final draft for
clearance December 8th, 2007. So we were pretty pleased with ourselves
that in eight weeks\' time, with the help of 30 people, we could create
this document and submit it into clearance.

Now, again, for those of you who are familiar with federal clearance,
that\'s a whole other animal, and that took four months unfortunately.
But we did finally have the announcement published on Grants.gov May 4th
of 2007.

So I don\'t know if any of you have had a chance to actually look at the
program announcement, but if you do, you\'ll see that the key components
include, number one, that the applications must represent a regional
partnership formed by a collaborative agreement, and the application
must have demonstrated documentation of either the existence of a
partnership or the new creation or development of a partnership. The
legislation calls the regional partnership a collaborative agreement
entered into by at least two of the regional partnership organizations.

If you look both in the law and on the program announcement, there\'s a
laundry list of who the potential partners can be. And then, as I said
earlier, they must have the child welfare agency involved if they\'re
non-tribal, and if they are a tribal application, they must have at
least one non-tribal entity.

One of the entities listed in that laundry list is the state substance
abuse prevention and treatment block grant agency, but the law says that
the partnership cannot be just the state child welfare agency and the
state substance abuse agency. There\'s got to be at least one other
partner.

So the regional partnership must designate a lead agency, and the law
and the program announcement both talk about what the capacity of the
lead agency must be. And that\'s got to be demonstrated in the
application.

Then, as I say, we had the unique funding structure, and basically after
all that debate that we had in our subgroup, we came up with four
program options with two possible federal award amounts and two possible
grant periods. So what we say in the announcement is that the
partnership must select one program option. One partnership can only
apply for one program option, and then they must select the option and
then justify their selection in terms of accomplishing their project
goals.

So what it looks like is this. We have, as I say, the money declining
over time. The million dollar awards decline in the outyears, and the
\$500,000 awards remain fixed. As I said earlier, all the awards have an
increase in match over time.

So if you look here ‑‑ and this is all in the program announcement ‑‑
for Program Option 1, that\'s a \$1 million annual award for three years
declining over time. So it\'s \$1 million in the first year, \$825,000
in the second, \$750,000 in the third. You see on the chart there the
increase of the grantee match: 15 percent in year 1, 15 percent in year
2, 20 percent in year 3. Again, that comes right out of the legislation.
Then we anticipate funding up to eight awards under Program Option 1.

Under 2, again, it\'s the million declining over time, the increasing
match right from the legislation, and then we anticipate funding up to
five \$1 million awards for the five-year time period.

Just to tell you, again, there was a lot of discussion about this, and
the group finally came to consensus that even though the law said the
grant awards could be from two to five years, the group really felt that
two years was too short of a time period. By the time you actually get
the money, you get up and running, and then you only have one year. How
much could you really accomplish? So we made the group decision that we
would have it be either a three-year time period for the grant or five
years.

So then you go to Program Option 3, and this is the \$500,000 annual
award, and it\'s \$500,000 each year, but again with that increasing
match.

And then Program Option 4, is the \$500,000 for a year for five years.

There\'s another section in the law which we then really kind of
explicated in the program announcement which talks about use of funds.
So what are the various activities that a grant could propose? So
basically what we tried to explain in the program announcement is that
it\'s really up to the regional partnership, number one, to define what
is their need in their region and then what approach would they propose
to address that need. So we say they can choose to test a broad-based
approach to substance abuse treatment and child welfare collaboration or
focus their efforts on a point along the continuum of care from
prevention to treatment to aftercare services. And you\'ll see that on
pages 6 to 10.

We talked a lot in the working group about really wanting to support
evidence-based practices. You know, we always talk about what works,
what\'s effective, and at the federal level, we always get nervous about
saying what\'s effective because you really want to have something to
stand on if you\'re going to make that statement.

So we had a lot of discussion and Sharon was particularly helpful here
in terms of looking at what is the evidence that we do have about
approaches that at this point in time, to the best of our knowledge, are
effective in terms of both practice and intervention. So you\'ll see
here some of the things that we proposed. Again, this is not exclusive.
Grantees who are applying don\'t have to select from this list, but we
were trying to give them as much information as possible to say we would
really like you to suggest an approach that has some grounding in an
evidence base.

So we talk about systems collaboration and improvements. Again, if you
look at your conceptual framework, you\'ll see these headings in your
conceptual framework. Systems collaboration and improvements, for
example, support for comprehensive training across disciplines; support
for family drug courts. Treatment linkages: support for co-location of
staff. Services for children and youth, such as the DEC or
substance-exposed newborns to enhance identification and intervention
with infants identified as substance-exposed at birth. Substance abuse
treatment services: support for long-term residential treatment programs
where children may reside with their mothers and services are provided
for all family members. Other services for parents: continuing care and
recovery support; parenting skills training and other ancillary
services. So you see that there\'s a real broad range here of potential
uses of the funds.

Again, I think the idea was that we hope we conveyed in the program
announcement that the regional partnership really take a look at their
targeted region, whatever that may be. It\'s up to them to define it. It
could be a county. It could be a series of neighborhoods in an area. The
language calls for inter- or intrastate. So the thinking was in some of
the rural states, the contiguous four states, there may be a rural sort
of four-county area, something like that. But the point was to really
tell us what your region is and tell us what is the demonstrated need in
that area and then what is the approach that you are going to propose to
address that need.

So in the working group, for example, there was discussion about an area
may have services but they\'re having a hard time getting people engaged
in those services, and they don\'t have a family drug court. So they
might propose to create a family drug court to help with that engagement
and retention in the treatment services that do exist. Another area may
not have any services at all and they really need to create some
services, and so on. So you get the drift here. The idea was for the
applicants to really tell us this is what we need in our area and this
is what we want to use the money for, and again, with the goal of
improving the rate of parents recovering from substance and meth use and
reducing the rate of children having to go into child welfare as a
result of their parents\' drug abuse.

I mentioned earlier this whole requirement about the performance
indicators. Congress told us very clearly that they wanted data to
support the expenditure of these funds. They wanted to hear from us in a
quantitative way what is the progress that these grants are making
because of the investment that we\'ve made on our end. So there\'s the
statutory requirement to develop the performance indicators.

As I say, we did have a subcommittee on that and we looked at the
current data collection efforts of SAMHSA and the Children\'s Bureau
because all of the federal agencies are now involved in the PART process
in some way or another, which is the federal government\'s looking at
our data and support for the outcomes of our programs.

Sharon, what\'s the name of the data collection system that you have for
the Family and Children\'s ‑‑

MS. AMATETTI: The SAIS system that we\'re using for our discretionary
portfolio.

MS. NOLAN: Right. So we looked at the SAIS system very closely. We have
a very, very limited data collection system for our discretionary grants
within the Children\'s Bureau. It\'s just been created recently and
it\'s pretty straightforward. It\'s nowhere near as sophisticated as the
SAMHSA system.

And then we looked at other data collection systems that we have. We
have an NCAN ‑‑ you know, the National Child Abuse and Neglect ‑‑ data
system. We have the AFCAR system. So we basically looked at all the
existing data collection systems and kind of came up with some of the
things that you see in the conceptual framework, and also if you look at
the announcement, you\'ll see the various performance indicators that we
suggested that they might use as a starting point.

There was another requirement in the law that talked about consultation
with grantees. Again, it was one of these odd things. We\'re not
awarding the grants until ‑‑ the final award will be made no later than
September 30th. So we couldn\'t have a consultation within nine months
of the legislation, which was what the language was, without having any
grantees.

So the way we decided to respond to that nine-month requirement was that
in the announcement, we have this whole section on the performance
indicators and we explain the statutory requirement for consultation.
And we asked them in their application back to us to look at those
performance indicators that we\'ve suggested, select the ones that they
think are most relevant to what they\'re proposing and comment on those.
And then if there are any indicators that aren\'t there that they would
like to suggest, to include that. If there are any that they feel are
not relevant ‑‑ so whatever commentary they may have on what we\'ve
proposed we\'re asking them to include in their application back to us.
So that\'s the proxy for consultation in this case. So you see there
what we asked them to do.

I want to say again it was very helpful to have the input from the
SAMHSA staff and particularly to walk us through your data collection
system to help us think about the indicators that we wouldn\'t be as
familiar with.

So you see here the categories include child and youth outcomes, adult
outcomes, family relationship outcomes, regional partnership/service
capacity outcomes because, again, if you look at this, there are sort of
two key components in the law. There\'s a piece that talks about
treatment and substance abuse treatment services, but then there\'s this
whole other piece that really has much more to do with sort of
infrastructure building and really improving that relationship across
the various disciplines in that regional partnership.

In the Children\'s Bureau for the last several years, we\'ve required
our discretionary grantees to have an evaluation component. So in this
instance what we have said is that we encourage the partnerships to have
a local evaluator not only to assist in their own evaluation of their
own program, but also to really help with this work on the selection of
the performance indicators.

Congress also had an idea that ‑‑ or not an idea ‑‑ a requirement in the
law that greater weight should be given to those applications that have
the most sort of demonstrated need and problem in this whole area of
parental meth use. So, again, looking at the program announcement on
page 42, what we say is, under objectives and need for assistance,
identify and describe the impact of meth use and addiction on child
welfare within your targeted region and then propose grant-funded
services and activities that appropriately address meth use and
addiction in the geographic area and the population targeted.

Again, we got a lot of questions on this, but the idea was that the
bonus points really were directed at the meth. In other words, you
couldn\'t just come in saying, well, we don\'t have a meth problem, but
we have an other substance abuse problem. You won\'t get the bonus
points if you don\'t have the meth. It can be meth and other substance
abuse, but the meth piece has to be there for that 5-point bonus.

So where are we right now? We had a technical assistance webinar. This
was a first for us in the Children\'s Bureau. We had a very successful
webinar on May 22nd. I was told by the webmaster that we had 400 lines.
So we\'re assuming we had over 1,000 people because most people were
telling us that their teams would be in on the webinar. So we were very
pleased about that. We got about 165 questions during the webinar, and
we\'ve had many, many calls and emails every day since. So we\'ve been
providing lots of technical assistance to all of the potential
applicants.

The due date is July 3rd. They must be received by 4:30 that day. Any
that come in after that time will be classified as late, and they\'ll be
screened out, which means they will not be reviewed.

Our system of reviewing within the Children\'s Bureau is that we recruit
experts and we ask them to come in for a week. We sequester them in a
hotel for a week, and each panel three panelists and one chair are
assigned 10 applications to review and score. So that will be happening
here the week of July 30th. Again, we\'re grateful to SAMHSA for
supplying us with a list of your approved reviewers. Our goal is to have
one SAMHSA reviewer and one CB reviewer on each panel and then a third
person who could be from wherever. The selection of the panelists is
very intense. We look at their resumes, and we only select those folks
to be invited who have the appropriate expertise.

So all the applications will be reviewed and scored that week, and then
we have a decision meeting with our ACYF Commissioner, Joan Ohl, in
August, hopefully the second week in August. And then she makes the
final decisions based on the scores, and then the final grant award
letters go out to the successful applicants no later than September
30th, the last day of the fiscal year.

Also, I think this is true across all of HHS, but we have a procedure
whereby the final decisions are made. All of that paperwork then goes to
our grants management office, and they actually do the award letter and
all of the technical stuff around the funding and how you draw down your
funds and so on.

While that\'s all happening, the Congressional Liaison Office of HHS is
also notified of all the successful applicants. So that office notifies
the various members of Congress whose constituents have won. I think we
give them three days to do whatever they want to do with that
information, and then we can, as the Children\'s Bureau, publicly
announce who the successful applicants are.

So it\'s always a very stressful summer, and this is going to be no
exception. The applicants work very, very hard, especially this one.
This is a complicated announcement. They\'re very anxious to know what
the results are. Again, as I say, it\'s a little frustrating for them
because we really can\'t give them any information until the
congressional offices have done their thing. So usually by the middle
but, again, as I say, no later than September 30th, they\'ll have their
letters.

So this last slide is just for you. The announcement itself is available
at this website. If you haven\'t had a chance to look at it, you may
want to.

Then, again, this was very exciting for us this year. It\'s the first
time we were able to do this. After the webinar, we were able to post
the transcript of the presentation, all the slides, the transcript of
the Q&As. We didn\'t have time to answer about 60 questions, and so we
just developed written answers and posted those. So all of that is on
the website you see there. And it\'s been great, when we\'ve gotten
calls, just to be able to say to folks I\'m going to send you the link.
Go on the link. There it is. So this is probably the most massive
technical assistance certainly my office has ever done for a grant
announcement.

So that\'s where we are. Any questions or comments?

MR. KOPANDA: Thank you very much, Catherine.

I\'d just like to note that I failed to mention earlier Sharon Amatetti.
Many of you might not know Sharon. She works in our policy office, and
she works very closely on a variety of issues with ACF. She\'s been
instrumental in helping us get involved in this new program.

MS. JACKSON: Thank you very much, Catherine.

I wanted to say, as a person who has been involved with treating
families and women with children over a number of years, that of course,
SAMHSA has been very active in getting that going, and if it weren\'t
for SAMHSA ‑‑ in fact, CSAT ‑‑ we wouldn\'t have women with children\'s
treatment in this country. So I give lots of credit to SAMHSA.

But I think just listening to you ‑‑ and also, I have read the program
and the announcement, and I found that it really does stretch across a
bridge that is very badly needed in this country of trying to work out
the differences. I wanted to note particularly ‑‑ and I don\'t know if
you want to make a comment on it or not, but the difference in
perceptions between those people who work in child welfare and obviously
look at the safety side of things and then those of us who are over on
the substance abuse side ‑‑ and while we certainly care about the safety
of the family and the children, we do believe addiction is a disease,
and once it gets treated, we can rehabilitate families very well. So I
want to thank you for that bridge.

I\'m hoping that, while I saw the complicated ‑‑ and you\'ve explained
the money thing. That was good. I hope that we can go forward with that.

And I just wanted to see if you had any comments on how you see your
agency continuing to try and work on that bridge with SAMHSA. Does your
joint committee, for instance, cease with the funding or will you
continue on? How will you continue to address this issue?

MS. NOLAN: That\'s a great question.

The work group that I described was really convened very specifically to
help us write the program announcement and then to help us with some of
the launching of the program in terms of getting the reviewers.

We haven\'t gotten this far yet, but I\'m sure that in terms of ‑‑ once
we launch a grant program and we actually have a group of grantees ‑‑
and in this instance, we\'re looking at probably about 55 grantees. We
sort of try to create a community around them. So we call them a grant
cluster. We bring them together. The first year we\'re actually going to
bring them together three times because we\'ll have a kickoff meeting to
do the final selection of the performance indicators with them and with
our contractors, and some of the work group members will be involved in
that. Then we\'ll have a second meeting which will be their first annual
grantees meeting, and then we\'ll have a third meeting, which will be
more of a subject matter-oriented meeting.

We have a plan anyway. I hope it works, but we have a plan that over the
next five years, there will be two meetings every year. The traditional
sort of grantee meeting, which usually focuses on a wide range of
things, both subject matter and more technical grant-related, but then
our plan for this group is to also have a second meeting per year that
is just strictly subject matter-oriented. So it might be two days really
focusing on the collaboration. That\'s huge.

What you just described ‑‑ I mean, we really dove into that in the
report to Congress in 1999, and we had some stakeholder meetings. And
I\'ll tell you there were fireworks in those early meetings. People just
did not get along.

I have to say ‑‑ I don\'t know if Sharon would agree with this. Westley,
you\'ve been to all those meetings. I want to say having Dr. Clark also
here following us for the 10 years, there\'s something to be said about
having that stability in personnel.

But I think we started that in a real formal way 10 years ago to really
say you can just bring people together. I remember we had four regional
meetings for that one time period, and at the end of each one, we had
this little routine ‑‑ it was kind of fun ‑‑ where we\'d go around. We
had the states all sitting together in teams at their tables. The last
question of every meeting was where do you think you are now and what
are your plans for when you go home because the whole point was this
team-building thing. We\'re bringing you together because we want you to
meet each other and we want you to do something with all this material
and talking we\'re doing for the two days.

And it was amazing the number of tables that would say, well, when I got
here, I didn\'t know anybody at my table, and now I find out that she
works just one floor up from me and he works down the hall from me and
we already have a lunch date planned for next Wednesday. And that
happened over and over again. There were some who said, oh, yes, we\'ve
been working together. Some of the states had already taken this on and
were already advanced with it, but that was a neat example of really one
thing the federal government can do is convene. And we do that pretty
well I think.

So we\'ll continue that. We\'ll continue the convening. The requirement
in the program announcement is that the meetings must be attended by the
program director, the evaluator, and then whoever they perceive as the
key partners in the partnership. So that will be going on for the next
five years.

We have our National Center on Substance Abuse and Child Welfare, and
that\'s all they do. So at least for the next five years, these will be
the things that we\'ll be doing. Beyond that, I have no idea. I have
ideas, but there\'s not anything carved in stone after the next five
years.

DR. MADRID: One question. First of all, I wanted to congratulate you for
a very needed type of RFP.

Your funding options were most interesting. Three years is very, very
fast. They type of graduation, insofar as matching, is also very
interesting.

You mentioned in your funding options Title IV-B and Title IV-E. Here at
CSAT, with the direction of some of the staff, including Linda
White-Young, we\'ve been talking about sustainability on day one. So
what I wanted to hear about this particular RFP, since you\'re working
with Title IV-B and Title IV-E, how are you planning on tying in with
the Medicaid situation since children are going to be involved, as it
relates to sustainability?

MS. NOLAN: I\'m not sure what you mean when you say we\'re tied in with
IV-B and IV-E. This whole program is a new section. It\'s section 437(f)
of the latest reauthorization of Title IV-B, Part 2. The only
relationship with IV-E is that IV-E is what pays for foster care. The
idea behind this program is that if we make investments in communities
and they improve all their connections and relationships in substance
abuse treatment, that it will help reduce the number of kids going into
care. So that\'s the only connection with IV-E per se, and then for
IV-B, this is a new program under IV-B.

DR. MADRID: How can we, for example, as providers take advantage of
Medicaid dollars to do sustainability on day one with some of these
children? I guess that\'s my question.

MS. NOLAN: It\'s a good one and it came up a lot in our discussions in
terms of the development of the program. And a lot of the people
calling, the potential applicants, have asked if they can use the
Medicaid as a match, which they can\'t because the match has to be
non-federal dollars.

This whole issue also came up in our regional meetings when we had the
regional stakeholder meetings. In fact, we had Medicaid representatives
at all of the meetings.

I don\'t know that I have a specific answer to your question other than
to say it\'s a real good one. Medicaid is so complicated because it\'s
state by state. So I think that it\'s a great question and it would be a
good one for us to consider in our discussions of when we bring our
grantees together. I don\'t know if that\'s helpful or not. It\'s kind
of a wishy-washy answer.

DR. CLARK: Well, thank you. It was great to hear from Catherine.

We\'re down to the final stretch of this meeting. Our last two
presenters are Ivette Torres, Associate Director of the Office of
Consumer Affairs, and Shannon Taitt, Coordinator, Partners for Recovery.
They will each provide an update on their programs and activities.

So that we may remain on schedule, we did not set aside time for council
discussion following their presentations. However, if you have questions
or comments for Ivette or Shannon, you may raise them during the
roundtable which follows their presentations.

Ivette?

MS. TORRES: Good afternoon. First, before I start, I really want to
think the council because I was not here during the last council
meeting, and I heard some of you were really terrific in defending
Recovery Month. So I applaud you for that, and I am very appreciative.

Many of you know the Recovery Month goals, but for those of you who
don\'t, it\'s to support the demand reduction goals; build momentum for
holding state events, regional events, national events that basically
assist individuals in recovery; take the message home that addiction
treatment works, that recovery is possible; and that we need money to do
that.

This is a presentation that I use for the ELT. So I\'m going to go very
quickly through it. You may get to see some of the stuff and some of the
stuff I\'m just going to go really quickly through because we are,
indeed, short of time.

I want to just show you this. Very important. Recovery Month. From the
year 2002, we spent roughly \$1.7 million, and we\'re now spending about
\$2 million. The \$2 million covers the kit, the commemorative posters,
and all of the materials, as well as the public service announcements,
which is our PSAs and our webcast, the multi-media materials, as well as
the meeting logistics. So I would say it\'s a relatively inexpensive
package given the exposure that we get for not only SAMHSA but for the
issue that we\'re helping to publicize.

Speaking of the series, we did nine shows, and I want to say ‑‑ Melody
Heaps is not here, but she just finished doing our justice show and it
will be aired in August. Or is it July? I think it maybe is July because
I have it in my computer to view the final version. She did a fantastic
job. So I am saying that to encourage all of you to want to be on the
show, and if we invite you as a panel, we will cover your travel.

What I\'m going to do is ‑‑ we\'re having a meeting next week and we\'re
meeting with the contractors ‑‑ I\'m going to get the topics. One of the
topics I think that necessarily has to be in there is that whole issue
of the recovery continuity systems of care. We will do one on that
because I know, Chilo, you were mentioning that you had a keen interest
in that and pushing that through anyway we could through our materials
and efforts. So we\'re going to be doing one like that.

So I want you to think about it. If you have ideas for a show, also give
them to Cynthia or George, and Cynthia or George will make sure to get
it to us. It\'s a very fluid process. So think about being on the show.

The number of stations airing. We\'re up to about 349. The impressive
point is that we\'re in 27 percent of U.S. households. When you think
about what it costs other people to even get a fraction of that in terms
of exposure, I think we\'re doing darned good. What does that translate
into? It\'s roughly 14.4 million or 14.7 million households, generating
free air time of more than \$8 million, roughly, a year. Those were the
topics for this year, which we\'ve already seen the promo.

Recovery Month events. We\'re hosting around 54 events this year. We\'re
trying to go on a state basis so that we\'re no longer encouraging
people or funding a city and saying, okay, so do it in your greater
metro area. What we\'re doing is trying very hard to work with the SSAs.
That came up as an issue not only that we have been trying for a long
time to get them engaged, but as the funding continues, hopefully not to
decrease ‑‑ but we\'re not looking at a very expandable budget. So we
really do have to get those states to begin to spend some of their
dollars related to Recovery Month and for local communities and
coalitions to begin to tap private sources and to get other resources to
assist in the observance of Recovery Month.

So for this year, we\'re going to have a Fun Walk here at SAMHSA. We had
a very successful one. And Carol DeForce is in the back. She was
instrumental in putting together last year\'s.

What else can I tell you? Adolescents and teens. We\'re doing five
events focusing on them.

African Americans, American Indians. I called, after our last meeting,
our council member who wanted to get engaged, and he got a hold of White
Bison, and now he\'s connected to helping us to put together an event.
So that was great. Asian and Pacific Islanders and Latino targeted
events.

Addiction Professional Day. I don\'t know if a lot of you are familiar
with that. It\'s NAADAC. NAADAC was one of the very first organizations
actually to put together Treatment Works Month, which was the
predecessor to Recovery Month. We\'re in our 10th year of calling it
Recovery Month in 2007.

Recovery Rides. I\'m famous to wanting to go on those rides. Here\'s
Anita who did a very successful ride last year in Ohio, and she got me
someone to cart me around and drag me off. But they\'re very enjoyable
and actually it gets a very nontraditional sector of the recovery
community to get engaged and to get involved in telling their story to
others in that sector.

Let\'s see what else you need to know about community events. Tons of
people. Last year 59 events generating 64,500, roughly, people that
attended those events. Nationwide we had 665 events posted in 2006,
reaching nearly 4 million people. That\'s overall. That\'s SAMHSA plus
everyone else. So it\'s very impressive.

Let me go back to that so you can see the growth from 2002 to 2006. This
year we want to reach 1,000. So go back to your communities. Tell them
to please post those events online because that\'s the only way we can
figure out that someone had an event.

Attendees nationwide, 3,800,000, which is not bad. Again, what we have
to continue to look at is the investment that we\'re making and what
we\'re getting for it.

Proclamations, 140 last year from 126 in 2005. So we\'re increasing.

Let\'s see what else. Our web page for this year, www.recoverymonth.gov.

It looks better every year. I don\'t know how our contractors do it, but
it really continues to improve and every year somebody thinks of
something else and we just enjoy that.

Website. Incredible. From January to April, we\'ve received 4,500,000
hits. So it\'s always increasing.

This is funny because I went into the SAMHSA website, and I usually end
up checking different websites all the time, and we didn\'t even have
the Recovery Month icon on our home page. Later I asked the
communications office upstairs for them to, please, put it on. But those
are being generated without the SAMHSA traffic to that website, which is
substantial. So hopefully, now that we\'ve got the SAMHSA icon back on,
we\'ll be able to generate even more.

As you can see, the growth, the average number of hits per year, and
we\'re up to 15 million for last year, 15,800,000. So we\'re just very
happy.

PSAs. I want to show you the new television PSAs. Here we go. Let\'s see
the first, and I hope this work.

(PSA shown.)

MS. TORRES: That was called \"Celebrate.\" No applause?

(Laughter.)

MS. TORRES: And the second one is called \"Cost,\" if I can find it.

(PSA shown.)

(Applause.)

MS. TORRES: Thank you.

So as you can see, the treatments every year really carry the message of
recovery extremely well, focusing on the individual that\'s in recovery.
Our 2006 campaign was in the top 10 percent of the Nielsen-rated
campaigns around the country. What does that mean? Nielsen takes about
481 campaigns around the country and they take a look at the ones for
quality and for the number of plays of the public service announcement.
So we\'re in the top 10 percent.

As for a breakdown, because I want to know what other campaigns are out
there that are within that top 10 percent so we can see ‑‑ what I really
want to do is see how much somebody else is spending to come back and
say, ha-ha, they need \$15 million, and here we\'re doing it with \$2
million. But it\'s going to be interesting to see if there are even any
other government agencies that are, indeed, in that top 10 percent or it
it\'s all corporate, you know, pharmaceutical, or if they\'re
considering the pharmaceutical industry with their public education,
what they consider public education PSAs. So we\'re very proud and
we\'re doing extremely well.

National Association of Broadcasters has done that booklet for their
stations, and they\'re helping tremendously in terms of getting out
those PSAs as well.

You already know that we were in the New York Times huge screen there in
Times Square last year.

I\'m just going to tell you, \$14 million August 2002 to December 2006,
and free air time for television, and for radio, \$7 million. So it\'s
getting out there.

But the real measure of the success of this campaign is not in the
awards. And I\'m going to go very quickly by. It\'s not in the amount of
money. It\'s really in the number of calls that we\'re getting every
single month from individuals and families who need help and are
actually calling our help line. In 2002, we got 22,000 calls on average
per month versus 2007. We\'re up to 29,165 for the month of ‑‑ I think
that was for January through April. An average number of calls was
29,165. So that\'s an awful lot of calls. I\'m sure that all those
individuals are getting help ‑‑ either information or they\'re getting
help.

We cannot track how many people are referred to treatment. So we don\'t
know how many of those calls are for information or referral because the
government is not allowed to do that. Otherwise, we would be doing it.

We just got a MerComm for the entire campaign. We always get PSAs or the
kit or the web. We got our first award for the entire campaign. It just
came in yesterday or the day before ‑‑ the GALAXY Award. And now we\'re
competing for the super-duper GALAXY. They told us that we\'re going to
wait for another couple of weeks and then they\'re going to tell us who
won what they call the grand prize.

But you can see. I mean, for the web, for the series, even the webcast
series is winning awards. That\'s why I want you to be in it so you can
be an award-winning panelist. So we\'re very happy.

With that, I\'m finito.

(Applause.)

MS. TORRES: Thank you.

MS. TAITT: That was wonderful, Ivette. I don\'t have quite as many bells
and whistles as Ivette, but it was a wonderful demonstration on what
Recovery Month does.

For those of you that don\'t know me, my name is Shannon Taitt, and I\'m
the new Partners for Recovery Coordinator. I have some pretty big shoes
to fill. I took over for Donna Cotter who retired in December, but have
been really pleased to be in this position and learned what Partners for
Recovery is about.

So here today I don\'t have a PowerPoint presentation because those of
you around the table should have received our new fact sheet, and that
should be in the binder that you have. For those of you who are out in
the audience, that is on the back table. So that is one of the new
developments for this year since I\'ve come on board.

Let\'s see. Partners for Recovery, created in 1998, was based upon input
from the field, and it\'s a collaborative effort for communities and
organizations that mobilize to help individuals and families achieve and
maintain recovery. PFR Initiative supports and provides technical
resources to those who deliver services in the prevention and treatment
of substance use and mental health disorders.

As you see on the fact sheet, we have five broad focus areas: recovery,
workforce development, cross-systems collaboration, stigma, and
leadership development. And I\'m not going to go over everything that is
on the sheet because you do have a copy of it, but some of the major
highlights that I did want to go over are that some of the core
activities are including supporting and facilitating the development of
recovery-oriented systems of care in states and communities, that we\'ve
been fostering collaboration among various systems, equipping recovering
individuals, providers, and state and local governments, and other
stakeholders with the tools to respond to stigma, and that we\'ve been
preparing the next generation in the substance use and mental health
fields.

In some of our cutting-edge initiatives in collaboration, The Outcomes
of Addictions Treatment and Approaches to Monitoring Performance was a
series of briefings that were done. In addition to the briefings that
were held at the NCSL Spring Forum, there was an annual conference and
Critical Health Areas Project meeting. Some of the outcomes in the
collaboration area are that 29 states and the District of Columbia were
represented among 31 legislators, 18 legislative staff members, and 14
other state officials attending a briefing at the NCSL annual
conference. Eight state-specific briefings have also been held.

On the back of the fact sheet, you will see some information on stigma
reduction. PFR developed the \"Know Your Rights\" brochure which
provides individuals in treatment and recovery and their friends and
allies information regarding federal anti-discrimination laws regarding
employment, housing, public benefits, and other domains. The training
manual is available on www.pfr.samhsa.gov, and the brochure was done in
English and in Spanish.

Some of the outcomes in the stigma reduction area were that there was a
very high demand for the brochure and the initial stock of 75,000 copies
was exhausted in less than 10 months. Approximately 600 stakeholders
from all 50 states have attended \"Know Your Rights\" training sessions.

In the workforce development area, PFR activities focused on
recruitment, retention, and professional development. The document,
\"Strengthening Professional Identity: Challenges of the Addictions
Treatment Workforce,\" was developed by PFR as a catalog for major
addictions treatment and recovery workforce challenges.

Also in the workforce area, some of the outcomes are that PFR is
currently funding activities related to improving recruitment efforts.
Some focus groups are going on around the country. One was done earlier
in April this year in collaboration with the Dr. Lonnie E. Mitchell
Substance Abuse Conference that focuses bringing African American
students from historically black colleges and universities to the
Washington, D.C. area so that they can learn more about the public
health field. So focus groups were held with students that are thinking
about entering the field and also some returning students that are older
and have decided that the public health field is an important area that
they wanted to go in. So we looked at second career people and wanted to
see why they decided as a second career to go into public health.

In the leadership development area, Partners for Recovery, in
collaboration with the ATTCs, has worked with the Leadership Institute
in 13 ATTC regions across the country. Part of the overall strategy of
PFR is to identify emerging leaders and build capacity to meet both the
organizational and systems demands in this field. It\'s a six-month
program that involves self-assessment, formalized appraisal by
supervisors, colleagues, and direct reports, and it has been going on
for the last three years. There\'s been approximately 342 graduates of
the Leadership Institute, and 4 CSAT staff have graduated from the
Leadership Institute, including myself. I\'m graduating this year.

The Second Annual National Conference for Leaders of Addiction Services
is going to convene its conference in August this year, August 5th
through the 7th, at the Grand Hyatt in Washington, D.C. These institutes
have also brought together some national experts such as Dr. Carlo
DiClemente, William White, and other state directors.

One of the major areas that I wanted to talk about just for a moment
that we\'ve been focusing on is the recovery area. This is a very
important area for Partners for Recovery right now, and we are in the
process of conducting regional meetings across the country that will
help states and communities implement recovery-oriented systems of care.
We did our first regional meeting in April, April 10th through the 12th,
in Portland, Oregon, and 10 states were represented there. Our next
meeting will be held in Dallas, Texas on July 15th through the 17th, and
we will have about 10 states for that region. And in September and
October, we will go to the Chicago area, and then we\'ll finish out the
year in probably the Rhode Island or Massachusetts area. We\'re waiting
to see what we can do about getting those meetings set.

So we wanted to make sure that as we go to these meetings, that we\'re
talking to not only the state directors, but we\'re bringing in the
recovery support community, we\'re bringing in researchers, we\'re
bringing in treatment providers and bringing them in as a team from each
state to be able to look at the challenges and look at the strengths
that they have in their states already to start implementing
recovery-oriented systems of care.

We also have an opportunity for them to share across states and see what
information they can gather from other states as they go home and figure
out how they can go forward with recovery-oriented systems of care.

As far as next steps with Partners for Recovery, on May 30th, the
Partners for Recovery Executive Committee had a meeting to discuss the
future direction of Partners for Recovery. The Executive Committee
decided to take a proactive approach to the proposed elimination of
Partners for Recovery. So we appreciate the fact that the National
Advisory Council has been so supportive of Partners for Recovery. So the
Executive Committee wanted to meet and discuss some of the issues that
would move us forward in all of the work that we\'ve been doing. We
discussed next steps to engage the prevention and treatment field and
additional Partners for Recovery activities that will support the
initiative\'s continuation.

As it was stated during this morning\'s public comment section, CSAT
needs to step in and coordinate some of the efforts around recovery and
recovery-oriented systems of care, and we believe that CSAT and Partners
for Recovery are doing just that. We are committed to working with the
field and bringing people to the table to look at the paradigm shift
towards recovery-oriented systems of care, and we want to make sure that
Partners for Recovery stays on the cutting edge of the issues that are
important to the field and also important to SAMHSA and CSAT on the
whole.

As some of you may know, Partners for Recovery developed out of the
National Treatment Plan and its guiding principles: invest for results,
no wrong door to treatment, commit to quality, change attitudes, and
building partnerships. This shows us that these guiding principles are
still relevant today.

PFR will have another meeting of stakeholders on July 26th here in the
Washington, D.C. area to continue discussing where we\'ve been, where we
are now, and where we plan to go. We are committed to the recovery
support community and we will also have representatives from those areas
there as well.

As I said earlier, the National Advisory Council has been very
supportive of Partners for Recovery. Melody Heaps, who couldn\'t be here
today, is the chairperson to the Partners for Recovery Steering
Committee. I know Frank McCorry has also been a big supporter of the
initiative, as is Dr. Chilo Madrid. He\'s been a part of Partners for
Recovery since its inception and even before that with the National
Treatment Plan. So as I close, I\'d like to introduce Dr. Madrid to talk
about Partners for Recovery as it relates to him in the field and also
being a part of the National Advisory Council.

So I thank you for your time.

DR. MADRID: Thank you, Shannon, and I\'d like to commend Shannon and
Ivette for all the fine work that both of them have been doing
concerning recovery.

I think that Anita Bertrand said it best during the last council meeting
when she said that so many things have happened that are good concerning
recovery and we are confronted with a lot of funding restrictions, that
it\'s time to get real creative and move this agenda forward, whether it
be the summit, whether it be PFR.

What I have done is I have talked to my congressional delegation and
they have informed me that that very conservative look that we looked at
concerning the budgets during the month of March is turning a little bit
better. The markup on those bills June 21st shows an increase both on
the Senate side, as well as on the House side, not just with the block
grant but regular CSAT money. And during the March meeting, there were a
lot of decreases and a lot of cuts that were being proposed. It was a
very conservative look at our CSAT budget, and I think it was a very
smart perspective to take.

But I think that has a member of the Partners for Recovery, what I\'d
like to do is ask this council to communicate to Dr. Cline the fact that
Partners for Recovery and all the work that Ivette has been doing is
essential. It has moved CSAT forward in many areas. It has represented
everything that we are and we do. It has looked at cutting-edge type of
situations. Again, as Anita said during March, we need to get creative.
We can\'t look the other way. Times are very tough and we know that, but
we need to carry the movement forward and not take steps backwards or
sideways but take them up and take them forward.

So I hope that this council takes this request seriously. As we
communicate to Dr. Cline, I believe that Melody Heaps wrote a letter,
and I believe that during the last council meeting, this council talked
about addressing a letter to Dr. Cline concerning some of the things
that we thought were important. Again, these are the things that are
represented so well by what Ivette has been doing and certainly what
Shannon is doing.

I believe that Cynthia has just passed around a letter that was
addressed to Dr. Cline by Bettye Ward Fletcher on behalf of the council.
Where is Bettye? Oh, she left. I wasn\'t privy to this particular
letter, but is the recovery movement elaborated here? Oh, okay.

The other thing that I was going to say is that I was informed by my
congressional office that there\'s a very promising bill, Senate bill
1367, that looks very promising by Senator Harkin that might bring in
another \$100 million into (inaudible). I don\'t know if you all are
familiar, and it talks about recovery. It talks about a lot of things
that we\'ve been talking about today.

So keep your fingers crossed because these are the things that I think
will turn this thing around. In other words, during the month of March,
we were facing a lot of decreases in budget. As of June 21st, most of
those decreases have been restored. And then, of course, right after
July, there\'s going to be the full Senate, the full House that will
look at that, and then it will go to conference. Up to now, even though
the House is the most gracious to us, the people on the Senate side are
saying that they are going to support the House version. So hopefully
with the help of these people and the Lord, SAMHSA/CSAT will experience
an increase rather than a decrease. It looks very favorable.

As we do that, I think that we need to take another look at the recovery
situation with what Ivette has been doing. And I think there were some
people here testifying this morning concerning recovery, the Recovery
Summit, a lot of things that really put us on the map that we need to
bring them back and restore them and move it forward.

Anita, do you want to say something?

MS. BERTRAND: Thank you, Shannon and Ivette, for the presentation.

In our community, each of the counties over the years ‑‑ I think this is
the fifth year that we\'ll be having this annual Recovery Month banquet,
and it\'s just amazing, right in the area that I\'m in, just to see the
different counties that are starting to develop other Recovery Month
events.

But I guess I just want to make another request that the administration
of CSAT really hears what we\'re asking here in regards to ‑‑ I know I
participated in the Recovery Summit. I participated in a planning
meeting actually earlier this month with the group, Health Systems
Research, that has the technical assistance grant for the Recovery
Community Services Program. But just that we put on the forefront of
CSAT\'s agenda that we look at the policies and just taking on some
leadership because what I would like to see is that from this level some
sort of stage is set and that we don\'t wait for the states to do these
things and that we just respond in a proactive manner.

MR. KOPANDA: Thank you very much for those comments. I think we\'re kind
of into the council roundtable here. I do want to thank both Ivette and
Shannon for their presentations. Dr. Clark once again was called away.
This is usually the way it goes here. But we could begin with any
comments we have for them following up on the recovery comments or any
other issues that the council would like to raise.

MS. JACKSON: Thank you very much, and Ivette, thank you very much for
all of your hard work regarding Recovery Month. I think that it is very
important. And I have a couple of ideas for air time things, so I\'ll
give them to you.

I want to follow up on what Anita just said because one of the things
that I think we have mentioned here before but I feel like we need to ‑‑
I don\'t know exactly what action needs to be taken or how we can stage
it. I think you said \"stage\" it, and that\'s probably a very good
word. Somehow it would be very nice if the National Advisory Council for
the Center for Substance Abuse Treatment ‑‑ if we were discussing in our
roundtables what we would like to see in 2008 and 2009 and 2010. You
guys start planning very early. We begin to hear about it a little bit
later, and we appreciate that. Don\'t get me wrong because I feel like I
get lots of information and I\'m very well informed.

But at the same time, for instance, what Greg Skipper talked about
earlier today, the idea of possibly coming up perhaps with a
discretionary grant or a pilot or something that looks or somehow,
again, sets the stage to be looking at the way that recovery comes to
the professions, the medical professions and also in the legal
professions. You can\'t argue with those statistics. They\'re very, very
important and they\'re very impressive. I think we need to look at that.

There are other areas. One of the things that struck me this year, while
I am, as most people here know, an avid, avid supporter, and have been
ever since we got started, of women with children\'s programming, and
it\'s truly a part of my life\'s passion, it was interesting when I
looked at target populations for some of the grants that people I worked
with took on this year. Frankly, it\'s really, really difficult for men
to get treatment. It\'s not easy. I don\'t think that there is much
progress in increasing money at the state level.

So that\'s just a couple of ideas and thoughts that go through my mind
kind rambling here just a little bit. I\'ll stop. But I would love to
have a discussion of what\'s important from the home front of those of
us, and we can also go out and ask a lot of other people, if we\'re
encouraged to do so, and then help perhaps to formulate some of the
policies and ideas that come forward for the future and have more
discussions about that. We would really appreciate that.

MR. KOPANDA: Thank you, Val. Yes, that is very important.

To kind of follow on something Chilo said ‑‑ and it was mentioned
earlier ‑‑ from the time that the council submitted the June 22nd letter
to Terry Cline ‑‑ and we\'ve received both the House and Senate marks ‑‑
it\'s become a bit different story for us, if you will. Last time we
were discussing the possibility of eliminating these programs. Now
we\'re talking not only the restoration but also hopefully some growth,
but hopefully not too limited a growth either. So we would be in a
different mode within CSAT in looking at how to program those dollars.

We would value the input of the council either now or in some future
meeting. But as we begin to go between now and ‑‑ you know, we like to
get the announcements out early. So I would suggest that any comments or
suggestions you have now would be well received or in some future
council meeting because we\'re not at the final part of our process yet.

We also have a number of things going on that we do support in recovery.
Of course, we have our Recovery Support Services Program, and we\'re
just at the point of reviewing, as you know, the awards for that. We
also have the Targeted Capacity Expansion Program where a portion of it
is targeted toward recovery-oriented systems of care. That\'s the first
time we\'ve kind of focused on that particular aspect of services and
we\'ll see how that comes out as well.

But any suggestions you have on recovery or other areas I think would be
well received.

DR. MORA: I have a comment related to that, our input specifically.

But before I address that, I wanted to say that I support the recovery
efforts and I will follow up with my congressional representatives after
this meeting regarding funding in that area.

But based on hearing everybody today, it seems that our role is more to
advise on policy and priority areas, that kind of a thing, but there\'s
no real place for us to do that. So one of the places that might be
feasible, as Dr. Clark mentioned, is at the writing of the RFAs where
priorities are set and identified. Where are we on that process? I mean,
what input can we have in that process? Maybe we can talk about that at
our next meeting in addition to talking about grant reviews. How can we
get at the front end of that so that we can have some input about
geography, about whatever issues we think are important based on our
involvement in the community?

MR. KOPANDA: Well, some of our initial discussions regarding funding for
the upcoming year have to do with how we distribute the money more or
less among the RFAs, how much in Targeted Capacity Expansion, how much
in Pregnant and Postpartum Women, how much for methamphetamine, how much
directed to the American Indians/Alaska Natives. Those kinds of
discussions we have.

In addition, we\'re accommodating the Hill priorities as stated. For
example, the Senate language here says maintain all your programs at
last year\'s level. Well, okay. There we go. There\'s a lot of the
discretionary funds already set because we\'re continuing the programs
at no less than what we spent last year. They also have earmarks. So the
amount of money left for which we are looking at different areas is much
smaller than you might otherwise think.

But, nonetheless, we do have some discretion in there, and the first
thing we look at is where that money goes. And I think that\'s what we
would first look to the council to say where would you suggest we put
what we would assume would be a moderate or modest amount of money. Once
we determine that, then we get into the issue you\'re talking about,
which is how are we going to do those funds.

I can bring up another issue I have here which, depending on council
time, is the kind of questions we\'re faced with in terms of what are
our longer-term priorities. How do we decide where we put the money? How
do we establish that within some kind of a strategic framework of where
the agency is going, those kinds of questions.

DR. MORA: Well, I had those similar questions. Is there some kind of
strategic plan available that we could look at to learn more about what
the long-term strategic goals are not only for CSAT but for SAMHSA,
things like that that would help us help you and provide appropriate
input in whatever areas have been already identified.

MR. KOPANDA: SAMHSA does have a strategic plan which we could provide
you. I\'m not sure ‑‑ George may here ‑‑ it gets to the level of
determining where you come down to this kind of money, you know, that
level, the degree of ‑‑

DR. MORA: That\'s okay. I think for me it would help me understand what
the general kind of future direction is. Also, even I understand that
some monies are already earmarked for TCE or whatever, but we may be
able to have some input within the parameters of a certain body of
funding. Maybe we can target within that target some special need or
whatever. So I think we\'d like to find out where we might have that
kind of a role because otherwise we see the proposals and the grants
after the fact and we have to just have faith that they\'ve been
reviewed appropriately.

MR. KOPANDA: Other comments?

MR. DeCERCHIO: I think, just to follow up, Rich, I was thinking more in
terms of the front end. When Dr. Clark this morning mentioned something,
I think the \'09 ‑‑ SAMHSA is having some internal discussions and
internal executive branch discussions about recommendations for the \'09
budget. So from my perspective, it was looking at that level, you know,
\'09, \'010, like Val mentioned and Dr. Moore mentioned because you are
going to have those restrictions on what you have. Believe me, the
sensitivity around how you allocate dollars and those processes have to
be very transparent. But what is important in \'010? Is there another
area that should be looked at or in \'09? Are there other areas that
have run their course?

And I don\'t know the answers to that, but maybe in an upcoming session,
we can just dedicate some time to what the agency\'s thinking is and
what our thinking might be around that and have kind of a constructive
dialogue session around that, you know, being way out in front of it and
my perspective is less, in terms of, well, you got your money, what are
you going to do with it. By that time, you asked for it in a certain way
to do certain things, and it\'s really even hard to change that. Two
years ago you proposed this is what we\'re going to do with it. Now they
give it to you. Because we want to see it go somewhere different, you
can\'t come in and really change that game plan very much. But now,
having that discussion about two years from now I think would be an
expansion and a good use of the advisory council.

MR. KOPANDA: I agree. I think that\'s an excellent suggestion and we
should put that on our next advisory council agenda.

MS. JACKSON: And if it\'s possible, I think that is a way that you\'re
hearing we would really like it to go. I think that we certainly
understand that Congress dictates a lot of what you do and that that is
going to happen or it depends on somebody who is very strong and lobbies
a particular issue. As we saw today, the results of the ACF money was
certainly a result of a strong effort last year, which is very good. I
applaud that. At the same time, had I had something to do with the front
end of it, I might have worded it a little differently. I\'ll say that
on the record. It\'s okay.

I think that if we were to discuss this, like Ken is saying, which would
be very helpful for \'09 and \'010, some guidance perhaps ‑‑ George,
you\'re great at that. Rich. Whoever would do it would kind of give us
some of your thoughts and what you\'re hearing because, of course,
you\'ve got a national ear, and then we have an ear and a perspective
from different areas at a different level. But a little guidance that
way, and then perhaps a little bit of structure to help us to then give
you the input would be very, very helpful, not just an open dialogue,
even though I think it has to be open, but maybe guided and open.

MR. KOPANDA: Yes, that\'s very important as well. We are, of course, in
the middle of the 2009 budget discussions.

And I should just reiterate to the council that if you are going to talk
to your Hill contacts, it should not be in the context of your official
SAMHSA council membership.

But along the lines you\'re talking about, the broader framework, what
we see right now is kind of a confluence of a number of things which are
impacting our programs and priorities and budgets. Several things.

The GAO, for example, which is now, as you know, the Government
Accountability, rather than Accounting, Office, has decided to take a
look at the PART process, the OMB program review process which scores us
based on a number of aspects of our programs, and is questioning how
managers use the information from evaluations and other aspects of their
program to determine program priorities for the future. We could go
through that a little bit. I actually did bring some of the questions
from PART. There are many, many questions.

The second issue is actually the PART process, which we just completed
for the Access to Recovery Program. Once you go through this process ‑‑
we\'ve done it before, but it\'s a very labor-intensive process. We
found, for example, that what we might think, in terms of meeting the
goals, not everyone necessarily might agree that those are the goals of
the program. So you do need to take a very, very careful and close look.

And we\'re looking at the application of PART principles to many of our
current programs to say if you were PARTed for this program, how would
you answer the question, are your goals aggressive? How do they go up
from year to year? We think we hold grantees accountable, but how do you
really hold them accountable in a more intensive way, akin to the PART
process?

Other types of questions we face through the budget process, we\'ve just
noted a few. Why is your proposal the right thing to do? How does it
clearly fit within the scope of your mission and avoid mission creep?
For example, one example might be are programs focusing on American
Indians and Alaska Natives. Why are you doing it rather than the Indian
Health Service? Why are you doing this type of program rather than HRSA?
That kind of thing.

How would your proposal fit within the complete package that the
Department is putting forth? In other words, are you out on your own
doing something? Are you proposing to do something over here, or is it
consistent with the rest of the Department\'s priorities?

How does your proposal benefit the field in the longer term beyond just
simple, immediate client services? Rather than just increasing the
number, how are you influencing? I like to think of how you are
influencing the field. My thought is that our programs are not all
intended to provide a grant to every single provider or to every single
state, and we do have kind of an influence that goes beyond the specific
dollars for that specific program, especially when our programs kind of
end after a while. We don\'t continue them forever. So how do we capture
the nature of that influence and kind of build it into our program
planning process for the future?

That influence might even extend, for example, to unsuccessful grantees
who, by developing an application which would propose to use, say,
recovery support systems of care in their area, have thought about that.
They might not get the federal grant, but they have conceptualized where
the federal government wants them to go. So these are the kind of
thoughts that we want to be bringing forth in terms of our future.
We\'re going to be asked and forced actually to bring into the future
discussions about the budget that it would be good to have the council
input on.

DR. MORA: Well, just one comment related to that. One of my major
concerns for a long time and still is is that I noticed that your
grants, your RFAs are getting more and more complex, and there\'s a lot
of very good community-based organizations that do not have the
technology, the support, the resources to compete even though they have
the trust of the community. So I want to have that dialogue with you
guys. What can we do about things like that?

MR. KOPANDA: Ken?

MR. DeCERCHIO: Are there any proposed changes to the block grant formula
that are being contemplated? Anything new on that or new or revised for
either \'08 or \'09?

MR. KOPANDA: I mean, we are going through the reauthorization process
right now. The word we\'re hearing informally is that nothing formal is
being proposed right now in terms of changes to the block grant formula.

MR. DeCERCHIO: Informally is there any feedback about there\'s a problem
with this or this needs to change?

MR. KOPANDA: Well, there are some members who are concerned about the
relationship between the formula and the need and its relationship to
need for funding, need for services. That\'s a very difficult issue
because it gets into the issue of every time you change it and you think
you\'re doing this, some states ‑‑ you have winners and losers. And
it\'s never always intuitive ‑‑ I\'ll put it that way ‑‑ as to who is
going to win and who is going to lose when you make a change like that.

Of course, how do you define need in terms of a formula? The initial
formula actually was constructed in a way which is supposed to mirror or
mimic need in a way that not everyone agrees right now is accurate. So I
think those are the kind of discussions that are going on, but they have
not resulted in anything concrete.

MR. GILBERT: I wanted to just add that apparently there is some thought
being given in the reauthorization of SAMHSA this year to include a
provision that would mandate a study of the formula and what some
options might be to change it to better reflect need. The last time the
formula was changed, I think the GAO wound up doing something like 86 or
90 formula runs for the Congress. What it ultimately boiled down to was
which one of those formulas was going to get the votes they needed to
pass the bill. I mean, how do you jigger it so that you can get enough
members to sign on?

MR. DeCERCHIO: I was on the NASADAD work group when there were \$275
million on the table under President Clinton and Barry McCaffrey. It was
a very tenuous kind of consensus on modifications to the formula that
got put in appropriations bills every year until the last
reauthorization between like \'99 and, I guess ‑‑ so it is real tricky
and real touchy. There were concessions made as that was being done in
order to get exactly what you said, the votes needed.

So anytime that\'s back on the table, it\'s one that requires a lot of
attention and really an opportunity for ‑‑ and I\'m not advocating for a
change. I\'m just saying it\'s always a tough issue, and sometimes the
field can lose. In other words, sometimes even though there are winners
and losers within, it can end up where the whole field kind of loses if
it\'s not ‑‑ in a political process. Let me just put it that way. So if
there\'s any strong movement around that, we certainly would like to be
apprised of it as it unfolds.

MR. KOPANDA: Also in answer to your question, I have heard a little bit
about the possibility of changing the minimum state allocation. I\'m not
sure where that\'s going. We haven\'t seen any actual proposal along
those lines.

DR. MADRID: I did want to add that on the House side at this time, as of
June 21st, there are \$35 million more being proposed for the block
grant. And there is some talk about how that is going to be allocated
based on the present formula.

But I wanted to perhaps make a recommendation based on what Dr. Mora
talked about this morning that she\'s doing a lot of research concerning
border issues. Maybe this coming year we should look at that. For
example, in my case I\'m right on the border. There are 23 other
programs on the other side of the border, treatment programs. There are
several methadone programs. I know some of my people are getting
double-medicated, but I don\'t have that type of relationship with the
methadone programs on the other side.

There are millions of dollars being poured by the federal government on
both sides concerning the supply side, but there are zero dollars being
invested concerning the demand side. We have a lot of young boys that we
saw pictures of that are getting very addicted to methadone, as well as
heroin. The prices are really, really down.

So there\'s just so much that we could study along the border. So
perhaps we can spend some time this coming year looking at how we can
collaborate better and take a serious look at the demand side, perhaps
as serious as we\'re taking a look at the supply side.

I was telling Shannon, going into Partners for Recovery, why not also
this coming talk about a Partners for Recovery national plan? The
National Treatment Plan was a big success with a lot of the treatment
providers and others, and perhaps we can learn from that and move that
forward if we have the opportunity concerning the budget restrictions
that are confronting us at this time.

But, again, on the border issues, there\'s just so much that we can do
together. Criminal justice is doing it. Why can\'t we do it also from
the demand side?

MR. KOPANDA: We will consider that for future discussion as well.

Val?

MS. JACKSON: Another issue that came up this afternoon in our ACF
presentation on that initiative is the fact that Congress saw fit to
fund it the way that they did last year, which is a very complicated
funding system that then the agency was stuck working with. I don\'t
know if that was unique. I would hope that it is.

However, one of the problems with match money is that it is very
difficult as an agency to ‑‑ you know, we can put in some soft match,
but we are expected, for instance, in Florida before we ever begin, we
have to match 25 percent of everything that\'s primary alcohol-related.
So we have a match that somehow the state expects that we will magically
come up with a quarter of what we need in order to minimally do services
within the state. Then if that happens to come up in other issues
nationally such as it has in the ACF, I think it makes it even harder on
agencies.

For instance, earlier today you talked about sustainability and how we
need to think about sustainability from day one. Well, you\'re
absolutely right. We all do need to think about sustainability from day
one. However, if you are a not-for-profit organization trying to live on
grants on what you can get out of the state through your block, on
hopefully a few foundations, on a very little bit of ‑‑ at least in our
state ‑‑ third party pay.

It used to be there was actually some insurance that would come in to an
agency and help support it, and there used to be some cash that would
actually come in to an agency and help support it. Those two things have
just basically disappeared. In our agency, The Village, for instance, 10
years ago probably 15 percent of our funds came from third party pay. I
would say now it\'s probably less than 2 or 3 percent.

And yet, the match kinds of things that come up are really, really
difficult for not-for-profits, which is what you deal with, to manage.
So I think that that\'s another issue that we would like to perhaps at
some point have a discussion about, look at maybe perhaps from the
SAMHSA side the sustainability, but with an eye to the fact that if
Congress is going to begin to throw match into anything, we would really
like for you to try to represent us in the difficulty of any of that
kind of thing and to be understanding about even the sustainability. We
understand you have five years to run a grant, but let me tell you, the
sixth year is a very, very difficult year and being able to do anything
rational about that.

MR. KOPANDA: Yes, thank you. There are a couple of issues there. One is
I guess the core question, does match help? I mean, the purpose of
match, as they define it, is to permit grantees to begin to develop and
think about those outside sources before the money just runs out.
Certainly the Pregnant and Postpartum Women Program has been one. As you
mentioned, Linda has been working on the sustainability issue, but
we\'ve never really looked systematically as to whether match programs
are sustained ‑‑ I don\'t think we have ‑‑ at any greater rate than any
of our other programs.

But I think the second and more key issue is the dollars in the system
as a whole from Medicaid on down. If you\'re not seeing much growth in
the dollars in the system as a whole, then it\'s difficult to increase
your capacity. And we\'re giving to these grants. You know, well, where
are they going to get their match from because the system as a whole, no
matter where you\'re getting your funds, private payments and such, are
declining.

MS. BERTRAND: One more thing. And with match for smaller organizations
and community-based organizations is that it alienates them because they
cannot match, whereas your larger hospital institutions and foundations
and universities may be able to make those matches.

MR. KOPANDA: Any other issues?

MR. GILBERT: Rich, if I could. I just wanted to go back to the issue
that Ken raised about the formula. There was something that I thought
about just as we kind of finished that conversation. There is not
anything that I know that\'s going on in terms of changing the formula,
but there is a proposal in the administration\'s budget this year that
would require states ‑‑ we\'ve said for a long time that states would be
required to report against the NOMs, the National Outcome Measures,
beginning in 2008. And that\'s been negotiated and worked out with
NASADAD. But the President\'s budget this year included a provision that
would withhold from a state 5 percent of their award if they failed to
report.

That provision ‑‑ we don\'t know what the House is going to do with it.
The Senate Appropriations Committee has said they won\'t support it. So
that\'s still kind of hanging out there as an issue that could come up
in the appropriations process that could affect the amounts that states
would get under the block grant program.

MR. DeCERCHIO: That\'s a large withhold, 5 percent.

MR. GILBERT: Yes, it is.

DR. CLARK: Well, I guess the key issue remains the expectation of
performance and data. I mean, for the longest, people would say, well,
we can\'t produce that. And increasingly the Congress, both parties,
said we want accountability. I think while we haven\'t promoted that, we
see this notion of accountability.

Fortunately, for the substance abuse community, most jurisdictions have
been responsible. There\'s always the outlier. And we continue to do
that. So we raised the alarm about these negative consequences, but
you\'re fighting uniform opinion that they want people to deliver on the
goods. They don\'t want promises.

You\'re right. It\'s a large amount and we\'re very sensitive to that.
We haven\'t supported that, but that\'s outside of our decision-making.
What we can do is make sure we work with jurisdictions so that we don\'t
have to visit that. We don\'t have to go there if we can produce the
data that we need to demonstrate that the money is being well spent.

I\'d like to let you know that we have tentatively scheduled a
teleconference meeting for grant review on August 23rd at 1:00 p.m.,
Eastern Standard Time, and the next face-to-face meeting is tentatively
scheduled for mid-October. We\'ll have a better idea of what the \'08
budget is going to look like by then. We\'ll know whether they\'re going
to move forward or not by mid-October.

I really appreciate your thinking about \'010 in terms of what we\'re
doing, and in terms of this notion of performance, I encourage you to
look at the OMB website for the PART, Performance Assessment Rating
Tool, so that you\'ll get a sense of what it is that is being expected
of all of our portfolio, not just the block grant, not just the
discretionary grant. It\'s very rigorous. The issues remain that people
want to know what we\'re doing with the money.

And as we think about where are we going philosophically, why do we need
the block grant? I think we in our hearts know that, but we need to be
able to articulate that. Why do we need a discretionary portfolio?
You\'ve heard us articulate principles about that in the past, but as we
think about \'010, we should do that.

I\'m fond of pointing out, at least in the arena of illegal drugs,
there\'s a unique federal role because, indeed, the Controlled
Substances Act is a federal act, and if indeed we don\'t play a role, we
create an unfunded mandate for the states because, unlike physical
health which you can say, well, is it a local jurisdiction issue, the
area of illegal drugs and prescription drugs has been carved out by the
federal government as federal government territory.

Now, I don\'t know that that\'s compelling to the decision-makers, but
indeed, these questions do surface. We need to recognize that. You\'re
in a good position as council members to have a sense of if this money
dried up over here, what it would mean; if money is invested over there,
what it would mean. So we can think about 2010.

So is there any other business we need to discuss?

(No response.)

DR. CLARK: If no further business, I will entertain a motion to adjourn.

PARTICIPANT: So moved.

PARTICIPANT: Second.

DR. CLARK: It\'s been moved and seconded that we adjourn. All in favor?

(Chorus of ayes.)

DR. CLARK: The motion carries. This meeting is adjourned and I look
forward to talking to you in August and seeing you again in October.

Sorry that I\'ve been in and out. We had multiple meetings I\'m
juggling. That\'s the problem with having a meeting in your own house.

(Whereupon, at 4:30 p.m., the meeting was adjourned.)