SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Wednesday,

January 26, 2005

Sugarloaf, Seneca, and Rock Creek Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

P.O. Box 360833

Strongsville, Ohio 44149

Kenneth A. DeCerchio, M.S.W.

Director

Florida Department of Children and Families

Substance Abuse Program

1317 Winewood Boulevard

Tallahassee, Florida 32311

David P. Donaldson, M.A.

CEO

We Care America

10 G Street, N.E., Suite 502

Washington, D.C. 20002

Bettye Ward Fletcher, Ph.D.

Professor

Jackson State University

1120 Andrew Chapel Road

Brandon, Mississippi 39047

Melody M. Heaps, M.A.

President

Treatment Alternatives for Safe Communities (TASC)

1500 North Halsted Street

Chicago, Illinois 60622

IN ATTENDANCE:

Valera Jackson, M.S.

CEO

Village South/West Care Foundation, Inc.

3180 Biscayne Boulevard

Miami, Florida 33137

Chilo L. Madrid, Ph.D.

CEO

Aliviane NO-AD, Inc.

7722 North Loop Road

El Paso, Texas 79915

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

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

Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 349

Crandon, Wisconsin 54520

[Ex Officio Members]{.underline}

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders

and Psychiatric Rehabilitation

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

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

PAGE

Welcome

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

Director, CSAT 6

Consideration of September 1-2,

2004 Council Minutes 6

Introduction of Council Members 10

Director\'s Report

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 15

Discussion 35

Engaging the Faith-Based Community in Recovery

David P. Donaldson, M.A.

NAC Member 53, 59

Jocelyn Whitfield

Senior Public Health Advisor

Office of the Director, CSAT, and

Co-Chair, SAMHSA Community and

Faith-Based Initiative Work Group 55

Clifton Mitchell

Chief Expert on Faith-Based Communities

Office of the Director, CSAT 63

Discussion 68

Treatment in Ethnic Communities

Chilo L. Madrid, Ph.D.

NAC Member 85

Discussion 96

Public Comment 102

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

PAGE

Translating Science-Based Treatment

Interventions into Service

Timothy Condon, Ph.D.

Deputy Director

National Institute on Drug Abuse 114

Discussion 140

National Survey on Drug Use and Health

Joe Gfroerer

Office of Applied Studies, SAMHSA 146

Discussion 159

Overview of Residential Treatment

Deborah Trunzo

Office of Applied Studies, SAMHSA 163

Discussion 173

Overview of Residential Treatment in

CSAT\'s Discretionary Portfolio

Joan Dilonardo, Ph.D.

Branch Chief, Organization and Financing Branch

Division of Systems Improvement, CSAT 179

Discussion 190

Legislative Update

Joe Faha

Office of the Administrator, SAMHSA 191

Discussion 209

Council Roundtable 212

[P R O C E E D I N G S]{.underline} (9:15 a.m.)

DR. CLARK: I\'d like to call the meeting to order. This is the 41st
meeting of the CSAT National Advisory Council. We\'ve got several new
council members. Please join me in welcoming Anita Bertrand from
Lorraine, Ohio, Dr. Bettye Ward Fletcher from Brandon, Mississippi, Dr.
Francis McCorry from Yorktown, New York, and Judge Eugene White-Fish
from Crandon, Wisconsin. I\'ll talk about them a little more
subsequently.

We now have a full council. Before we move forward, I\'d like to
entertain a motion for the approval of the September 1st and 2nd
minutes. These minutes were forwarded to you, council members,
electronically. You have a copy in your notebook. But for those who feel
more comfortable discussing the minutes, is there any discussion?

(No response.)

DR. CLARK: May I get a vote on accepting the minutes?

MR. DeCERCHIO: So moved.

MS. JACKSON: Second.

DR. CLARK: All those in favor?

(Chorus of ayes.)

DR. CLARK: Those opposed?

(No response.)

DR. CLARK: All right. We\'re going to accept the minutes as presented
without any corrections. The minutes are adopted.

I want to emphasize again the importance of your role as council members
to the Center for Substance Abuse Treatment, and also to SAMHSA. It is
good that you are able to take time out to be here. We know that you
have busy schedules. Many of you are running programs or are involved in
community activities, so this is a sacrifice on your part. We want to
make sure that you feel that the sacrifice is justifiable by giving you
an opportunity to contribute to our thinking, our reasoning, and our
efforts.

At this point, I\'d like to officially say a few lines about some of our
new members in alphabetical order. We\'ll start with Anita Bertrand. She
is the Executive Director of Northern Ohio Recovery Association in
Strongsville, Ohio. She has a Master\'s degree in social work
administration, and a comprehensive knowledge of public policy and
community development in research issues. She has expertise in criminal
justice in planning, implementing, and monitoring new and evolving
substance abuse treatment and housing programs.

She is also one of our grantees in one of our recovery support services
grants. I think this is an important thing. She talks about her own
recovery. So not only does she come to the issue of substance abuse
recovery from the perspective of a manager, but also from someone who
has a personal history.

Welcome to the CSAT Council, Anita Bertrand.

Also joining the council is Dr. Bettye Ward Fletcher. She is currently a
professor of sociology at Jackson State University, a historically black
college and university. She has expertise in workforce diversity,
organization assessment, capacity building, program planning and
implementation, and research and evaluation.

She served as Executive Director of the Mississippi Department of Human
Services, a cabinet-level gubernatorial appointment. Her research is
focused on the social and behavioral correlates of substance abuse and
HIV/AIDS. Since she\'s an educator as well as a policymaker, our whole
workforce efforts by which SAMHSA is concerned will benefit from the
contribution of Dr. Fletcher.

Welcome, Dr. Fletcher.

I\'m delighted to welcome Dr. Frank McCorry. He is the Director of the
Clinical Services Unit, Division of Health and Planning Services, New
York State Office of Alcoholism and Substance Abuse Services. Dr.
McCorry is responsible for clinical policy and practice improvement
issues, particularly in the areas of public health,

co-occurring mental health, addictive disorders, and managed care.

He also oversees development of new initiatives that respond to emerging
issues, such as improving clinical practice through the adoption of
evidence-based interventions and hepatitis prevention and control. He is
also working with the Washington Circle Group in developing quality
standards for the delivery of services. He has worked in the field of
substance abuse prevention and treatment for over 30 years.

Welcome, Dr. McCorry.

And finally joining us on the council is the Honorable Eugene
White-Fish. He is a tribal judge for the Forest County Potawatomi Tribal
Court. Judge White-Fish is President of the National Tribal Court
Association and the previous Director of the Alcohol and Drug Treatment
Council for the State of Wisconsin. He also provides outpatient
counseling.

He was talking about the kinds of materials that he had to review for
this meeting. He said, \"Hey, I limit my lawyers to only ten pages.\"

(Laughter.)

DR. CLARK: He said, \"I haven\'t had to read this much since law
school.\"

With his extensive background and his involvement with the legal
process, we welcome Judge White-Fish\'s contribution to the council.
He\'ll be able to assist us in any number of ways.

So welcome, Judge.

So I have given you a thumbnail sketch of the new members. The bio
document is on the handout in the back.

Speaking of the back, everyone who attends this meeting, we would like
for you to sign in in the back so that we will have a record of those in
attendance. That applies to council members as well as staff, and
anybody else in the audience.

With that, I\'m going to take a few minutes so that we can go around the
table so that our new council members are introduced to our old council
members, and those in the audience will be able to hear a few words from
those present.

Why don\'t we start off with Dr. Fletcher?

DR. FLETCHER: Thank you, Dr. Clark.

I am Bettye Ward Fletcher from Jackson, Mississippi, where I serve as
professor of sociology at Jackson State University, and probably have
come to this board by way of my involvement in the substance abuse field
over the last 30 years as one of the founding directors of the
Interdisciplinary Alcohol Drug Study Center. So I value the opportunity
to be part of this body and look forward to the discussions.

DR. SKIPPER: Hi. I\'m Greg Skipper. I\'m a physician in addiction
medicine. I run the Physician Health Program and Veterinary Wellness
Program in Alabama. I\'m on the faculty at the University of Alabama in
Birmingham. I\'m happy to be here.

Thank you.

MS. JACKSON: Hello. I\'m Valera Jackson from Miami, Florida. I am with
The Village, which is a treatment center that has been around for about
30 years. I was a previous Assistant State Director and worked on the
state side as well as the private side. We also have programs in the
U.S. Virgin Islands, and we are affiliated with West Care, a foundation
and corporation which has programs in seven different states in the U.S.

My main interest I think is in a lot of programming and development
areas. I have worked a lot with SAMHSA and members of the Clinical
Trials Network with NIDA. I just have a great love of this profession
that I can\'t seem to let go of, so I look forward to the discussions in
our work.

MR. DeCERCHIO: Good morning. I\'m Ken DeCerchio. I\'m the State
Substance Abuse Director in the State of Florida.

When we last met, we were on the eve of our third hurricane in Florida.
I thought it was going to be the last one. But since we met, we\'ve had
another one. So we had a total of four before the discussion tomorrow on
disaster response and preparedness. I certainly have to compliment
SAMHSA\'s response in partnering with us. We\'ll talk more about that
tomorrow over those four disasters.

Since we last met, I\'m in an interim acting capacity as Acting Deputy
Secretary for Substance Abuse and Mental Health. So I\'ve been real
involved in mental health issues the last 90 days, and look forward to
being here.

I had a good trip up. Unfortunately, my luggage didn\'t have the same
kind of trip that I had, and it is still traversing the countryside
somewhere between Reagan National and Gaithersburg, Maryland. So maybe
we\'ll reconnect over the course of the day.

Thank you.

DR. SUCHINSKY: I\'m Richard Suchinsky. I\'m the Chief for Addictive
Disorders at the Department of Veterans Affairs here in Washington, D.C.
As an ex officio member, I think I have the privilege and honor of
having been the longest serving member of this council.

MR. DONALDSON: Dave Donaldson, President of We Care America. We are an
alliance of primarily

faith-based organizations across the country. We focus on four areas in
helping these groups build their capacity. Government relations,
training, we have the National Grant Center where we research, write
proposals, and do grant management. Then also our Care Corps, which is
the volunteerism. So we have been very active with these disasters as
well, especially with the tsunami.

DR. McCORRY: Good morning. I\'m Frank McCorry, and I\'m thrilled to be
part of this council. I look forward to the work we\'ll do. It is such
an exciting time to be part of such an important body, having an
evidence base that now we can try to move into practice, extending the
continuum of care through such things as Access to Recovery and bringing
faith-based initiatives and collaboration with other systems, which I
think is so key in terms of substance abuse work, particularly with the
mental health community, but also with criminal justice and social
welfare.

It is just a terrific time. It is just an exciting time to be in this
field, and I look forward to being part of this deliberation.

DR. MADRID: Chilo Madrid from El Paso, Texas. I\'m the CEO of a
comprehensive drug treatment and prevention program out there. I\'m very
happy to be with you all enjoying the snow. We don\'t get this type of
weather out there where I\'m from.

DR. CLARK: You can have it.

(Laughter.)

MS. BERTRAND: Good morning. My name is Anita Bertrand, and I identify
myself from Northern Ohio, which for me is three major cities, Akron,
Cleveland, and Lorraine. I do work in all three cities. I\'m excited to
be here, and just believe that the recovery community has a lot of
valuable input that can be given to other professionals. I do identify
myself as a professional, a person in recovery. I\'m going to be working
with the churches trying to bridge that gap so that individuals can
retain their recovery once we release them from treatment centers.

JUDGE WHITE-FISH: Good morning, everyone. Thank you for the warm
welcome.

Most people have not heard of Crandon, Wisconsin. It is a small
community. I represent a tribe, the Forest County Potawatomi. It has
approximately 1,200 members.

I am currently the President of the National American Indian Court
Judges Association that represents tribal courts throughout the United
States and Alaska. This is my second consecutive term. I had hoped to
step down because they limit our terms. However, they decided to change
the bylaws on my behalf.

When you look at retirement, the main question is can I take NIDA any
further than what I have already taken it. Apparently some of my members
must think so, so I feel privileged to do that, as well as looking at a
very important issue. In tribal courts, and I imagine in any other
courts, the state courts, the federal courts, the chemical dependency
disease is definitely out there.

In training, they asked me where I learned to write orders. I said, how
I learned to write orders is, all it is is a treatment plan for those
people that are addicted, is what it is. They were impressed that I
could write orders in the way that I did, looking at the full scope of
things, looking at family, and looking all ways. I think every judge
should have some training definitely in chemical dependency for they may
see things through different eyes if they were.

Thank you.

MR. KOPANDA: Good morning. I\'m Rich Kopanda, Deputy Director of CSAT.

DR. CLARK: Cynthia, do you want to introduce yourself? Cynthia Graham is
the person who is responsible for coordinating and pulling this meeting
together. So I want to acknowledge her effort, and the efforts of her
coworkers in the back and elsewhere, all working with George Gilbert so
that this meeting is a successful meeting. We appreciate the support of
staff as well as those that have attended.

This is an important time period. It is a time period in transition. We
are in the second phase of the administration. We have got obviously a
number of new political appointees at high levels. Speaking of new
political appointees, as you know, we have a new

Secretary-designate, and that last word \"designate\" is supposed to
evaporate sometime today. There should be a swearing in today or
tomorrow. I think it is today. Washington is a strange place. You
schedule things, everybody anticipates it, and then they either happen
or they don\'t happen. It is supposed to happen today.

The reason that is important is because we are supposed to have Mr.
Charles Curie present, and he was looking forward to presenting. But in
anticipation of the swearing in, he received the call. So when your boss
calls, you can either ignore your boss and say no, I\'m going to go to
the CSAT Council, or you can say well, maybe I\'d better go to the
swearing in. So he won\'t be able to make it here today. He was
summoned, and I think it is an appropriate thing for him to do. So I
will be actually giving his comments.

The key issue is this is the second term for this President. Now we get
to focus on dealing with a new Secretary, new policies, and new issues.
So this council comes at a critical time. We can\'t assume that what we
have done in the past four years will be done in the next four years.
We\'ve got budget issues. This council meets, basically this is ten days
before the budget is supposed to be delivered to Congress. We will have
a new budget, that is being proposed. So we\'ll be able to see in ten
days, and you\'ll get a copy of the new budget when it comes, what our
resources are going to be like for the next fiscal year.

We already know from public accounts that there are projections of
deficits that money is going to be tight. So we\'ll see how that affects
our programs in short order. So again, we\'ll need your input.

We have scheduled a number of presentations from council members in
SAMHSA staff on status reports in specific CSAT and SAMHSA activities.
We will also have presentations from other entities, from Dr. Nora
Volkow, the Director of the National Institute on Drug Abuse, and
Michele Leonhart, the Deputy Administrator of the Drug Enforcement
Administration, each talking about activities at sister agencies that
are important for substance abuse.

Since the last council meeting, CSAT has been very busy. If you have
copies of the director\'s report, I won\'t read from that directly, but
it summarizes a lot of activities that we have been pursuing as a part
of the largest SAMHSA agenda, working in collaboration with the other
centers and the other offices within SAMHSA, and the service of Mr.
Curie\'s vision and our mission.

We will be releasing a new TIP next week, \"Substance Abuse Treatment
for Persons with Co-Occurring Disorders,\" on January 31st during a
roundtable at the Press Club. Some of you are familiar with the
co-occurring TIP. It has been long in development. I can tell you it is
a thick document. But of course we are very familiar with the issue of
co-occurring as a very complex issue.

Frank, you have done some work in there. So you can understand the
importance of this document.

We did have a meeting on e-therapy, telehealth, and telepsychiatry in
December. You\'ll hear more about that from my special assistant, Dr.
Sheila Harmison.

We have been actively involved in the disaster area. Of course we have
had a number of both domestic disasters, and as was pointed out by Dave
in terms of the tsunami, we have got some international disasters. We
have got SAMHSA staff who have been mobilized to participate in the
relief effort, and literally going off to the Indian Ocean as a part of
the support effort.

So SAMHSA in general has been actively involved in a lot of issues. CSAT
of course with our central focus being on substance abuse treatment, but
our partnership with the other centers and the other offices in the
service of Administrator\'s agenda is to deal with our vision, which is
a life in the community for everyone, and our mission is building
resilience and facilitating recovery.

With that, I\'m going to give you the comments from Mr. Curie. Taking
the time to read those comments becomes very important because, indeed,
he sends his regrets. He had up until the last moment planned to be
here. He feels that this is an important council. He feels that this is
an important issue. The block grant is \$1.6 billion, it is the largest
chunk of change that SAMHSA manages, and so it is understandable that he
would be invested in your opinions and your attitudes.

He wanted to welcome you here, and begin by welcoming you to our new
building. That\'s the other thing. Since our last meeting, as some of
you have commented on, we have a new building. We will have a walk
around toward the end of the day. We are all getting used to it. We have
been here since late August. CSAT moved in, so we\'ve had time to
acclimate. We\'re still working out the kinks that happen whenever you
move into a new building, a new place.

Mr. Curie wanted to say, \"I want to thank the Advisory Council members
for the tremendous work you do on behalf of the people we serve. I want
to thank each of you for grabbing every opportunity presented to you to
create real and lasting change in the President\'s first term. With your
hard work and the work of SAMHSA employees, the foundation of lasting
improvements was laid.

\"Now, during the second term, we can move ahead, cementing our gains
and building on our new initiatives. As we move ahead, I want to review
our progress, examine what still needs to be done, and map out our
future directions.

\"One of the major changes since our last meeting is in fact that SAMHSA
has moved. I hardly need to tell you how fundamentally important it is
to have SAMHSA together for the first time in this remarkable new
building. In the past what was working well in one center was seldom
communicated to those in other centers located in separate buildings.
Not so any longer. Where we once had single stars, we now have one
bright constellation. This building and the sense of community it is
creating has opened a new door to SAMHSA, and will truly help us in our
goal to become one agency with one vision and one mission.

\"Being together makes our vision of life and community for everyone a
little more attainable. It brings our mission of building resilience and
facilitating recovery a little closer.

\"Throughout our work to achieve our vision and our mission, HHS
Secretary Tommy Thompson was our biggest supporter. He supported our
move to this new building. He has supported and believed in our vision
and mission, and he has supported our budget requests. Most importantly,
he made it possible for us to continue to save the lives of those
Americans and families who struggle with mental illness and battle with
addiction. He has been our good friend and our strongest ally in
prevention. I will truly miss his leadership and guidance.

\"I also know that Secretary-designate Mike Leavitt plans to build on
Secretary Thompson\'s legacy. In his confirmation hearing, he has
outlined the issues and opportunities he sees confronting our nation. I
have every confidence that SAMHSA will continue to receive high levels
of support and will continue to advance the President\'s initiatives and
directives that benefit the people we serve.

\"The people we serve are often thought of as the unwanted. Those who
are homeless, who struggle with mental illness, and who battle addiction
are the very people our President spoke of in his inaugural address.
During his inaugural address last Thursday, President Bush said, \'In
America\'s ideal of freedom, the exercise of rights is ennobled by
service, and mercy, and a heart for the weak. Liberty for all does not
mean independence from one another. Our nation relies on men and women
who look after a neighbor and surround the lost with love. Americans, at
our best, value the life we see in one another, and must always remember
that even the unwanted have worth.\'

\"If ever those were people assembled to pursue a larger goal and a good
with a heart for the weak and who place value in the lives we see in the
unwanted, it is this advisory council. Among the many tasks that will be
asked of you in the future, I ask you to approach each one with a sense
of surrounding the lost with love.

\"Some major themes I expect to see emerge over the next four years
include increasing efficiencies and focusing on outcomes, pushing
science to new heights, containing health care costs, and increasing
access to health care services. I believe you will see major advances in
the use of health information technology. I expect SAMHSA will play a
key role in each of these focal points, because these themes are already
woven throughout SAMHSA\'s major initiatives.

\"The administration\'s support for and confidence in SAMHSA, coupled
with our sharpened focus on a few key program areas, could not have come
at a more important time. With a recently approved fiscal year 2005
budget of more than \$3.4 billion, SAMHSA will continue to administer
and fund a rich portfolio of grant programs and contracts.

\"Clearly we are entering tighter budget times, and we will not be
seeing the same increases we have enjoyed in the past. However, we have
built a solid foundation through our relationships. We have focused on
common ground, and will undoubtedly be able to swiftly and judiciously
rally our resources.

\"Our emphasis on fiscal responsibilities are no stranger to those of us
in government, and no stranger to those who rely on government dollars
to operate, nurture, heal, and support. As you know, SAMHSA\'s matrix of
priority programs identifies 11 areas to ensure that our work is
focused. I will highlight only two today for the purpose of my update.

\"The first is substance abuse treatment capacity and Access to
Recovery. As you know, President Bush resolved to help people with a
drug problem who sought treatment but could not find it in his 2003
State of the Union address. Toward that goal, he proposed Access to
Recovery. The President proposed to provide grants for a state-run
voucher program for substance abuse clinical treatment and recovery
support services. It was designed to accomplish three main objectives.

\"First, expand capacity by increasing the number and types of
providers, including faith-based providers who deliver clinical
treatment and/or recovery support services. Second, allow recovery to be
pursued through many different and personal pathways. Third, require
grantees to manage performance based on outcomes that demonstrate
patient successes.

\"Access to Recovery recognizes that the process of recovery is a
personal journey. It can take many pathways, including physical, mental,
emotional, and/or spiritual pathways. Under the Access to Recovery
program, people in need of addiction treatment and recovery support
choose the programs and providers that will help them most.

\"President Bush had proposed \$200 million for this in FY 2004 for
SAMHSA\'s set in place for the first year of Access to Recovery.
Congress ultimately appropriated \$100 million. The President again
requested \$200 million for Access to Recovery for 2005 to expand the
program. Again, Congress only appropriated \$100 million, eliminating
any opportunity for expansion this year.

\"I had the honor of joining President Bush in Dallas in August when he
announced the first 15 ATR grants. Fourteen states and one tribal
organization were selected through a competitive grant review process
that included 66 applications submitted by 44 states and 22 tribes and
territories. So you can see we\'ve got the investment of a number of
entities in Access to Recovery.

\"While all applicants had the opportunity to expand treatment options
for different target population groups and utilize different treatment
approaches, they all had to meet some specific common requirements.

\"The first was to ensure genuine, free, and independent client choice
of eligible providers. Second, they had to establish how clients would
be assessed, given a voucher for identified services, and provided with
a list of appropriate service providers from which to choose. Third,
applicants were required to supplement, not supplant, current funding,
thus expanding both capacity and available services.

\"Finally, they will all report on common performance measures to
illustrate effectiveness. In both program design and implementation,
applicants delineated a process to monitor outcomes. These performance
measures that I will discuss later will be used to measure treatment
success and the ultimate success of the voucher program itself.

\"The second priority program I want to discuss is the Strategic
Prevention Framework to help all Americans lead longer, healthier lives,
and to get at health care cost containment. We must use the power of
prevention. Fortunately over the years we have shown prevention programs
can and do produce results.

\"The word about what works in prevention is getting out, but much work
remains to be done in substance abuse prevention in the relatively new
and emerging area of mental health promotion and mental health
prevention. To provide a structured approach to substance abuse
prevention, mental health promotion and mental health prevention, we
launched SAMHSA\'s Strategic Prevention Framework during the National
Healthier U.S. Prevention Summit in Baltimore, Maryland in April of
2004. With the launch of the framework, both President Bush and
Secretary Thompson recognized that it is time that programming policy
and America as a whole recognize that substance use and mental disorders
should be treated in the same concern and urgency as diabetes, obesity,
heart disease, stroke, and cancer.

\"In 2004, we took a major step toward building this framework. We
announced the availability of and awarded \$45 million to 19 states and
two territories through a competitive grant process. The challenge for
SAMHSA in the coming year is to continue to build a national commitment
to the community-based risk and protective factor approach to prevention
used in the framework.

\"As you know, the SAMHSA matrix priority programs are managed by
applying the same cross-cutting principles to all priorities. One
cross-cutting principle that I will provide an update on today is the
SAMHSA data strategy. To help present consistent and reliable
information, we are continuing to implement our data strategy.

\"The strategy is simple. The tighter our measurements become, the more
we can prove our effectiveness. The greater our effectiveness, the
greater the number of people served, and the greater the chances for a
life in the community for everyone.

\"Developing a data strategy is a task that has been hanging around for
years. Now we have gotten real about doing it. Just last month we held a
major meeting with substance abuse prevention and treatment leaders on
implementing our strategy. We have committed to holding a similar
meeting with the nation\'s mental health services leadership in the very
near future. Our work with the states and our grantees is critical to
building requirements to achieve true accountability in a performance
environment by transforming the way we do business.

\"We have learned that a limited number of key outcome measures in
structured ways can help us all know how well SAMHSA and its grant
programs are building resilience and facilitating recovery. Our emphasis
on a limited number of national outcomes and related national outcome
measures is built on a history of extensive dialogue with our colleagues
in state mental health and substance abuse service agencies, and the
people we serve.

\"Ultimately these outcome measures will extend across all SAMHSA grant
programs. All of our programs are about achieving our vision of a life
in the community

for everyone, and our mission, building resilience and facilitating
recovery. So it only makes sense that SAMHSA uses the same outcome
measures across all of our programs.

\"The national outcome measures we have identified are, one, abstinence
from alcohol abuse or drug use, and decreased symptoms of mental
illness. Two, increased or retained employment and school enrollment.
Three, decrease involvement with criminal justice system. Four, increase
stability in family and living conditions. Five, increase access to
services. Six, increase retention in services for substance abuse or
decreased utilization of psychiatric inpatients beds for mental health.
Seven, increase social connectiveness.

\"Already SAMHSA is implementing these national outcome measures through
Access to Recovery and the Strategic Prevention Framework. Focusing on
these handful of national outcomes will minimize the reporting burdens
on the states and other grantees, and will promote more effective
monitoring of client outcomes and system improvements.

\"Ultimately they show that people are achieving a life in the
community, a home, a job, and meaningful personal relationships.
Achieving SAMHSA\'s vision of a life in the community for everyone will
require collaborative efforts from all individuals, organizations, and
levels of government that deliver these services and supports. Although
barriers still exist, they are being overcome.

\"Together with our many partners, our new Secretary Mike Leavitt, and
you, our CSAT Advisory Council members, we will continue to bring the
message of hope, courage, recovery, and the promise of a life in the
community for everyone.

\"Thank you.\"

Those are Mr. Curie\'s comments, but I think they summarize all of what
we have been doing here at SAMHSA, and they capture our commitment to
make sure that we have services available to people, and that we have
outcome measures. It is no longer sufficient to say give me the money,
trust me, I will spend it wisely.

As a result of our focus on performance, we have been able to achieve,
shall we say, green status from the Office of Management and Budget in a
number of areas, because indeed, we recognize that it is critical that
grant programs deliver. If we fail to deliver, then basically the money
can be spent best elsewhere.

We all know that we have a major substance abuse problem in the United
States. We have a major treatment problem in the United States, and that
is fueled in part by denial. There is a profound denial gap in the
United States.

When we look at our Household Survey data, and you\'ll hear from several
members from the Office of Applied Studies, we find that 78 percent of
the people who meet criteria for needing substance abuse treatment
services do not perceive a need. Eighty-nine percent of people who meet
the criteria for needing services secondary to alcohol abuse and
dependence do not perceive a need. So the engine that drives illicit
drug use is not just those who are presenting for treatment, but
actually the overwhelming body of individuals who do not perceive a need
for treatment.

This is why community-based organizations and faith-based organizations
can play a major role. The vectors of values of a community can help
reinforce the notion that recovery is necessary, recovery is possible,
and that people in recovery are welcome in the community.

We need to be able to address this issue of not in my backyard, NIMBY.
The community conveys a contradictory message. We want you to stop using
drugs, but oh, by the way, we don\'t want you to stop using drugs in our
neighborhood. The interpretation is okay, as long as we\'re using drugs
in your neighborhood, that\'s okay.

By that, I mean if the community will tolerate the drunk driver next
door or the person using crack or methamphetamine down the street, but
says to the people who want a drug-free halfway house in the vacant
building, we have this building, we have people who are in recovery in
this building, they say no, we don\'t want drug users in our
neighborhood.

Stigma distorts recovery in the minds of the neighborhood. For no other
condition, if someone says, I\'m trying to recover from diabetes, the
neighborhood doesn\'t come up with hue and cry and placards and banners
saying we don\'t want recovering diabetics in our neighborhood. If
you\'re trying to recover from arthritis, the same thing does not
happen.

The community is safer actually for those people who are saying, I
perceive a need for treatment, I\'m actively involved in a treatment
process, and I\'m actively involved in recovery. But somehow that gets
lost in the dialogue. It discourages people from pursuing recovery
efforts.

So what we are trying to do is make sure that by demonstrating that our
programs work, what we are trying to do is demonstrate that the
community needs to have a commitment and an investment. So all sectors
of the community need to be involved in the recovery process.

That is what recovery management services are about. We started a
recovery support services program a number of years ago to facilitate
that kind of construct. It has been subsumed under Access to Recovery in
part because we see that it is not the acute treatment effort that
resolves the problem, it is that continuum, because you need acute
treatment and you need community support. If we don\'t do that, then the
attitude is people in recovery are going to relapse, they are no good,
they are this, they are that, and we don\'t want them in the
neighborhood. Until of course somebody sends their daughter or
themselves, and then all of a sudden everyone wants efforts.

We need that, because we also recognize that private payers of insurance
have retreated from playing a major role in paying for services. That is
unfortunate. So one of the things that we will be discussing is this
notion. We need council members to bring to us information about what is
going on locally, what is going on in your jurisdictions, what is going
on in the communities that are struggling with this issue about who you
know. Whether it is at an HBCU, tribal community, recovering community,
a treatment program, or a state agency, we need to all put our heads
together to address this. That makes our efforts here at SAMHSA more
viable. We need to be able to deal with the needs of those with
co-occurring disorders.

Our TIP is going to speak to that. We\'ve got efforts that address that,
but they don\'t constitute the largest group. The largest group of
substance users are those in denial. We need new strategies. We have got
a screening and brief intervention effort to attempt to reach people in
different settings. If you wait until they show up at specialty
substance abuse treatment programs, clearly you are dealing with a
different group of people.

We know from DSM-IV and from your own experience that people who meet
criteria for abuse and dependence are having problems. So you are not
surprised when the person who is on his fifth DUI comes before you,
Judge, and says, I don\'t have a problem. He is on his fifth DUI, and he
promises, well gee, maybe the first one was an accident, and the second
one was unfortunate. But by the time you get down to five, I think
pretty much there is a pattern there. Yet this person is able to
conclude that they don\'t have a problem. How is that?

So 78 percent of the illicit drug users are saying I don\'t have a
problem. We must reach those individuals in different settings. We
can\'t simply rely on the professionally driven treatment programs. We
need the treatment programs, but we also need to be able to reach the
people elsewhere like the community health centers, the schools, whether
it is the churches, whether it is the community centers, or whether it
is the employment setting.

If you are having problems, they are manifests. We know that these
people are having problems, and they must be manifested to others in
their community. We need the community to help us with the intervention
so that we can address the problem. That hopefully will save money.
That\'s what we are also relying on. If we address people early in the
addiction, they won\'t have lost so many things, they won\'t have
crossed so many barriers and created so many problems for themselves,
their families, their neighborhood, and their community.

So with that, I\'m going to ask Melody Heaps, who has managed to join
us, and travel is difficult these days.

Melody, do you want to introduce yourself?

MS. HEAPS: It\'s not travel. It\'s just reading agendas, which I seem to
have lost the ability to do.

I\'m Melody Heaps. I\'m the President of TASC, Inc., in Illinois. We\'re
an agency that specializes in sentencing alternatives for substance
abuse and the mentally ill, as well as working with other public systems
to be a referral and case management system for people for the public
sector to get into treatment.

DR. CLARK: Melody has been a stalwart contributor to our reflections and
discussions over the years. So another person who has got a historical
commitment.

Welcome again, Melody. Thank you for being able to make it. That helps
us.

Before we start, any comments from council members?

DR. MADRID: I had one question, Dr. Clark.

On the Partners for Recovery, could you give us just a very brief
rundown as to where we are at with that one in reference to follow-up on
those collaboration conferences that we had and some of the work that is
being done there?

DR. CLARK: We are in the process of doing follow-up for Partners for
Recovery. We are expanding the steering committee so that all of SAMHSA
is able to be represented. We are going to have mental health
representation on the steering committees of PFR.

We have got support from Mr. Curie on PFR, so we are trying to refine
that right now. Then we are going to go off and continue the work about
which you speak. It is clear that the recovery construct is one of
paramount importance to Mr. Curie. It is of also paramount importance to
the President. So recovery is a construct, and it weaves its way through
all of what we do from PFR to other activities.

Some of you may also know that there is the question of what is
recovery. So we have got a subcommittee working with OAS and others
trying to put a spin on the whole definition of recovery. There has been
a recent report released by NIAAA that was published in the journal
Addiction, trying to capture the essence of the recovery process.

So part of what PFR is doing is not only the work of which you have been
involved in, but also trying to get a better handle of recovery across
the spectrum of conditions associated with mental illness and addiction.
Mr. Curie points out that the mental health community has adopted the
recovery construct, and now the issue is how to refine it so that it has
meaning to all those who are pursuing recovery, whether it is recovery
from mental illness, a mental health oriented recovery, or recovery from
substance abuse. So we will be working on that dynamic. So PFR is alive
and well, and we will be pursuing the refinement of our activity over
the next couple of months.

Frank?

DR. McCORRY: Dr. Clark, I was interested in Mr. Curie\'s comments on
SAMHSA\'s data strategy and the SAMHSA outcome domains. Does the
strategy reach out to other care giving systems, or other systems that
might have some of the data relative to such things as decreases in
criminal justice and an increase in employment, which really isn\'t in a
mental health substance abuse care giving system. Does the data strategy
talk about an integrated database that might have to extend beyond
SAMHSA, or is it currently now just trying to get mental health and
substance abuse to come up with the same kinds of measures?

DR. CLARK: Clearly, the uniform measure strategy is the first step, so
that you have some common understanding across platforms. As you know,
nationwide many substance abuse programs are subsumed under either
public health or mental health. So what we need to do is get everybody
on board.

What you point out is in terms of additional data, collateral data, and
whether it comes from criminal justice or child welfare, that\'s very
important, and we are interested in facilitating those kinds of
relationships, because at the end of the day, from the substance abuse
treatment point of view, our biggest referral source is the criminal
justice system. Our data shows that 36 percent of the referrals for
substance abuse treatment come from the criminal justice system.

So it is in their best interest and our best interest to get data,
because at some point, as Judge White-Fish would say, the questions will
be asked of them. Well you\'ve got all these newfangled strategies, what
are they doing? Re-arrest rates, is the community safer?

So all of us are interested in the same outcome, and that is the beauty
of the seven domains.

DR. McCORRY: Being new to the council, I don\'t know, perhaps there was
a presentation recently, but I\'d be interested in kind of knowing more
about that at some point in our deliberations to see both SAMHSA\'s
vision, as well as its impact on corollary systems or kind of sister
systems in providing care to people who end up with alcohol and drug
problems. Just kind of get a better feel for it, a deeper feel for it.

DR. CLARK: Very good, and we\'ll put your name down as someone
interested in our data strategy.

Val?

MS. JACKSON: Yes. I just wanted to make a comment on your comment
concerning the 78 percent of those people who do not perceive themselves
to be in need of treatment.

I think we need to really think seriously about that figure and what
that says. One of the things that I thought about while you were
speaking is the fact that it would be interesting to know if some of
that 78 percent doesn\'t have a pretty good idea that they need
treatment, but they are scared to death to bring that out into the open,
because that\'s a dangerous thing to do in many communities. It is
dangerous because people are looked down upon, it is dangerous because
if one person identifies themselves as an addict, then they seem to not
become a person anymore after they go through treatment. They are that
recovering person, that recovering addict, so their whole self is
defined in that afterward.

It would be very nice if we somehow could move into a state. I see the
prevention messages that talk about I have better things to do than
drugs. I think those are really marvelous. I would love to see at some
point, whether it is us, ONDCP, or our states, get involved in messages
that say you know, recovering is a really positive thing, recovering is
an okay thing. Here is my pal, and this person is employed. I am
speaking to the choir, I know.

It seems like our public perception of addiction is still really
negative. I\'d just like to punctuate that with one thing, and that is
some people will know the name of this once-famous football player who
recently in Miami was arrested. On the news, it was said he was bipolar
and had substance abuse problems, and he was found recovering in the
upper floors of a hotel room. I don\'t know if there was a robbery
involved or not, but it was very clear that the man was very ill.

The last bite that they did on this was to have a guy with a nice
baseball cap on come up and get interviewed by the press and talk about
the situation. They said, you know, I wouldn\'t want to have this guy
around me. That was the bite that got on the 11:00 news. I thought it
was just embarrassing for my field to have that kind of public image.

DR. CLARK: Two things. One, we\'ll have an opportunity to discuss the
issue of perception and need of treatment with Joe Gfroerer, who is
presenting on the Household Survey data, where some of this comes from.
In anticipation, though, of his presentation, the questions are asked to
segregate those who perceive a need for treatment but are reluctant to
pursue treatment for reasons against those who do not perceive a need of
treatment.

Oddly enough, only about 7 percent of the people who perceive a need for
treatment are not in treatment, and they have a host of reasons, one of
which is stigma. As I interpret the Household Survey data, and again,
we\'ll have Joe here, he will be able to answer that, but basically 78
percent do not perceive a need for treatment, period.

The data shows that of the remaining people, the bulk are in treatment,
and then there is about a 7 percent cluster of individuals who perceive
a need for treatment, but who are not in treatment. The chart blows that
7 percent up. But the 78 percent, that seems intransigent. But again,
you\'ll have an opportunity to talk to Joe Gfroerer.

With regard to the second matter in terms of recovery, that\'s why we
have Recovery Month, and that\'s why we need communities involved. It is
not only celebrating recovery from the perspective of the person
recovering, but it is getting the community to have an investment in the
recovery construct.

Unless we get the community to recognize the utility of recovery, then
we have a problem. Because indeed, you can have people who disdain those
who have substance abuse problems as if indeed it is not to happen. I
think what you are saying is correct, but it is not the stigma. It is
the social reinforcement. You either have a problem or you don\'t. As
long as you\'ve got denial that says, I\'ve got a job, I\'ve got a
family, I\'ve got a car, I\'m doing this, I don\'t have a problem. So
what, me worry? Why are you telling me I have a problem?

So by the time that person crashes and burns, now the costs go from
nominal to astronomical. So then that remaining 22 percent start to have
a problem. But the problem is actually developing well before you hit
the wall. There is no message to you that they are developing well
before you hit the wall. Recovery Month becomes a critical construct in
this effort.

MS. JACKSON: If we could just have Recovery Year after year, after year,
after year. I was seeing PSAs and so on that were addressing the very
things that we do in Recovery Month. It needs to be a repeated,
repeated, repeated message. I think Recovery Month is great, and I have
participated in it. I would love to see our state, and every state
somehow be able to carry that.

I see PSAs on television about diabetes and how important it is if you
have diabetes, you can manage it, you can take care of it, you can do
something about it. I don\'t see PSAs about hey, if you\'ve got an
addiction problem, you can manage it, you can do something about it, you
can live with it.

DR. CLARK: Okay. Back to Recovery Month, in fact we do produce PSAs. The
decision to run the PSAs is a local decision. Part of the Recovery Month
construct is not just to focus on September, but also to make it clear
to the local media that indeed these are things that we want to see on
TV. If you are going to choose to run PSAs, we want some of those things
on recovery.

These things are not September-specific. We work to design PSAs that are
generic, and can be. But part, again, of the issue is what does the
community want, what does the community say, and where is the message to
pursue recovery coming from? But again, we value your continued input
into this.

Ken?

MR. DeCERCHIO: I\'ll pass for now.

DR. CLARK: Richard?

DR. SUCHINSKY: Apropos of your very interesting statistic of over
one-third of the patients who come into treatment are from the criminal
justice system. It strikes me that the whole issue of involuntary
treatment really has not been put on the agenda in any sort of specific
way.

The criminal justice referrals are involuntary treatment for the most
part. There is a real question of whether there shouldn\'t be greater
emphasis on involuntary treatment in the civil system before they enter
the criminal justice system. We have all met individuals who have
serious problems who deny that they have any problem. The families are
at their wits end as to how to handle those individuals, yet they have
no mechanism that is implemented, even though most states have
involuntary commitment laws that would allow these individuals to be
induced into treatment even though they perceive themselves as not
having a problem.

I understand that it is a very dicey issue, but on the other hand, I
think it is something that should be on the agenda, because I think it
does represent a mechanism that could be of tremendous use.

DR. CLARK: Gregory?

DR. SKIPPER: This is interesting to me because most of what I do with
physicians and other professionals is basically inducing them to face a
problem early because the profession has taken up the mantle, so to
speak, and said we\'re going to maintain this program to try to identify
physicians earlier, or veterinarians, or other professionals, the
lawyers have it, airline pilots, before they are actually really ready
for treatment, we\'re going to go in and say, you\'ve got a problem,
here is why, let\'s get an assessment.

It is a good process. I\'m meeting today with someone to look at
studying these professional health programs to see if we can move this
into the marketplace more to get other employers. I have attempted,
because I have seen the utility of having the profession, so to speak,
the workplace more or less coerce treatment. I wonder if we could get
that in the school systems and through industry and that kind of thing.
I have run into barriers with companies feeling like it is none of our
business. We just want them to perform well, we don\'t really want a
role in monitoring, we don\'t want to do contingency contracting and
that kind of thing.

But anyway, so we are looking at doing a study to study these programs
and see why they are so effective, because they do appear to be very
effective. Early detection, accountability, that kind of thing. I think
that would be a good direction to move in.

DR. SUCHINSKY: I might just say that I\'m associated with an
organization called the Group for the Advancement of Psychiatry, GAP,
and we are about to submit a paper for publication on the whole issue of
involuntary treatment in the substance abuse field. It is a survey of
what is being done, what is available, and what could be available in
that area. So I think it has relevance to this. It will probably be in
Psych Services sometime in the next six to eight months.

DR. CLARK: Melody?

MS. HEAPS: As someone who runs an involuntary treatment program or
treatment system, I just want to caution you to think about the impact
that would have on the justice system, that the whole civil justice
system now becomes once more the repository of what we have failed to do
in other health or social service systems.

The inability of physicians to early detect, the inability of school
systems, the failure of many of our institutions to detect, encourage,
and make as a significant alternative the ability to get into treatment.
That is one of the problems. The justice system is barely functioning
now given what has happened in terms of the explosion of substance
abuse, and now we would add this layer on, and pretty soon all of what
we are doing would be justice oriented. I\'m very concerned about that.

DR. CLARK: Judge?

JUDGE WHITE-FISH: Court systems across the nation have seen involuntary
commitments, but a lot of it falls back upon them. When the court system
does go ahead and order it, there are no monies from the county system
in order to pay for that treatment.

I was very interested in what Richard was saying, and I would like to
see a copy of that paper addressing that. Now, it has been a problem
across our nation for years, especially when insurance then decided to
reduce treatment costs, or insure treatment costs down to 14 days from
30 days.

I\'m one of those old therapists that we kept our client as long as we
possibly could until the disease was treated. We know there is a lot of,
I don\'t want to say evidence, that isn\'t the correct word, but we have
a lot of data saying it takes longer than 15 days to treat an
individual. But if we turn around and look at the justice systems, their
hands are bound as well because a lot of court systems, a lot of judges
cannot order the treatment because where does that fall upon? That falls
upon the county system or whatever system.

Personally speaking from the tribal level, we have great insurance. All
of our tribal members are insured. The tribe insures every one of the
tribal members once they are enrolled. That is covered at 100 percent,
100 percent. However, the problem is if I order treatment, even though
we have our own health insurance, our health insurance department will
not cover it.

So even our tribal members are caught, which I am pushing even in our
own tribal government. If we have our own health insurance, then why do
you limit our judicial system when we order treatment? It is going to
come off of our health insurance anyway.

So what I do, what the judicial system does in my area, I give you an
option sir, or ma\'am, as you stand before me. You can either take this
as a suggestion of looking at treatment, or if I have to order it, you
are going to have to pay for it. That is where, again, our judicial
system, and not only ours, but a lot of judicial systems across the
nation, their hands are tied. As Ms. Heaps says, then it becomes a
judicial problem. We already have one, as has been identified to you.

Thank you.

DR. CLARK: Ken?

MR. DeCERCHIO: We have a civil commitment process in Florida. But the
feedback that I get regarding it is that as treatment continues, the
high expectation for secure treatment and secure assessment that goes
with civil involuntary commitment, we evidently don\'t have that. We
have a couple of secure detox or assessment facilities, but we generally
don\'t have secure residential treatment. So there is a frustration out
there with folks who are very difficult and very much in denial about
not following through with even initial participation in treatment, then
using the power of contempt and due process in order to potentially
incarcerate someone as part of the sanction around the civil commitment.

You can see where this goes. I mean, you get into a lot of dangerous
areas. You start talking about incarcerating folks over a civil process,
you talk about creating secure treatment. It is a reluctant development,
if you will. It is a reluctant growth, and I\'m not sure that it is one
that we want to look at.

I personally have kind of resisted moving in the direction of secure
treatment, frankly, for adults outside of the criminal justice system.
We have some secure treatment in jails, obviously, and correctional
facilities. But on the civil side, it is a bit dangerous. It is a bit
dangerous. You look at our history, you look at the Hughes Act and
decriminalization, and it is a bit dangerous I think in the other part
of that development in terms of going very far on that end on the civil
side.

DR. CLARK: Frank?

DR. McCORRY: It would seem, though, that this issue of involuntary
treatment may have shifted in the past, I\'d say, because there is a
fairly strong database on the value of involuntary treatment in terms of
similar outcomes, whether it is voluntary or involuntary that was put
out by NIDA years ago. But with the introduction of drug courts and more
of these civil commitment processes that I see more on the mental health
side than on the substance abuse side, and some kinds of civil coercion
or civil direction, as well as drug courts in which judges are now
acting much more in a clinical or a treatment mode rather than just a
judicial mode, that whether this issue of involuntary and what is
considered involuntary versus some other kinds of shifts in the way
clients are engaged is an interesting topic.

There may have been some movement here in kind of subtle ways, but
dramatic ways in terms of how the cudgel is used as much as the carrot
in terms of inducing someone into treatment. A cudgel might look like it
is judicial, but it really might be kind of more the format of the court
rather than the actual implementation of it. It is an interesting issue
maybe to look at at some point.

DR. CLARK: Melody?

MS. HEAPS: I obviously have very strong feelings about this, having
worked with the justice system now for 30 years. It isn\'t the form. It
is the fact that a defendant comes before a judge and the judge says,
you have two choices. You can either go to treatment, or we\'re going to
incarcerate you for X number of years. That\'s the choice the client
has. It is not the form, it is the sanctioning process.

We have absolute research that says there is no question that that
sanctioning process actually is very effective in breaking down denial
and moving persons into treatment with successful outcomes. In fact,
unfortunately research which is being done on Prop 36 in California
where no sanctions are offered, there is simply referral, shows a very
dismal success rate. So we know sanctions work.

But to extrapolate from that, we now need to move to a civil commitment
process where once again, it is like opening Pandora\'s Box. Ken talked
about what happens from when the person doesn\'t comply. We have now
moved it into a justice system, into the criminal system. It starts out
in the civil system.

The courts right now don\'t have the capacity to treat the criminal
justice clients that it sees, much less to add to it. So I just want to
caution you that I think one of the problems becomes, and one of the
reasons that I started TASC, was that I saw that our social and health
welfare system failed and was putting the burden on the criminal justice
system.

I hear in some of the dialogue, not just here, but in other places, oh,
well, we can\'t make it work, so therefore, let\'s get the court
involved, let\'s get the justice system involved. We further criminalize
the population, we further stigmatize the population, and we take the
burden off the physician, off the school, off the employer, off the
family, and off the church.

So I obviously feel strongly about that. Not that we shouldn\'t look at
this, but I think we have to do that with these factors in mind.

DR. CLARK: Gregory, last comment.

DR. SKIPPER: I think one thing to look at here is definition of
involuntary. It doesn\'t have to be moved into a court. Involuntary,
what I\'m thinking of is the family says we\'ve had enough of this. Too
often you hear family members saying well, we\'re not going to do
anything because they\'re not ready yet, they don\'t want it yet. So the
whole idea of enabling and that kind of thing.

I consider involuntary treatment as a definitional thing when the
employer says look, you either get some help or you\'re fired. It
doesn\'t have to go onto the court process. So the message we need to
get out there is people don\'t have to be ready. We can set limits in
any sphere in the community. The community that says that that crack
house isn\'t my responsibility, we need to have people know they set the
standard for their community, they set the standard for their family.
The employer needs to say we set the standard for the workplace, and get
people to start demanding a higher level of health with regard to
addiction. That is what I mean by involuntary.

DR. CLARK: Well, thanks. That has been an exciting discussion.

(Laughter.)

DR. CLARK: Well, it\'s an important one. I think you have mapped out the
spectrum of concerns, and indeed this is not going to go away. So this
dialogue actually needs to continue, except for not today. We can bring
it back from time to time.

We do need to figure out how to get the engine that drives the illicit
drug market to care. I mean, if I were a drug dealer, as some of you
have heard me say, would I worry about the 22 percent of people who are
either in treatment or want to be in treatment? Or the 78 percent of the
people that say, \"What, me worry?\" That should be obvious. From the
marketplace dynamic, it is the 78 percent that I\'m interested in.
They\'ve got jobs, they are good customers, they don\'t think they have
a problem, and they are less likely to be narcs.

So our job, the community\'s job, is to say how do we address that 78
percent? We know that in order for them to have jobs, they\'ve got to
have an employer, they\'ve got families, they\'ve got this, they\'ve got
that. Somebody knows that there is a problem. So we just need to figure
that out. I\'m glad to hear this discussion.

Now it is time to move onto our next discussion, which will be engaging
the faith-based community in recovery. The lead on that is our council
member Dave Donaldson.

MR. DONALDSON: Thank you, Dr. Clark, for this opportunity.

Martin Luther King, Jr., once said, \"A social movement that just
changes people is revolt, but one that changes both people and
institutions is a revolution.\"

We are experiencing revolution as it relates to the faith community
partnering with government. I think it needs to be said at the outset
that the goal of this revolution is not to publicly fund proselytizing,
but it is to ensure that both faith-based and community-based groups can
compete on a level playing field, regardless of whether they are
religious or non-religious, so that our brothers and sisters that we
have been talking about here this morning that are enslaved by drugs and
alcohol can have access to the best help.

Nobody is saying that just because a program is faith-based that it is
going to be the best, but it may be the best. We just need to make sure
that the most effective programs are not marginalized so that people who
have needs, that deserve the best, get it.

In this revolution, in many ways CSAT has been a vanguard. Some of you
if you know the history of the faith-based initiative, it didn\'t start
with President Bush. President Clinton signed into law charitable
choice, and then part of this bipartisan continuum, President Bush
signed the Executive Order in January of 2001 for the Faith-Based and
Community Initiative.

We are grateful for the leadership of Mr. Curie and also Dr. Clark, and
the implementation and talent of these two individuals right here.

We are going to believe for a miracle this morning, because we\'ve got
three people that are going to share in 15 minutes. We are going to
start with Jocelyn, and Jocelyn is going to talk about the past
successes of CSAT\'s outreach to the faith community. I\'ll talk about
our strategy, and then Clif will talk about the future.

Jocelyn?

MS. WHITFIELD: Well, good morning to you. It is also a real privilege to
have worked with Dave over the last three years. We have worked with We
Care America, and they were one of our intermediary organizations that
have really pioneered some of the technical assistance that we have
provided to the field in the last four years.

I just wanted briefly to just kind of give you an overview of what
we\'ve done, and some of our accomplishments. In fiscal year \'02, the
faith-based roundtables and discussion groups identified grant writing
as one of the top priorities. As a result of that, we began to really
work endlessly to provide technical assistance to faith and community
groups all throughout the country.

In fact, I think we covered almost 46 states, did we not, in our first
year. We conducted about 42 grant writing workshops. In fiscal year
\'04, we continued the emphasis on grant writing and expanded to address
licensure certification, best practices, and 92 events. As a result of
that effort, we had three to five organizations that have applied for
certification and licensure, and have received it. They are now
receiving state, federal, or local funds as a result of it.

In fiscal year \'05, our strategic effort changed a little bit. We
recognized that we needed to begin to look at treatment providers and
recovery providers that could compete for federal funds, that could work
with state systems, and also work with ATR. So we began to really look
at their organizational readiness to see whether they were capable of
providing those services.

We wanted to look at the infrastructure and some of those other things
to make sure that they had the capacity to deliver these services. So we
are doing a lot of work with that this year.

Well, as a result of the training, we have had about 6,500 individuals
representing faith and community organizations that have participated in
our training activities. As a result of those activities, over \$18
million has been awarded to faith and community grassroots
organizations. Most of that has come from private foundations, some from
state, and some from the federal arena.

As a result of that, as a result of our effort, what has happened is
that we have been able to increase access to private funding. We have
been able to increase treatment recovery options and services, and we
have been able to engage state FBOs and single state agencies in
partnering with our faith-based organizations.

These are some of the training activities that have taken place. We have
dealt with grant writing programs, development programs, and evaluation.
We have also provided training on evidence-based practices, because we
wanted to make sure that they are providing quality treatment and
recovery services.

We have also done a lot with addiction certification for counselors, and
licensure for

faith-based organizations to make sure they are meeting the standards
and licensure requirements of the state. One of the publications that
I\'m going to talk about in a few minutes, most of you have in front of
you, and that\'s our national overview. That\'s a technical assistance
document that will provide these community organizations and faith-based
organizations with the standards and the licensure requirements state by
state, and also the counselor and prevention professional requirements
for certification and credentialing.

These are some of the services that

faith-based organizations have offered in the past. It isn\'t that they
just started offering these things. They have been doing it historically
for a long time. They have offered mentoring programs, job training
programs, housing programs, and transportation programs. They have also
provided support groups. You are talking about recovery support today,
but they have been doing this for the last 15, 20 years.

So these are some of the things that they are offering, and still are
offering the community at large. They have also partnered with SAMHSA to
do some of these things as well.

These are the two resources that will be available to you and all of the
consumers as of February of 2005. They will be on the SAMHSA website,
and you can get them from NCADI. That is the national review that I
talked about previously, \"Successful Strategies for Recruiting,
Training, and Utilizing Volunteers.\"

So I want to thank you and Dave.

MR. DONALDSON: Thank you, Jocelyn.

Give her a hand. I thought that was tremendous. Thank you. That was good
and fast.

(Applause.)

MR. DONALDSON: Engaging the faith community. First of all, hopefully
you\'ve had a chance to read the report that was done by SAMHSA in the
\"Core Competencies for Clergy and Other Pastoral Ministries.\" I\'m not
going to read it, but there is some interesting information that the
panelists delineated. The multiple intersecting roles of clergy and
other pastoral ministries in our country.

It is just a terrific report on how the faith community is part of the
answer to addressing the crisis that we\'re in. The strategy that we\'ve
employed with engaging the faith community is what we call the five
R\'s. The first is relationships, and as Dr. Clark mentioned, finding
common ground. These workshops that have been conducted across the
country have been just a fabulous catalyst for bridging this relational
gap between SAMHSA and the faith community.

It is interesting, some of the ones that I have spoken at, I have asked
for a show of hands on how many even knew there was a government office
there. Most of them were not even aware. So that was a good place to
start. Also we have helped literally thousands of groups understand the
process of how to apply for the grants, how to work with SAMHSA, and
specifically CSAT.

For many of these groups, working with government, it is like dancing
with a porcupine. They don\'t know exactly where to grab onto. So we
have been able to I think help there as well. But we feel like on the
SAMHSA site, some ways to build the education there is through your
in-service day, which can focus on CSAT\'s work with the faith
community, and to inform SAMHSA, but also to solicit feedback. Regular
communications, such as email updates, that\'s another that needs to
happen.

The second is representation. Another byproduct of these events that
again, have happened across the country, are coalitions that have
evolved. Multisector coalitions. It has also been a unifying way for the
faith community to come together, which is not easy. But we have seen
faith-based organizations that are now working together, sharing best
practices. So these coalitions are beginning to emerge across our
nation.

We need to increase faith-based involvement in the review process, and
we\'re going to be working more on that. Application, making sure that
more are applying for the funds. We want to continue to work with Ivette
for mobilizing for the National Recovery Month. That\'s a wonderful
entry point for the faith community.

Three is results. Results. We want to mentor. We really feel as we have
literally got an idea of what is out there, that there are many groups
that have the potential to qualify. Those are the ones that we need to
coach, we need to mentor and get them over the goal line.

We also want to continue with developing our trainer of trainers, the
TOTs, so that we can move from addition to multiplication. There are
people out there that have the ability, they have the expertise, they
just need to be equipped to equip their sphere of influence.

Resources. Leveraging private with public resources. We heard this
morning about the cuts and how we are needing to tighten our belt. We
need to communicate to these groups that are applying that they need to
leverage their private with public resources. I think there needs to be
incentives there. Increased scoring points for groups that are
leveraging those resources.

Another thing that I didn\'t mention is that with our committee, our
Subcommittee on Faith-Based, this has not been organized here. A lot of
it is because there has been a lot of turnaround for this council. But
now I think we\'ve got a group here that is going to be here for awhile.
So if you are interested on serving on the Subcommittee for Faith-Based,
if you\'ll talk with me, Jocelyn, or Clif, we want to get that
organized.

Unofficially, we\'d like to see an alliance with many of these network
leaders that we are working with across the country. So if that is of
interest to you, please see us afterwards.

The last is replication. We want to see the multiplying of these
effective models. I know through the TFE, it was Targeted Fast Expansion
Grants, that has been helpful, but we need to establish standards for
recovery.

Dr. Clark, you mentioned earlier that we need to define what is
recovery. What is recovery? For the faith community, we need to help
them understand what recovery management services are they currently
engaged in that are congruent with ATR.

So that is really one of our next areas. I know, Clif, you are going to
mention that. We need to establish standards for recovery. What is a
successful recovery model? What does it look like? And then finally,
using our web system to exchange these best practices.

If I can just conclude with this. I think I\'ve got ten seconds left.
Just a personal note on why I\'m involved. I have experienced firsthand
the havoc that substance abuse can have, not only on the user, but also
on a family. It was in 1969 my mother and father were hit head on by a
drunk driver. My father was killed. My mother survived, but they pretty
much had to pin her body back together again.

It was this community, not just the faith community, but this community,
the different sectors coming together that helped our family get on our
feet and serve as wounded healers. So I conclude with that to say
that\'s why I\'m involved. That\'s why I\'m so grateful for all the
great work that each of you do.

Thank you.

(Applause.)

MR. MITCHELL: I think the conversation that you were engaged in this
morning is really apropos to what we are trying to do. I was just
sitting there glad to hear this, because we need your help. We really
need you to be more active in your communities. We appreciate you coming
here and advising us, but we need you to go back to your communities and
help us change the attitude of what is going on in the country.

We have approximately 15 to 20 coalitions in cities around the country.
Jackson, Mississippi, Newark, New Jersey, Omaha, Nebraska, El Paso, San
Antonio, Pittsburgh, all around the country we have these coalitions
that are being developed. We plan to bring these coalitions together so
that we can expand capacity. That is what ATR is all about.

The President wanted to bring about vouchers, but the ultimate goal was
expanding capacity. We can\'t expand capacity if you are just going to
concentrate on treatment programs. There is a huge resource out there
that has been doing recovery work since the beginning of time. That has
been our faith organizations. They have been providing this kind of
support.

We have to make it easier for them to come to the table, easier for them
to get the training that they need to provide the kind of quality
services, and we need your help in that. Recovery. ATR. The President
and many people are missing the goal on that.

I\'m going to say this, and politically some of you may get upset with
me. But this President of the United States talked about faith-based
organizations. But because of political ramifications, it couldn\'t go
down that way. So we now talk about faith-based and

community-based. But the underlining thing is bringing faith-based
programs to the table to help us. They have got the resources. They are
there, and they have been doing it.

We talked about Recovery Month, and I think Dr. Clark made it very
clear. It should not just be Recovery Month in September. Recovery Month
is year round. I think one of you mentioned that. It is year round.
That\'s the only way we can change attitudes. We really need to change
attitudes and change stigma. That is what it is all about, folks.

I bet you there are quite a few people sitting in here who have had
problems, but because of stigma, they don\'t want to come out and talk
about it. This is what we are trying to do with our programs and
bringing communities together, bringing the coalitions together. We
bring the state, local, churches, the stakeholders, we bring them all
together to talk about this. We\'ve got to develop a constituency out
there.

For example, one of the coalitions that we have in Omaha, Nebraska. I
was surprised to go to Omaha, Nebraska and find out that they had people
with programs up there that could be replicated across the country. Case
management, job training, parenting classes, transitional housing, GED
classes. They are doing what we also want them to do and provide the
jobs for the patients who come through there. They just negotiated a
contract with a franchise, a national franchise, to provide \$90,000 a
year in work for the people who come through the program.

Recently we negotiated with five ministers in Richmond, Virginia, to
start a job training program where these men will learn how to clean
tile. They will be learning how to clean tile and start their own
businesses. Sustainability, this is what we\'re talking about, where we
can get these programs not only to receive federal funds and state
funds, but become self-sustaining, that they don\'t have to depend on
the government.

The worst thing that can happen to any community is to have a program to
start and be there for three years, and then cease. So what we\'re
trying to do with them is teach them how to be self-sustaining so they
continue.

Also we don\'t want people to be trained in jobs where they go back to
being waiters and waitresses. We want them to have meaningful jobs. We
want them to have jobs where they learn with their hands and their
minds, where they can be successful.

I used to run a methadone clinic. When a person would walk into my
clinic with a hard hat on and mud on their shoes, and I\'d see his wife
in a clean dress, and I\'d see the child going to school, that was a
success. Many people have attitudes about methadone. That is just one
means of treatment.

But that is what this faith initiative is all about, getting people
spiritually motivated to be welcomed back into the community. That is
what we are attempting to do. These are just some of the things that our
programs are doing.

And as I said before, we really need your help, the council. We need
you, the staff here at SAMHSA, to help change these attitudes, because
recovery is about building up our communities. Recovery is about people
having dignity. We\'ve got to do away with stigma.

A lot of people get upset because the people who are in treatment think
that we are trying to take money away from them. We are not trying to
take money away from treatment. We are trying to help treatment to do a
better job. Traditionally, federal and state has never funded treatment
programs adequately. You do six months, you do 90 days, you do 30 days,
then you are released. Where is the aftercare? That is where the faith
community comes in.

We are telling them that the faith community can be your partners and
take care of the continuing care, because recovery could be six months,
nine months, it may be a lifetime. That is what this is all about. But
we really need your help. We really need your help to help us with this.
This is what the President wants, this is what Dave Donaldson wants,
this is what the Muslim wants, this is what the Baptists want, this is
what the Jewish community wants. This is something we all are yearning
for, and we really need your help.

We have changed our strategy because of budget constraints. Instead of
having large conferences where we being people in and get them hyped up
and get them some training, we can no longer do that because of the
budget cuts. What we are doing now with the 15 coalitions we\'ve got
around the country is identifying those programs who already have the
501(c), having some infrastructure where we can bump them up to move
where they can compete with everybody else. That is what our strategy is
for this year, to bump up folks.

It was shown where we had one coalition last year that got \$10 million
from the Department of Labor. Coalition California, \$10 million. We are
shooting for \$8 million this year. We are shooting high in case we
can\'t make it here, we will fall there. We are not going down there. We
are shooting up here. But that is what this is all about.

I thank you.

MR. DONALDSON: Thanks a lot.

(Applause.)

DR. CLARK: I want to thank Dave Donaldson, Clif Mitchell, and Jocelyn
Whitfield for their comments and for their presentation.

I\'ll entertain discussion from council, starting with Dr. Fletcher.

DR. FLETCHER: First of all, I\'d like to commend CSAT and this group for
the work that you are doing with faith-based communities, because there
is such a tremendous need in this area.

My experience in Mississippi is that the need is particularly demanding
in terms of working with small faith-based organizations that do not
have the infrastructure development that would allow them to be
successful in this area.

One of the areas that I would hope that, and maybe it has happened
already at some point in time, there could be some further discussion
regarding how do we link those local faith-based organizations with the
resources in their communities so that there can be a mentoring process?

For instance, how can we begin to forge relationships between colleges
and universities and

faith-based organizations? I appreciate Mr. Mitchell\'s comment in terms
of not wanting to go in and do a project. I call it \"projectizing.\"
You go in and provide a project for a number of years, the funding ends,
and the project is gone and there is nothing left.

How can we build the indigenous capacity in those communities by linking
them with the opportunities in their local community so that they become
proficient in interacting at the local level I think is so critically
important. This work I think is very important, and I\'d like to be a
part of this task force.

DR. CLARK: Ken?

MR. DeCERCHIO: I agree with you 100 percent, Bettye.

I know, Clif, you exude passion, and you have for awhile on this.
That\'s helpful when you come into our state as well.

I think that\'s the promise of Access to Recovery. In addition to
increasing access and involving faith-based organizations in that
process, it is the linkages between faith-based organizations and more
traditional, not more traditional, but let\'s say publicly sector
funded, traditionally funded. We have a number, and that is really one
of our goals, so that when the Access to Recovery dollars go away, the
partnership, the networking that is occurring, and we\'ve got agencies
that are doing staffings together, all the training that is available in
community-based agencies in Orlando is now open to probably 10 or 15
faith-based organizations.

They actually have a network with treatment organizations and
faith-based organizations that do any level of recovery work. Some are
licensed treatment agencies, others provide housing, and others are just
ministers that are ministering to their congregation.

We are requiring those types of partnerships and linkages so that you
are infusing the obvious. You are infusing both the passion, the
compassion, and the power of faith healing into the publicly funded
system, and some of the clinical expertise, some of the training, some
of the practices and infusing that into the

faith-based organizations. I think that that is the longevity that
you\'re talking about, and one of the real promises of Access to
Recovery.

DR. CLARK: Melody, and then Chilo.

MS. HEAPS: Yes, I absolutely concur with previous speakers. I want to
get specific about Access to Recovery. Forgive my own ignorance since we
are one of the agencies participating in it, I know what we do. But can
you tell me in terms of Access to Recovery the requirements, or what
specific activities CSAT has engaged in or could engage in in terms of
working specifically with those sites on Access to Recovery to help
develop these coalitions. Is that part of the requirement? Part of the
monitoring? And I don\'t know this, and I\'m sorry, I probably should.

MR. MITCHELL: At all of our workshops, ATR was a primary part of the
workshop.

MS. HEAPS: Right.

MR. MITCHELL: Where we explain what ATR was all about, and we bring the
stakeholders together and we try to show them how to collaborate and
work.

As I mentioned before, under ATR, each state has a goal of how many
people they are supposed to bring into treatment or recovery.

MS. HEAPS: Right, right.

MR. MITCHELL: We recognize the fact that they can\'t do that with just
treatment alone. So what we are trying to do is work with the faith
community to help them expand their capacity.

MS. HEAPS: Right.

MR. MITCHELL: We provide technical assistance, we call the state
faith-based office. Some states have faith-based offices. We contact
them and offer our services to provide technical assistance to work with
them.

When we go in to do conferences or workshops, we let the state know so
that the state official can be there. In this ATR process, we know three
states. Because of the workshops that we did, they developed ATR plans
from those workshops. They have focus groups at our workshops, and so
their plans came out of those workshops.

MS. HEAPS: I would like to volunteer, and I guess we would do it through
our committee, to specifically focus on the ATR component and how we
might accomplish the kinds of things that Ken has been doing in Florida.
Maybe a more directed set of guidelines that might go along to helping
some of the states do this.

Oftentimes a single state agency is not, or the applicant agency is not
the best one to organize the faith-based. It may be a lead community
agency, or a lead coalition agency. I think there are ways that we can
set up some guidelines and directions in ATR that would continue to
facilitate this kind of coalition development. I\'d very much like to be
a part of that discussion if that\'s possible.

MS. WHITFIELD: (Inaudible.)

MR. DONALDSON: Yes, there are, and for example, Anita, in your state,
Ohio, with Christian, the state Faith-Based Director is doing a great
job at building those coalitions, and also helping to integrate the
various funding streams, including compassion, capital fund, the healthy
marriage initiative, TANF, as well as incorporating the business
community, too.

DR. CLARK: While ATR is not a faith-based program, the objective is to
diversify those providers that are contributing to the recovery of
people in a community. We believe the community-based organizations,
including faith-based organizations, can play critical roles in that.

One of the reasons we articulated a model that involved recovery
management services, because the recovery process extends from the
traditionally licensed professional treatment providers into the
community. If you look at entities like AA, they have known that all
along. I mean, I don\'t know how many AA programs are licensed providers
in any jurisdiction. Does anybody know? To my knowledge, it is probably
zero. But I may be wrong.

But the key issues is that those entities have played a key role in the
recovery of individuals by offering say 24/7 community support. As
someone who provided treatment through people through the VA, we made
liberal use of community support. I see you three hours a day, what do
you do the rest of the time? What happens when cravings ensue, or you
encounter a buddy, friend, or spouse who wants you to do drugs? How do
you cope with that?

What happens when you are feeling overwhelmed, anxious, or tempted? How
do you cope with that? So the community support becomes a key issue.
Faith-based organizations play a role in that larger construct of the
vectors of values in the community-based organizations, faith-based
organizations, so that we without having to infuse large amount of funds
to recreate the community, you could invest in the traditional system,
recreate that system, but it becomes cost-prohibitive.

So we need to augment the traditional delivery system by creating this
conduit of care, if you will, that reaches into the communities and that
mobilizes community constructs in the service of the recovery effort.
That way, we don\'t increase our cost to the point that it discourages
the Governor.

The Governor isn\'t going to say, well, how much more is this going to
cost me? If we tell her, this is going to cost you three times what
you\'ve been spending, they\'ll say \"Not!\" And we know that. At least
those government officials know that, and people who are writing
programs know that.

So Access to Recovery was created to link traditional providers. It is
not to substitute traditional providers, but to enhance and to leverage
the reach of traditional providers by bringing in

community-based organizations to facilitate the recovery process. The
focus of introducing recovery management services into the construct
offers the state an opportunity not to have to say okay, everybody has
got to be licensed, everybody has got to be certified, so we are going
to create this stultifying, bureaucratic process that essentially leaves
us where we are.

By extending the conduit of care, we preserve the contribution of the
professional and traditional providers. We leverage that by reaching out
to new providers in the construct, and we target the services that an
individual needs.

I recall, Judge, you mentioned the 28-day program. One of the reasons
the 28-day program crashed and burned is because it was used
indiscriminately. A person had one DUI, never had an alcohol problem in
their life, they got 28 days. A person was drunk every day of his life,
in and out of treatment, in and out of jail, they got 28 days. It
didn\'t make any sense.

When the studies demonstrated that it didn\'t make any sense, the
insurance company said exactly what we wanted, no more \$10,000 a pop,
we\'re not investing. Shortly after that, other studies came about after
the great change that demonstrated the fact of the utility of the 28-day
program.

The message was that one size does not fit all. If you can
differentiate, there were a group of people who benefitted from the
28-day programs, but the damage had been done. So our construct of there
are many pathways to recovery is the construct that we\'re trying to
enhance here by offering the person who is adversely affected by alcohol
and drugs a choice, by mobilizing the community to participate in that
so that traditional providers in effect are able to demonstrate their
utility, and that utility is leveraged by a positive relationship with
community organizations, including faith-based organizations. So that
six months after the treatment episode, if you will, you are able to
demonstrate that this is working.

The Prop 36 data, Prop 36 actually works. But if you don\'t look at the
data correctly, it doesn\'t work. It turns out that because of the
absence of mandating treatment, a lot of people are not actually
engaging in treatment. But of those people who actually engage in
treatment, they are doing better than the control groups.

It is these kinds of things that we have to address. I appreciate your
willingness to work with Dave, Bettye, and others here so that we can
clarify. There is a lot of confusion about ATR. Some people are saying
it is a faith-based program, and other people are saying you\'ve got to
have all these licenses.

We are erecting barriers to treatment, and part of what ATR is trying to
do is to eliminate the barriers. At the end of the day, this is only a

three-year program. As was pointed out, we need to think about how do we
enhance care beyond ATR? It doesn\'t appear to be any movement to infuse
a large amount of money to any question.

The issue is okay, we need to reassure the community that treatment
works. We have the data, but nobody seems to believe it. We need to
reassure the community that the person living in the halfway house in
their neighborhood is contributing to the vitality of the neighborhood
and is creating an option not only for those individuals, but for the
families of the people in the neighborhood.

We can only do that not just with professionals, but with
community-based organizations and faith-based organizations working
collectively together, tied in with criminal justice and child welfare,
which is the community. When the community acknowledges that the
community has to be invested in recovery, then recovery is possible.

Chilo?

DR. MADRID: I\'d like to go ahead and pull back a little bit if I may,
Dr. Clark, and allow Anita to say a couple of words since she is
developing an excellent faith-based program in Ohio.

Anita?

MS. BERTRAND: Thank you. This is a wonderful initiative. I think that it
is this type of thinking that is going to help us reach the 78 percent
that is meeting the criteria that you\'re talking about, Dr. Clark.

In Ohio, we are looking at efficiencies and ways that we can help the
faith-based communities work with other community-based organizations.
An example might be, does each organization need a fiscal officer? Is
there a way that we can share staff and collaborate? I think that we can
help achieve this goal through

cross-trainings.

I think that you are doing a wonderful job. But also if we can identify
some leaders in the community to help bring the churches and the pastors
to the table, because many people are misinformed about the work that
we\'re doing. I think the major city projects, because they are leaders
in the community, and as most of you know, a lot of the 12-step programs
are in the churches, which means that the pastors are supporting the
work that we\'re doing, but they don\'t know everything about some of
the regulations and barriers, and they\'re being misinformed. So I want
to also say that I\'d like to talk to you at some point about the
subcommittee and the work that you\'re doing.

DR. CLARK: Chilo?

DR. MADRID: I\'d like to go ahead and commend Dave and certainly Jocelyn
and Clif for their walk, as well as their talk. I certainly thank Dr.
Clark, Clif, and Jocelyn.

We had a real nice conference in El Paso, a faith-based conference, the
first annual Cesar Chavez Conference. We had 300 people join us, and
about 150 were kids, teenagers, and high schoolers.

I was very, very moved when Clif got up there and talked about
faith-based programming and kids. Then at the end of this talk, he was
flocked and ganged by about 150 of those kids asking him all kinds of
questions. This longing, this hunger, for the spiritual way.

Clif, thank you so very much for the assistance that you all gave us.

We\'re planning on doing it again. We have about 20 programs on the
Mexican side that used Christ therapy. So this coming year, it will be a
faith-based conference, but it will have a lot of the international
flavor. Hopefully it will be as successful, if not more successful, than
the first one.

So Clif, thank you, and Jocelyn, and certainly Dr. Clark for giving us
that opportunity along the border.

DR. CLARK: Frank?

DR. McCORRY: Thank you. I\'d really like to publicly articulate our
continuum of care, because it has always been going on in faith-based
communities, but it wasn\'t really articulated.

It is just a terrific opportunity. Also this term of \"Recovery
Management Services.\" You have these kinds of different parts of the
continuum of care working together. It is terrific.

I know the treatment community, as ATR unfolded and faith-based
organizations came to the floor, was worried about how their work might
change. I was interested in looking at it from the other side. I\'d be
interested in hearing from David, Jocelyn, or Clif, what were some of
the fears that the faith-based organizations might be confronting in
working with public sector community organizations, or in taking public
sector dollars and the requirements that come with that. What were some
of the FBOs struggling with as they kind of entered this kind of
relationship?

MR. DONALDSON: I actually wrote a book with Stanley Carlson-Theis, who
set up the faith-based offices on that issue. I\'ll get you a copy so
you can double the circulation for us.

(Laughter.)

MR. DONALDSON: I think it would be good for Anita to chime in here, and
Clif and Jocelyn. It is a very important issue. The faith community is
concerned that in taking public funds, it is going to lead them down a
slippery slope. Instead of being faith-based, they are going to be
based.

So through these workshops, and even Dr. Clark has come and shared, we
have been able to communicate to them that they can create a fire wall
where they don\'t have to compromise their mission, their values, and
their methodology, and at the same time, receive public funds. So that
has been part of our education, and has probably been, wouldn\'t you
say, Jocelyn and Clif, one of the strongest questions that are asked.

DR. CLARK: Ken?

MR. DeCERCHIO: What our faith partners have taught us, or have
communicated on that issue, is don\'t chase the money in communicating
to other faith-based organizations. If it can support your mission and
it is part of your ministry of what you do and there is an enhancement,
look at it. But don\'t change, and don\'t chase the money, because
you\'ll go down that slippery path and not stay centered, I guess. Early
on that was a very strong message in the work that we\'ve done that
we\'ve heard communicated.

MR. DONALDSON: That\'s well said. We have communicated don\'t let the
next RFB be your next mission statement. Secondly, don\'t become
dependent on public funds. I know for the President, the last thing he
wants to see is a new welfare system called nonprofits.

So a lot of our education has been tied around that. You couple the
relationship building with that education, and we\'ve done a lot of
spade work. One of the concerns that I do have about ATR is that right
now, we are looking at 14 states and a territory, which is wonderful,
but we\'ve done a lot of great spade work in some of the major cities
that are not in those 14 states. I\'d hate for us to lose the momentum
that has been developed there.

DR. CLARK: Again, we\'re working together with state and local
jurisdictions, as well as

community-based and faith-based organizations to flesh out the construct
of Recovery Management Services. We are trying to do that in the service
of the recovery process. We have three states actually represented here.
One officially in terms of Ken, who is a state official, but Illinois,
Melody has pointed out that she\'s at an agency. Wisconsin also has an
ATR.

Part of what we are, as we start to unfold, and this is essentially
phase one of ATR, is addressing some of these barriers and clarifying
some of these issues so that we dispel the fears. There is a lot of
mythology that has crept up around ATR.

I like what Florida is doing, to reassure traditional providers that
this is not a repudiation of their works, or an abrogation of their
contribution, while at the same time recognizing we need to extend our
reach of the recovery process into the community. In doing so, it
doesn\'t endanger, it doesn\'t threaten, but only enhances and
facilitates, because it gives us a better message that we can go to
funding agencies, Medicaid, the Governor\'s Office, and the federal
level.

Not only do we work, but we can give you good numbers in the long run.
At the end of the day, the Judge is going to be confronted with the
question, are your orders working? Is my community safer? Child welfare
is going to say, is this parent a safer parent? If we can\'t answer
those questions, then it doesn\'t matter whether you are a licensed
professional or a certified recognized faith-based provider or
community-based provider. The monies won\'t be there. Not only the
monies, but the community attitudes won\'t be there.

I think as we deal with stigma, we have to deal with this issue of
community attitudes. The community will not mobilize if they perceive us
as not meeting their needs for a healthier and safer community.

So with that, we can continue later, but we\'re going to take a break,
as has been promised, and we can come back in 10 minutes.

(Recess.)

DR. CLARK: We\'re running behind, so we need to move forward. Our next
presenter is going to be Chilo Madrid. Chilo is going to talk about
treatment in ethnic communities.

DR. MADRID: Thank you so very, very much, Dr. Clark.

I\'d like to go ahead and preface my presentation by taking the gum out
of my mouth.

(Laughter.)

DR. MADRID: And again commend the last presenters.

All of us I guess in life have certain biases, and certainly I do also.
My thoughts are as follows, and that is whether it be in personal or
professional life, the Lord comes first, family second, and then my job
comes third.

I have been in the drug treatment business for over 30 years. I come
from an area where heroin is a lot cheaper than methadone, and a lot
cheaper and more convenient than treatment, believe it or not. So I have
developed some biases concerning that.

I also come from an area where the NIMBY concept, not in my backyard, is
alive. I remember I spent three years fighting a community over the
opening of a residential treatment center of which now it is running
after five lawsuits. It is running, it is doing real well. Most of the
people in that facility getting treatment are people from that small
town. Most of the people that run that facility are from that small town
also. So a lot of things have changed.

I also have my thoughts concerning criminal justice, and I\'m giving you
this preface because I think the fact that I\'m very, very involved with
criminal justice has definitely developed some thoughts and biases on my
part.

Where I come from, I have to work with the DUI/DWI court, the family
drug court, the felony drug court, the truancy drug court, the juvenile
drug court, and the adult drug court. So as you can tell, I spend a lot
of time in court. I\'m glad that I\'m on the other side of the bench.
That works well.

Being that heroin is a lot cheaper than treatment, 90 percent of our
patients, of our clients, come through the courts, whether I want them
to or not. We force them to court mandated type of treatment, and
that\'s the way it is where I come from.

I believe also, and I have formed some biases, that stigma is worse than
the sickness. Certainly where I come from, that is very, very real.

I also grew up with a father that was an Apache Indian, a mother that
was a German Jew, and I grew up in a Mexican American community. So that
developed some ideas and some thoughts.

I come from an area, believe it or not, where heroin is not called
horse. To a lot of people in the country, horse is the nickname for
heroin. Where I come from, it is called \"goat,\" like an animal,
G-O-A-T. I come from an area where addicts, when they use drugs, they
say they are going to \"go jump off,\" not get high.

Why is it that Mexican American addicts are talking about jumping off
and not getting high? Why is it that they want to feel down rather than
move up or go high? That type of mentality has a lot of ramifications in
the treatment that I do.

Then lastly, as I\'m prefacing my presentation, I am very, very
convinced that when it comes to youth in the high schools that are
beginning to use cocaine or marijuana, and in some instances heroin,
that it is very simple. I think I have come up with a treatment approach
that can be 97 percent successful. All we have to do with those kids is
send them to school with their mother holding their hand for two months.
The mother gets to sit between the boy and the girlfriend for two
months. Believe me, 97 to 98 percent of those kids will get it together
very, very fast. So that is a big bias on my part.

Now, why did I tell you all these things? Because as I do my
presentation, a lot of these thoughts that I have given to you have
affected me through the years, and they have formed certain biases on my
part. So now that I have told you how I think, let me go ahead and talk
with you about my real presentation. If I can go ahead and move my
technology piece here.

I\'m going to go ahead and review with you some data. Before I go into
the national percentage of substance abuse or dependency by ethnicity,
I\'d like to go ahead and tell you that the Services Accountability
Improvement System under CSAT as of January \'04 talks about ethnics of
color occupying approximately 66.8 percent of all treatment slots. In
more specific terms, let me just say that Hispanics, 46,000 Hispanics or
28 percent were in treatment and captured by the SAIS data system. Then
43,000, or 27.8 percent were African American, and then 10,000 or 6.7
percent were American Indian, and then 6,000 or 4 percent were Asian or
Pacific Islanders.

Now, that\'s a total of 66.8 percent of minorities of color that were
captured by the SAIS data system. When we look at the clinicians
nationally, we see that most of them are white, most of them are 45 or
older, and most of them are women. So when we look at the majority of
clinicians, and when we look at the majority of people in treatment as
captured by the SAIS, you can see that there are some major differences
there that we need to look at, study, analyze, and then proceed
accordingly.

The reason why I say proceed accordingly is because according to the
Institute of Medicine in 2004, they talk about the desire and the need
to advocate for what they call racially concordant health care. That is
very, very important. We talk about how the National Institute of
Medicine in their latest report, \"In the Nation\'s Compelling Interest:
Ensuring Diversity in Health Care,\" they call for increasing racial and
ethnic diversity among health care professionals.

I\'m going to talk an awful lot about health care professionals, because
one of my biases is that in the substance abuse arena, we talk about the
5 and 10 cent store in our workforce. We pay them the least amount, they
have the least amount of fringe benefits, and I can just go on and on.

I run an agency with about 200 employees, of which probably two-thirds
are counseling employees. I have a lot of turnover. They are always
going from my 5 and 10 cent store to the store where they get paid
sometimes twice as much. I\'m talking about private health care. I\'m
talking about other more recognized public health care agencies.

So there is a big, big workforce problem. Let me just touch on some of
the charts, and then I\'ll try to come back on that particular issue.

When we look at some of the TEDS data, Treatment Episode Data Set, for
the year 2000, when we look at just three particular drugs, it is very,
very clear to me that opiates are hitting the Hispanics in great
numbers.

I think Cynthia passed to you a copy of an article on hepatitis C that
came out in the El Paso Times. Apparently a health care worker infected
six patients at Sierra Medical, and the health care profession in El
Paso are up in arms because there are all these hepatitis C issues. Yet
when we look at I.V. drug users in our area, we are looking at 87
percent of those individuals being hepatitis C-positive.

I want to thank CSAT for developing training programs in hepatitis C,
especially those programs that deal a lot with I.V. drug users. I think
that\'s a very, very good start. But that article begins to point out
that it is pouring into the private sector now, and that something that
we always knew was a big problem to them is a new problem.

So again, when we look at cocaine in

non-Hispanic blacks, we look at about a 29 percent reading there. So
that is also significant. So what I\'m presenting to you is not new
data. It is data that the federal government, CSAT, and SAMHSA has
developed, but it is data that I think we need to look at when we look
at developing perhaps some type of direction concerning the different
ethnic groups that we deal with.

I\'m talking about all ethnic groups, not just Hispanics, blacks,
American Indian, but all groups. We need to be very sensitive as to
their preferences and how they perceive, whether it is a horse, whether
it is a goat, whether some of them want to get down, or whether some of
them want to go up and get high, we need to be very sensitive to those
type of issues.

The next one, again, this one is for females. You can see that it is
almost the same as for males when we look at preferences concerning
these three drugs. Again, Hispanics are into a lot of heroin.
Non-Hispanic black are into a lot of cocaine, and there are certainly
very, very clear trends there.

When we look at, for example, such issues of ethnicity as associations,
when we look at NAADAC, which is probably the largest association that I
know of, and I\'m very proud to be a member, they are very sensitive to
my issues. Yet when I look at their membership, you can see that among
the ethnicities, there are some very clear patterns that I think we need
to seriously look at, consider, and develop some type of effort to
attract a more diverse representation there.

In America, when we look at different studies, we notice that there is
about 9.1 percent of Americans that are either abusing or dependent to a
certain degree. But when we look at the American Indian or the Alaskan
Native, we are looking at 17.2 percent. Again, this is not my data, this
is data that the federal government has developed through years of
study.

My question is what are we doing there, what are we going to do, and
what type of future agenda should this particular group, who in my
opinion is the leading treatment group in the nation, what are we going
to do with that type of issue? The issue of Native Hawaiians, Pacific
Islanders, looking at 12.9, that is a big, big problem. When we look at
Hispanics and white at about 9.2 versus 9.1. Again, it is not just one
group, we need to look at all the groups, and we need to look at their
individual issues.

The last section that I want to just spend a little bit of time talking
about is the possible and probable considerations. When I talk to some
of my counselors, I say, what do you all need when you work with
Hispanic heroin addicts and when you work with American Indian
individual patients that have a real severe and acute alcohol problems?

They say, we need tool boxes. We need a universal tool box for
everybody, and then we need a tool box for people that have heroin
problems, for Hispanics, for American Indian. That is what we need, we
need the tools. If the research is there, let\'s go ahead and get it
together, get it in here, and then present it to us in a way that will
be useful for us.

So again, we need something that definitely bridges that research to
practice in this case. When we look at our ethnic minorities equally
represented in associations, those that are licensed, we know that
they\'re not when we look at ethnic minorities. So we need to develop a
workforce strategy. For example, Partners for Recovery has been looking
at workforce audits.

They are advocating for, for example, loan forgiveness programs and loan
repayment programs. They are looking at more practical internships for
young people. I mean, there are a lot of us in the field that are
getting old. I was telling Mr. Gilbert that I have been in the field
since \'65, so that\'s about 40 years. I do tint my hair, that\'s why I
don\'t look too old.

(Laughter.)

DR. MADRID: But eventually I will be retiring and we need to attract
young people. They are coming and going faster than they are coming in.
So we need to look at a lot of the strategy that Partners for Recovery
is developing, has been studying, and I think that we really need to
engage that strategy, advocate for that strategy, and try to move it
forward very, very fast.

In federal government, there are many groups that look at ethnic
minorities, that look at ethnic ideas and patterns. There is the SAMHSA
Minority Fellowship Program, the National Institutes of Health National
Incentive for Minority Health, and so forth. I think that we might want
to consider collaborating with those groups, and inviting them to the
table. What are they doing? What are Partners for Recovery doing
concerning the different ethnic situations and ethnic problems in this
country? Rather than maybe reinvent the wheel, proceed from there.

So that is something I think we need to look at very, very seriously.
Again, why reinvent the wheel? Let\'s go ahead and proceed accordingly.

One thing that I work with a lot in the ethnic minority community where
I live is I work a lot with HMOs. I think that when we look at managed
care, when we look at Medicaid, when we look at children\'s insurance
programming, we need to be very, very aware and cognizant as to how
these particular payers of last resort, fast resort, or first resort are
looking at the different ethnic groups, and how they are being affected.

I think that that is very, very important. I think that as we proceed to
study this issue a little bit further, we need to be very realistic and
look at the money and how it is flowing, not just from CSAT, but from
the states and other payers.

So again, I think that Dr. Baxter is not here, but I talked with him to
great length about this, and I think that SAMHSA has published a
cultural competence work some years ago, so perhaps looking at that
again, and then proceeding accordingly.

Lastly, I think that what we need to do is to look at the different
ethnicities in this country and some of their unique needs, and be
sensitive. Even though there are universal things that happen, there are
very unique things that we need to be on the lookout for, that we need
to analyze, and that we need to look at as a gauge as we approach these
groups with best practice, with evidence-based approaches, and so forth.

So again, I presented to you an overview of the existing data, some of
the ideas that perhaps you all might be considering, or you might want
to consider, or discuss more in depth concerning ethnicities in this
country in substance abuse.

Are there any questions at this time? Yes, ma\'am? Melody?

MS. HEAPS: Chilo, you talked about tool boxes which could be used in
helping to treat various populations. Do you know if anything like that
exists? Are there particular guidelines or publications which would be
helpful to send to treatment programs so that they are more aware?

I say this because I remember a discussion with someone in California
who was treating the Asian population and how very, very difficult it
was because of the issues of shame, the issues of not wanting family
involvement because of shame, and their needing to bring in someone who
was a healer. It was a very interesting discussion. I wondered if
anything existed anywhere that represents a tool box, or some
publications.

DR. MADRID: I really haven\'t seen a tool box let\'s say for Asians, but
I have seen, well, I have seen some tool boxes that are universal, but
I\'ve never really seen a tool box that is for a specific ethnic
minority.

However, if somebody else knows of one, I stand corrected. But if there
isn\'t one, I think there is a need, and I think our counselors are
really craving for this type of support.

Yes, ma\'am?

MS. JACKSON: Thanks, Chilo. I really liked your presentation. I think
that it is an extremely important issue. Certainly one that we face in
Southern Florida, and I know the rest of the country faces in different
populations.

As to the tool box thing, I think that\'s a very good comment. There
should be tool boxes that are maybe in a sense tweaked. I mean, we have
evidence-based practices. I certainly recall, as I\'m sure you do,
Melody, and you also, Chilo, reading the research on evidence-based
practices that say this has been tried in certain populations, and so we
know that there are practices out there that have evidently worked for
different populations and have been proven to work for that.

Perhaps, and maybe somebody else can shed some light on this, what we
haven\'t done is to come at it from that angle of saying how would we
tweak this particular evidence-based practice so that it would be much
more effective for this population based on the discussions and work of
those people who worked with those populations.

DR. MADRID: Again, when we look at the American Indian, the Alaskan
Native, we are looking at some very serious alcoholism problems. I think
that definitely a tool box, something would be very, very indicated
there. Not just for the American Indian, but I think for all
ethnicities, because we all have unique problems.

Bettye?

DR. FLETCHER: Chilo, I too thank you for your presentation.

I would ask a little bit more fundamental than the tool box. How is
training related to ethnic groups incorporated into curricula as a means
of institutionalizing content in those areas so that counselors and
other professionals in the field get that as a part of their training?

DR. MADRID: Bettye, I think that\'s a very, very good point that the
Partners for Recovery has dwelled in. What they are talking about is
curriculum that is practical and that is relevant for the different
groups in this country. So I think that\'s a very good point in that we
all learn a little bit differently.

I think that there are a lot of studies, learning studies that have been
done, and we need to look at those as we approach the different ethnic
groups. So curriculum that is practical and that is relevant.

Frank?

DR. McCORRY: Chilo, I took two points from your presentation that I\'d
ask you to kind of expand on.

To me, substance abuse treatment has become a much more complicated
enterprise over the years that I\'ve been doing this. Yet your point
about workforce and the turnover in workforce that no matter how we
address these issues, if we can\'t hold onto the folks that we\'re
trying to train to be sophisticated in this care for lack of incentives
in being able to retain them, I don\'t see how we make progress in
improving care unless we can stabilize our workforce. That\'s one point.

Second point, your NAADAC slide in which clearly the treating people are
different ethnically and racially from the people they are treating in
large part. Our ability to attract minority candidates and hold onto
them, that will reflect ethnically and racially the people that we are
trying to serve.

Those two thoughts, our basic problem with workforce, and then our basic
problems in attracting people who are from the same ethnic and racial
communities that we are treating. Your thoughts on how we might, and I
know there is probably a lot going on on this, but we just haven\'t been
able to really crack that. We can\'t hold onto our folks, and we
haven\'t been able to diversify our workforce efficiently to meet the
needs of the people we\'re treating.

DR. MADRID: Well, both points are \$64 million issues that I don\'t
think I can answer completely. But again, your first point, how to
retain our counselors, our workforce. We need to be competitive as far
as salaries, and we need to develop some type of an incentive system
very similar to what Partners for Recovery is looking at. I think that
is very, very important, and we need to totally engage PFR for the work
that they\'re doing.

On your second point, God, I don\'t know. I would need some help on that
one.

DR. McCORRY: I was talking about Bettye in terms of we talked a little
bit yesterday about that, trying to set up something within the
historically black colleges and other kinds of institutions in minority
communities that might able to promote the value of working in this
field.

DR. FLETCHER: I think that\'s a very critical area. For instance, at
Jackson State University, one of the older graduate programs in
substance abuse treatment and prevention is offered, and special efforts
are made to recruit students into that program.

It requires a lot of outreach, it requires working with the field as
well as the credentialing bodies that relate to those areas. My earlier
point, however, in terms of working with special populations, one of the
ways that we have developed our competencies and our skills in that area
I would say is through institutionalizing that content into the
curriculum.

DR. MADRID: Thank you all so very much. I think my time is up. Again,
hopefully this will be the beginning of this conversation.

Thank you.

(Applause.)

DR. CLARK: Thank you, Chilo.

I wanted to reiterate that workforce issues is on the matrix. We are at
SAMHSA engaged in a cross-SAMHSA effort to address this. These issues
are not particular to substance abuse treatment. They are also evident
in substance abuse prevention and mental health. In fact, in nonprofits
in general. So we will be putting our heads together and value the input
of this process.

We are now moving to the public comment period. But before we do that,
we had planned to have Joe Faha give a legislative update. It looks like
we have run out of time for the first half of the day.

The question is would council like to hear from Mr. Faha later today
around 3:15? If that\'s something that you would like, he has graciously
agreed to appear then. He has a meeting from 2:00 to 3:00, but would be
available later.

MR. DeCERCHIO: I would like to have him come back, if he is willing and
available.

DR. CLARK: All right. Then we will do that.

In the meantime, public comment. We have Arthur Dean from CADCA, who
would like to approach the council. He also has a brief slide show.

Have at it, Arthur.

GENERAL DEAN: Well, good morning to all of you. It is a pleasure.

Thank you, Dr. Clark, for the opportunity to give some public comment
during the CSAT Advisory Council meeting.

Before I start, though, I would like to just thank you for your service,
because your service is important not only to CSAT, but to the country
as a whole. We all are trying to improve substance abuse, which is a
major public health problem as you know.

With that said, I want to just take a couple of minutes to acquaint some
of you and reintroduce others of you to Community Anti-Drug Coalitions
of America. I know most of you just looking at your faces are familiar
with us, and I did meet one council member this morning who had not yet
heard of us. I want to give you a little information.

That\'s our mission, to strengthen the capacity of community anti-drug
coalitions across America so they can help build in their communities
safe, healthy, and drug-free communities. That is what we have been
doing for some time now.

This is what we call an anti-drug coalition. It is a lot of words, but I
wanted you to kind of get a feel for what is it I\'m talking about when
I refer to the Community Anti-Drug Coalition. It is really normally a
nonprofit in the community where sectors in the community, all of them,
to include the faith, to include education, to include judicial and law
enforcement, all come together to work the problem holistically and
strategically to rid their community of the problems associated with,
and we are talking about underage drinking, we are very concerned about
that obviously.

We are concerned about illicit drug use, we are concerned that people
who are beginning to get involved with drugs are intervened with, and
then we want to see them get into treatment. Then we\'re concerned about
them staying on the road to recovery. So it is all encompassing that
we\'re talking about.

That is who we are. We came out of a presidential commission in 1992.
That council met from \'89 to \'92 and recommended that to help these

community-based groups that were being developed, and Miami was one of
them, that a nonprofit be created to provide those kinds of core areas,
and we have been doing that for some time.

We take great pride in being the voice of the substance abuse field on
Capitol Hill. I have a registered lobbyist that works for me in a public
policy department, and they work across the federal budget totally from
Justice, Education, HHS, to SAMHSA, to DEA. We are the voice there doing
the very best to make sure that the appropriate laws are passed, and
that appropriations are obtained. So we work that very diligently, as
well as train in other items.

That is what we represent now. That sign says 5,000 community anti-drug
coalitions. The last count I looked at, it was a little over 5,400 of
them existed across America. Obviously we are in all 50 states, but we
have an actual association where there is kind of a membership in 40 of
the states. We have a webpage that has more than 400 pages of
information. Every Thursday afternoon at 5:00 we send it out online to
talk about what is happening in the field so people can have it. It is
free. Anyone can subscribe. It goes to 12,000 people.

We started one recently that talked specifically about evidence- and
scientific-based practices. That is the one that you see there where we
have over 1,000 subscribers.

You were talking about cultural competency. We are doing on the 24th of
February a satellite downlink that goes into the cable network system.
The title of the one on 24 February is \"CADCA Across Cultures: Uniting
the Community to Work Together.\" We are going to be talking
specifically about the importance of how we make the training and other
items culture-specific at the community level. So the topics that you
were talking about are very important topics.

Those are the electronic means that we communicate with people. I just
wanted to share those with you. You can go onto my webpage at www.cadca
and be a part of any of these that you wish to be a part of.

We do training in the mid-year. Last year it was in Chicago, and this
year it is going to be in Desert Ridge in Phoenix, Arizona. We do four
days of training, in-depth training there where people are trained in
subjects like grant writing and others that go from two to four days in
length. This one is going to be 25 to 28 July in Phoenix, Arizona.

We just finished with the support of our federal partners, and I wanted
to highlight CSAT there and thank them and Dr. Clark for being a
platinum sponsor, we just finished our first convention that we had in
the D.C. Convention Center. We have outgrown all the hotels here in
Washington. That was the 15th one that we\'ve had. We had 2,500
attendees. They were there from Monday through Thursday, 80 workshops,
five plenary sessions. We had a press conference that got national
coverage on alcohol and recovery, and we had a press conference with
NIDA on inhalants that got national coverage. A half page was in the
Washington Post just this Monday. Our next one, number 16, will be
February of 2006.

We were fortunate enough to have a law passed called the Drug-Free
Communities Act. It now funds 714 local groups. They get \$100,000
annually for up to five years. They can reapply for six through ten.
They must have an equal match, so therefore they end up with about
\$200,000.

In that Act recently when it was re-approved or reauthorized, they
created the National Community

Anti-Drug Coalition Institute, and CADCA bid and was awarded that grant
to manage the institute. It does these three things. Provides training
and technical assistance, dissemination in tools, and research to
practice. I\'m not going to take a lot of your time to explain all the
details and the importance, but this is a way for the federal government
through a grant to help institutionalize the training that these
coalitions desperately need across America.

Just a summary of some of the kind of things that we have done. At our
big conference we had just this month, many of our workshops were around
the areas that are important to you. It is prevention, it is
intervention, it is treatment, and it is recovery. Dr. Clark has
appeared on one of our downlinks. We are always there for you and with
you on Recovery Month. We have workshops that relate to that.

We actually published a scientific base with NIDA that lays out the
effective principles of treatment that went out to all of our groups. We
are encouraging our coalitions to be holistic in their approach, and we
even have a few coalitions now like the one in St. Petersburg, Florida
that the actual coalition manages 125 in-resident based treatment
facilities and then those that do not have close relationships like
Miami does with The Village, and we encourage that across the country.

We think that we can help with the denial issue. I heard you talk about
that. We certainly have a problem with stigma. When I was going down to
Miami to do TV and radio, we had a doctor that was going to appear. At
the last minute he backed out because he didn\'t want to go public. He
had already agreed, and at the last minute he did not go public.

We certainly believe that you talked about this morning that building
capacity at the local level is what really is key. Getting the civic and
business leaders involved which leads to greater treatment, also
improved treatment, and institutionalize it. We just think that in order
to resolve this problem, you have got to work it holistically.
Otherwise, you\'re not going to have any real benefit.

So I wanted to come by and thank you for your work and share with you
some of the things that we are doing to introduce CADCA to others of
you.

I know Westley does not like for people to recognize him for his work
and leadership, but he has been a staunch supporter of ours, and I want
to publicly thank you for that.

(Applause.)

DR. CLARK: Thank you, General Dean.

We have another public comment from Katherine Fornili from the
International Nurses Society on Addictions.

Katherine?

MS. FORNILI: Good morning. Many of the people in this room know me
through other capacities that I have in the substance abuse treatment
field. But I\'m here today to represent the International Nurses Society
on Addictions.

On behalf of our president, Dr. Christine Savage, and our Executive
Director, Mr. Jim Scarborough, and myself, the chair of IntNSA\'s public
policy committee, I\'d like to thank the members of the advisory
committee for inviting us to participate in the dialogue here at CSAT.

A couple of the messages that I\'d like to portray to you from IntNSA is
that we are committed to improving the quality of substance abuse
treatment research and prevention. By doing that, we believe that we can
help accomplish several of SAMHSA\'s missions, which would include
increasing capacity for treatment by having more addictions nurses
become credentialed and certified, and by recruiting nurses to the field
of addictions.

Nurses are highly qualified to work in this field, but they have not
traditionally worked in the field as much as social workers, counselors,
LPCs, and psychologists. So one of our goals is to recruit new nurses to
the field, and train and credential them.

Another way that we think that we can help improve capacity is by trying
to get support from SAMHSA and the federal government to consider
advance practice nurses being allowed to prescribe buprenorphine or
other pharmacological therapies. Right now the data 2000 restricts the
prescription of these buprenorphine products to physicians, but there
are a lot of Masters and

Ph.D.-prepared nurses who have advanced prescriptive authority in their
states. I think we\'re underutilizing the nurses in that capacity.

We are well aware of the workforce issues. We know that our membership
is aging out and we\'re not recruiting enough members to our
organization. We are aware that at the same time, there is the aging of
our patient population. So we are trying to prepare for the workforce
crisis in the coming years.

The three major activities of our organization are credentialing, we
have the only addictions registered nursing credentials, so a national
certification. There is the CARN, or Certified Addictions Registered
Nurse, and a CARN-AP for Masters Prepared Specialists in Addiction. We
have a certification test process.

Another activity that we\'re highly involved in is peer assistance,
working with nurses who have addiction histories in their own
backgrounds and current addiction problems to make sure that they\'re
not excluded from future work and nursing if they\'re able to achieve
their recovery objectives.

Lastly, we have the only peer-reviewed professional journal for
addictions nursing. It is called the Journal of Addictions Nursing. I
serve on the editorial board of that, and on the Board of Directors for
IntNSA, like I said, as the newly appointed chair of the Policy
Committee.

So to summarize, I\'d like to say thank you again for inviting us to
participate in this process. I hope that we can continue to engage in
dialogue with you about how nurses can increase their role in visibility
and

usefulness in the field of addictions.

DR. CLARK: Thank you.

Any other public comment?

(No response.)

DR. CLARK: With that, then we shall adjourn for lunch and reconvene at
1:15. Thank you.

(Whereupon, at 12:15 p.m., the meeting was recessed for lunch, to
reconvene at 1:15 p.m.)

[AFTERNOON SESSION]{.underline} (1:25 p.m.)

DR. CLARK: If we can get people to come to the table, we\'d like to
start. We\'ve got guests, and we\'d like to start the afternoon program.

We were originally supposed to have Dr. Nora Volkow, the Director of the
National Institute on Drug Abuse, present. She could not be here. She
searched around for a suitable replacement and came up with her deputy.

Tim Condon was appointed Deputy Director of the National Institute on
Drug Abuse in 2003. As Deputy Director, he supports the Director in
developing, implementing, and managing the institute\'s programs,
priorities, resources, policies, and research dissemination efforts.

He has held a number of prominent science policy positions at NIDA since
he arrived in 1992. He served as Chief of the Science Policy Branch and
the Acting Deputy Director of the Office of Science Policy and
Communications until 1996, when he was appointed NIDA\'s first Associate
Director for Science Policy, as well as the Director of the Office of
Science Policy and Communications. In this capacity, he is responsible
for the institute\'s science planning, policy, congressional, and
communications activities, and coordinates NIDA research training and
science education programs.

Prior to joining NIDA, Dr. Condon coordinated research service programs
at the former Alcohol, Drug Abuse, and Mental Health Services
Administration ‑‑ that is ADAMHA, and that was awhile ago ‑‑ for four
years, serving as the Deputy Associate Administrator for Policy
Coordination and Deputy Associate Administrator for Science.

From 1986 to \'89, he served as Science Policy Analyst Project Director
at the U.S. Congress Office of Technology Assessment, where he directed
an assessment of emerging technologies in the neurosciences. He received
his Ph.D. in neuroscience from the Ohio State University College of
Medicine. He pursued post-doctoral research in neuroendocrinology and
neuropharmacology at the University of California-Los Angeles Brain
Research Institute and at the Oregon Health Sciences University.

He joined the faculty at OHSU in 1985. He has been working with NIDA for
awhile during the six years that I have been here and have had the
pleasure of interacting and working together in an effort to forge a
functional relationship between the science-based people and the
services-based people so that we\'ve got this bidirectional bridge. They
do science, we do services, and yet the two have to inform each other.
Tim has played a major role, and of course he works in the effort of his
boss, Dr. Volkow. But independently, he has been ‑‑ how many directors
have you worked for?

DR. CONDON: My fourth director.

DR. CLARK: Fourth director. So he has been in it for the long haul, and
I really appreciate his presence here.

I\'ll turn it over to Tim Condon. Thank you, Dr. Condon.

DR. CONDON: Well thank you, Westley.

I\'m delighted to be here today, and actually when I got the call this
morning, so this is a true story. I got the call this morning, and I was
supposed to be on the NIH campus because the President was visiting.

I got the call that Dr. Volkow was ill and she wouldn\'t be able to come
and do this. So there was this, what should I do? Of course I was
delighted to come here to talk to all of you, because I know a lot of
you already, and this is one of the things that quite frankly has been
something that I can point in my own career to something that is working
really well.

I thank you, Westley, for mentioning that. But it has taken a lot of
effort by a lot of people. People in this room, Dr. Clark, his staff. I
want to particularly mention Mady Chalk, Carl White, and some of the
other staff that I, quite frankly, and my staff find a delight to work
with on these science to service issues. We call it blending research
and practice, but call it what you want.

I\'m going to tell you a little bit about what we\'re doing in terms of
our research portfolio in translational kind of research, where we are
just up front of translational research, and then I\'m going to tell you
about some of our dissemination efforts and some of the science to
service efforts.

Fran Cotter. I forgot Fran Cotter. We have been working with Fran for
awhile as well.

Then we can have some discussion. As I said, I know a number of you
because of our efforts in trying to make our research, and this was an
Alan Leshnerism. He was the Director for eight years. Alan always said,
\"We need to make our research useful and used.\" That really has been
our mantra for the last 10 years now.

So I actually have learned how to use technology a little. It is a
surprise, I know it was a surprise to somebody here today. Was it Dr.
Suchinsky, you said you were shocked that I could do this myself. But
let me tell you a little bit about it from our perspective.

Advances in science are and have been bringing us to really a new
understanding of drug abuse and addiction. We spent a lot of investment
and basic research having to do with drugs in the brain, showing that
there are changes in the brain, and that that is really some of the
essence of addiction. But that is not just about changes in the brain,
it is not just about chemistry. It is actually about the environment and
behavior as well.

One of the issues here is that this knowledge is allowing us to develop
more targeted strategies, both behavioral and pharmacological, for
prevention and treatment. The problem is that we\'ve got this
bottleneck, if you will, from the bench to the bedside, to the
community. These are very real barriers. Moving from the bench to even
the clinic or the bedside, and then quite frankly I tell all my
audiences, years ago I used to be a lab neuroscientist where I\'d get
electrophysiology. I did intracellular recordings in these incredibly
tiny cells in the brain. That was easy compared to moving things from
the bedside to the community. So it really is a science and an art, and
it is something that we\'re learning a lot about.

Here is an article that was published by Steve Hyman, the former
Director of the National Institute of Mental Health. We call this the
translational bottleneck. Steve did a great job of demonstrating it in
this pictorial. The top here is the number of research papers published
on cognition and schizophrenia. You can see this dramatic increase over
the years down here around 50 to 300 papers in 2001/2002. Of course it
is not a surprise that NIH\'s budget was increasing during this time.

But if you look at the number of clinical trials associated with that
increase in those publications of kind of basic research, you see that
there really hasn\'t been much of an increase. So not just in our field
of substance abuse, but in every area of medicine there is a bottleneck
of moving these things from the bench to the clinic, and the clinic to
the community.

So I guess we could take some satisfaction in knowing we\'re not alone,
but in fact the situation in some people\'s mind is particularly acute
for substance abuse.

This is another paper published in the New England Journal of Medicine
by these investigators. What they really did was they just looked at
standard practice of care. This is the percentage of recommended care
received. They looked at all these specialties.

Senile cataract. Well, this is what the recommended standard of care is,
you know, as identified by the specialties. You can see 80 percent.
That\'s the best, about 80 percent. Breast cancer, hypertension. You can
see in here depression. We\'re not doing really badly, a little over 55
percent, but the only one for substance abuse that they indicated was
alcohol dependence. As you can see here, they were suggesting that about
10 percent of those who in fact were doing treatment were in fact using
the recommended care, I believe in this case established by ASAM.

So anyway, it says that we have a problem in all areas of medicine that
in fact the information and the evidence-based practice is not getting
out, so you have to think about why that is not happening, or is it the
right material to get out. Are we doing the right research? So this goes
to what Dr. Clark said. It is the bidirectionality of the science to
service.

Is science really servicing the service community and vice versa? Is
there some barrier that we can figure out how to get more evidence-based
practice? That is what we spend a lot of our time doing.

The science to service cycle, this is of course a concept that we\'ve
all very much been participating in. I believe Charlie Curie coined this
early on. We early on had our own terminology called blending research
and practice. But this really has kind of come to be known as this
interaction between NIH and SAMHSA, the science to service workgroup. In
fact, we have a workgroup, and it has AHRQ on it also. It has three of
the NIH institutes, NIAAA, NIMH, and NIDA on it, as well as our
colleagues from SAMHSA and AHRQ.

We also have research to practice liaisons that I\'m going to tell you a
little bit about. This is essentially our cofunding of the ATTCs,
NIDA\'s cofunding of the CSAT ATTCs. I have got to tell you, originally
when we proposed this idea, and Jack Stein ‑‑ are you here, Jack Stein?
This was really Jack Stein\'s idea about six years ago. It was a time
when Alan Leshner was the Director. Telling Alan, we\'re proposing to
give \$1.5 million to CSAT at that time, you can imagine it took a
little convincing. But he eventually agreed that this was a good idea,
to use the infrastructure that was out there and to work with our
colleagues in the field to get evidence-based practice out there.

Maybe we are a little slow to get going, but I tell you, I think it is
going gangbusters now, and I\'m happy to tell you a little bit about
that. Blending teams. Well, that has to do with our dissemination
efforts, and I\'ll explain a little bit about what those are. But those
are the dissemination of materials both from NIDA\'s research portfolio,
but also from the Clinical Trials Network.

Consultation on evidence-based practices. NIDA staff is working with
CSAT staff on the NREPP program, giving out advice, making
recommendations about who should be on these panels because they are
peer review, and giving them ideas about what treatments are ready for
prime time, as we call it. What treatments have a good base of evidence,
if you will, or research publications that are ready for really movement
into the field.

We have also done some grant writing technical assistance with SAMHSA
grantees with the interagency support of NIDA research. We have a
criminal justice drug abuse treatment system project, the CJ-DATS we
call it. We have a primary care initiative, and we have a state research
capacity building, all of which we are cosponsoring, or all of which
SAMHSA is cosponsoring with us. So we call this the braiding of funding
streams. In fact, I believe this is really the wave of the future, too.
As resources get tight, we\'re going to in fact be in a good position to
get the biggest bang for our research and our services buck.

So science and service treatment research. Well, we are continuing the
clinical research on medication development, on behavioral research, the
behavioral treatment research development. We of course established
awhile ago the Clinical Trials Network in community-based settings, and
we have a health services research portfolio second to none looking at
how to in fact apply these evidence-based practices in real life
applications.

You all know we\'ve got four medications essentially for the treatment
of substance abuse. Well, treatment for opiate abuse. We of course have
a couple more now for alcoholism. But we haven\'t been successful for
cocaine or methamphetamine yet.

I am just putting this up to let you know that we\'ve got a lot of
targets in various phases. Phase I, Phase II, and Phase III clinical
trials trying to identify medications for cocaine addiction. It also is
true with methamphetamine, and it is also is true with opiates. We have
a number of things, but I left the slide out for the opiates. But in
fact we also have a number in Phase I and Phase II clinical trials
trying to identify a medication for methamphetamine addiction.

That is a program we started a little bit later than the cocaine, but
building on what we learned from the cocaine program since they\'re both
stimulants, we actually were able to get a little bit of a jump start on
it. So this is very important. The point here is that there are a number
of things in the queue.

NIDA is not just about medication development, it is also about
behavioral therapies. So part of what we have identified, and these are
the behavioral treatments with a strong science background, again, a
number of these, actually I think all of these are treatments that
we\'ve suggested to CSAT that are ready for prime time, because they do
have a strong evidence base.

You can see a number of them in behavioral treatments for marijuana
abuse, behavioral treatments for smoking, and cognitive-behavioral
therapy. It shouldn\'t be a surprise to anyone. Motivational incentives,
motivational enhancement therapy, family treatments, drug counseling,
there is a contingency management approach. There is a number of these
here that in fact are ready for prime time.

But just so that you know, we also have a couple in the queue. So about
10 years ago, we said if we\'re going to develop medications using the
FDA model ‑‑ Phase I, Phase II, Phase III clinical trials ‑‑ we should
be doing the same thing for behavioral therapies. In fact, Phase I
behavioral therapies are supposed to be in our program that are
theory-based from the basic behavioral science.

What is a good idea? That\'s where contingency management would have
come from, the reinforcing effect of things like vouchers or incentives.
Cognitive-behavioral therapy came from early on from research on
cognitive neuroscience.

There is no test here, Melody. You don\'t have to study. I see you\'re
studying.

These are a number that we have in these various phases. Hopefully
they\'ll in fact be fruitful in the future and that there will be a lot
more in the pipeline to move onto our colleagues at SAMHSA.

Well, the research/practice gap has a couple of different elements to
it. The accessibility gap. Do I have the same resources as a researcher?
I heard it all the time. You come in, you do the research, the feds drop
their payload, they move on, and what is left? Well, can we support at
the community level what the practice was, what was shown to be
successful? It is something that we\'re paying a lot of attention to in
our health services research portfolio.

A couple of ways we\'re doing that, and I\'ll mention one, is in our
behavioral research portfolio, in some of those ones that I saw, we had
a meeting this past year, which hopefully will initiate, well, it has
initiated a number of grants, where we are trying to identify
in-therapies that have been shown to be effective to tease out what the
active ingredients are, if you will.

We know that if you do a big comprehensive Cadillac program, you\'re
probably going to have a good success. But if you can tease out what
really the critical active elements are, you may in fact be able to
reduce the cost, make them more user friendly, and actually be able to
maintain fidelity.

Credibility gap. How different is the implementation setting? Things
need to be transportable. We recognize that. We have a number of grants
in the health services portfolio that are addressing that.

The expectation gap. Is it necessary or realistic for me to use
science-based interventions, or can I just approximate? Well, that\'s
the one that is always critical.

We call it the wobble or the drift. If you understand the technology
transfer theory ‑‑ and I have to admit, I didn\'t understand it two or
three years ago, but I\'ve tried to learn a lot more about it ‑‑ there
is a natural drift that comes with the transfer of technology from one
organization to another.

This was pioneered by a gentleman who recently passed on. Everett Rogers
is the pioneer on this.

It is estimated that for some of the research that NIH does, it takes
about 17 years to get from the bench to the community practice for a
finding. Well, Dr. Zerhouni has told us that\'s way too long.

I have to tell you, I\'ve taken some solace when we talked with Everett
Rogers, who actually pioneered this work I believe in the \'60s.
Actually his first studies were studying hybrid seed corn in Iowa. He
kind of looked and me and said, yes, that was my first study. He became
a world expert on this, because what he found was it took 14 years for
the farmers of Iowa to adopt hybrid seed corn. So I looked at him and I
said, we\'re not doing so bad. He said, well, you\'ve got to do better.
That is what our goal is in terms of technology transfer.

Developing an evidence-based practice is only one piece of the
translational puzzle. We know that, that the intervention itself as we
try to strip out particular things, we try to make it user friendly,
transferrable, keep the fidelity, and keep the active ingredients. There
are lots of other things that are important. Again, we have a portfolio
in organizational structure and climate, environmental stigma and
financing, provider knowledge and behavior, and access and engagement.
These are all critical factors, and we probably have a good portfolio in
all of these, but we need to do a little bit more in each and every one
of them.

A couple of examples of what we\'ve been trying to do in terms of
outreach over the last few years to try to make research more relevant,
is we have established these two things. One is the National Drug Abuse
Treatment Clinical Trial Network, and one is the NIDA Criminal Justice
Drug Abuse Treatment Study Center. I\'m going to talk a little bit about
each one of these.

The vision for the CJ-DATS is to improve outcome of offenders with
substance abuse disorders by improving the integration of drug abuse
treatment with other public health and public safety systems. Grandiose
vision, so where does the rubber meet the road?

Well, a couple of the research questions currently being addressed are
alternative treatment models, particularly for understudied approaches,
research on systems integration, and that is critical if we\'re going to
make some progress in this area. Types and levels of criminal justice
system, drug abuse treatment integration, linkages between the
correctional health and drug abuse treatment professional. Melody, are
you listening? Are you smiling? Is this making you happy?

Continuity of care and after care during reentry, treatment models
matching chronic nature and drug use. A couple of other ones, treatment
and recovery process, external and internal motivation, and the relation
to coercion. For a long, long time, people thought you needed to change,
you needed to want change really for any treatment in substance abuse to
be effective.

We now know that in people, people who become incarcerated and have some
levels of sanctions leveled against them can in fact eventually be
helped by various kinds of treatment.

Role of monitoring surveillance and sanctions, relationship between
public safety level and treatment progress and outcome. That is always a
critical issue. One of the things that I\'ve learned over the last two
years actually working with Melody and her organization is that there is
always this balance when you talk to a judge between public safety and
public health.

That is something they are always cognizant about, something we need to
help them more with. Access to medical, mental health and social
services after reentry. So we have a number of centers around the
country. One is the Research Coordinating Center, and that is here, and
then a number of CJ-DATS, a total of about ten, ten altogether. I
believe two of them are adolescent centers, studying adolescents in the
criminal justice system as well.

So we are very excited about this. This is kind of under the leadership
of Jack Stein and Wilson Compton, the Division Director there. It is
very exciting.

Our federal partners on this are many. Of course SAMHSA is a partner on
this, the Center for Disease Control, NIAAA, Bureau of Prisons, the
Department of Justice, and again, a number of organizations within
there. So this really is truly a great collaborative effort. I actually
think it is going pretty well, although it is very early in the
establishment of this, but I have great hope for that.

I have great hope for that because of the success of this one. This is
one that we launched about five or six years ago. This came about as a
result of an Institute of Medicine report that said we really needed to
do a better job of bridging the research into the community.

Alan Leshner was the Director then, and so we established what we called
the NIDA Clinical Trials Network. Its mission was to conduct clinical
trials to determine the effectiveness of drug abuse treatment
interventions in diverse community-based treatment settings, and with
diverse patient populations, and to transfer research results to
treatment programs, and for clinicians and their patients to improve the
quality of drug abuse treatment throughout the nation.

I\'m also going to tell you a little bit about some of the protocols
over the last five years, and the ones that are current. These are
selected CTN trials that really I think are in current progress. Opiate
dependence, we have a couple on buprenorphine, one for tapers, one for
adolescents, and smoking cessation. We have motivational enhancement
therapy for Spanish speakers, as well as for pregnant women, and a
protocol called \"Seeking Safety Intervention for Trauma and Substance
Use.\"

We have a pretty large study for families, brief strategic family
therapy for adolescents, as well as a number related to HIV, HIV and
hepatitis intervention, and HIV risk reduction in both men and women.
These are a number of the ongoing protocols currently. I think they are
all shown there pretty much.

A number of protocols have already been completed, and these are the
list here. Buprenorphine for detox, detox outpatient/inpatient, and
motivational enhancement therapy. We are not ready to disseminate that
one yet, but that one I believe has finished. Motivational interviewing,
motivational incentives, and drug-free clinics, as well as methadone
clinics. Those are topics that we\'re already working with SAMHSA on
disseminating. What we call the tele study was a follow-up
post-discharge headed up by a number of investigators.

We have positive findings so far in all the studies that have finished.
Coordinated dissemination efforts, I\'m going to tell you a little bit
about what we\'re working with the ATTCs on. I\'m going to tell you a
little bit about what some of the proposed studies for the current year
and the next couple of years are for CTN. Of course I\'m from NIDA, so I
have to show you a brain scan.

This actually isn\'t Nora Volkow\'s work, but I believe this is work
from our colleagues at Wayne State. I just use this as an example of
normal control methadone maintained patients. What this is telling you,
this is looking at the occupancy of the receptor, the opiate receptors
in the brain.

What this is telling you here is that in the methadone patients, you can
see that this is in the normal control. This is the total number of
opiate receptors, occupancy, and then methadone displaces this radio
label opiate receptor agonist in these particular areas. You don\'t need
to know about what the areas are, but it says that methadone really does
in fact occupy those receptors, but it doesn\'t occupy a grand
percentage of those, a really great percentage of those receptors, as
you can see.

If it occupied a great percentage, you might envision as a
neuroscientist that I\'d tell you, well gee, if it occupied all the
receptors, then it would probably be a pretty good thing if somebody
took heroin, they probably couldn\'t get high from it because our
receptors would be occupied. There is a whole host of things that you
might conclude from this.

Well, buprenorphine as it turns out, and we didn\'t know this early on
when we developed it, but we know it now, with the 16mg dose of
buprenorphine, this is MRI, this is bup zero, this is 2mg, 16mg, this is
how much opiate receptor is available when these patients are medicated.
You can see that there is a reason that the pharmacology or the
pharmacokinetics of buprenorphine are very different, and that the
patient population may be different, and that the safety in fact of this
particular medication is very different. You can see 85 to 92 percent.

So this says a lot in terms of heroin addiction, but it also might say a
lot about how do you use buprenorphine in some of these
pharmacotherapies for this epidemic that we\'re seeing. That is the
increase of prescription drug opiate analgesics in this country. This is
a big problem of national importance, and this is one of the priorities
that Dr. Volkow has decided we need to do a lot more work in.

Another area that Dr. Volkow has been very interested in is attention
deficit hyperactivity disorder. I\'m not an expert on ADHD, but in fact
there is data out there to show that 15 to 30 percent of those
individuals, especially in adolescence, who are being treated for
substance abuse also suffer from ADHD. So there is a comorbidity going
here.

If you stretch that a little, as we always do if we\'re clinicians,
neuroscientists, or treatment providers, if they are having problems
paying attention, they may in fact seek out drugs to do self-medication.
We know that\'s true for many kinds of mental disorders that people are
likely to do self-medication with substances of abuse. In fact, we think
that is what is going on here as well.

This just shows you some of the odds ratios. What this is telling you is
that adjusted affect of ADHD and pharmacotherapy on substance use
dependence, this is unmedicated individuals versus controlled, and this
is medicated ADHD versus unmedicated ADHD.

What this is just telling you is that an individual who is unmedicated
is six times as likely to in fact abuse substances than in fact somebody
who is medicated. Six times for alcohol and marijuana. A little bit
different in terms of prevalence or incidence in tobacco, but the major
drugs of abuse, you can see that there is definitely a beneficial effect
to treating people on their substance abuse outcomes.

So again, that is another reason of a very important research
opportunity and one of the things that we\'re going to be exploring in
the CTN. We have a couple of new studies in the Wave 5 that we\'re
looking at. One is a randomized controlled trial of buprenorphine
naloxone in assessing liver function in opiate dependence treatment.

Well, this is a study that the FDA required to study liver toxicity or
liver function in the opiate addicts that are undergoing buprenorphine
treatment. So we are investing a large amount of money, and I\'m sure
Westley would share this opinion. We have a lot invested in
buprenorphine. We think it is a very good medication, and we want to
make sure that it succeeds and that we do everything that we can to make
sure it gets in the hands of practitioners.

We are also starting this randomized control trial of ‑‑ now, how many
of you know what OROS is?

(No response.)

DR. CONDON: Well, I didn\'t know it until this morning either. I am
looking at this going, what is this? Oh, this is long-acting
methylphenidate. So it is a long- acting preparation. It is an osmotic
preparation. It is an oral preparation. That is what OROS is, oral
osmotic release something or other.

Anyway, the bottom line is that these are long-acting methylphenidate
looking at ADHD in adolescence and substance abuse, and we are also
doing one in adult smokers who have ADHD as well. We are also starting
one to address the prescription drug issue of the opiate analgesic
looking at the use of buprenorphine as a treatment for opiate analgesic
dependence.

So services research at NIDA, and this is part of our portfolio, one of
the things that we\'re doing in the bup liver study as we call it, it is
actually not being done by the CTN, but is being done in the CTN by one
of our other divisions. So in other words, one of our goals in the
future is to have this infrastructure around the country of the CTN, and
to use it as a platform for doing other kinds of research. All kinds of
research. Health services research, genetics research. In this case, we
are going to be doing some toxicology research related to the
pharmacotherapies.

The criminal justice, the CJ-DATS, which SAMHSA cofunds, we actually
think that is also another infrastructure, and we are so delighted with
our collaborators that we are establishing this infrastructure out there
around the country, and we\'ll build an infrastructure that everybody
can use to do these kinds of studies.

Primary care initiative, which is something that Jack Stein is leading,
and we had an RFA out on the street, and I think it is closed and the
applications are in, if I\'m not mistaken. That is something that also
our colleagues here at SAMHSA, and that is in fact essentially getting
health care, primary care physicians at all levels, to do brief
interventions to assess and to do referrals.

A new thing for us is enhancing state capacity to foster adoption of
science practices. We put out an RFA where we encouraged states to send
in applications to give small grants so that they too can start to build
a research infrastructure to start to apply for some of the other
projects.

Science to service research dissemination. I want to run through this
quickly. NIDA publications. We have, as I say, the CTN/ATTC blending
teams, the blending products and the conferences.

Again, this is the CTN. I love to show this slide, because this is where
we\'ve established the Clinical Trial Network sites around the country.
There are 17 of them, and we see them as the snowflakes. The CTN is the
snowflakes.

If we add to that the ATTCs, which are also geographically distributed
around the country, you can see that we\'ve got a good partnership here
now that we\'ve linked the ATTCs and the CTNs, as well as with
headquarters for both NIDA and SAMHSA.

Research findings. Well, one of the things that I always tell the groups
because I stay personally involved in these research dissemination
efforts, one of the things that I\'ve been talking to the groups about,
and it is kind of just the way things are, is that we have never really
done this kind of research dissemination in a systematic way. We don\'t
really have a guidebook.

There is technology transfer theory, and let me tell you, there are lots
of people\'s ideas about what needs to be done. But we really have never
done it in a systematic way before that I can tell. As you heard, I have
been around for awhile.

So I tell them we\'re making this up. To some of them people laugh and
giggle, but the truth is we are. We are making this up as we go along. I
don\'t think we\'ve made any missteps yet, and I\'m very pleased with
these efforts.

We start with a research finding from a CTN, let\'s say, from one of the
clinical trials. Let\'s say the first one I think we did was the
motivational interviewing protocol. It had a positive finding. So we had
what we call a handoff meeting where we bring most of the researchers
from the CTN together with some of the colleagues from SAMHSA and the
ATTCs, and we sit there and talk about the protocol, what went on, what
were the barriers, what did we think was right, what was wrong, and what
the results were. Then we kind of make a determination, is there
something here to disseminate? Is there something here that is useful?

Each one of the three handoff meetings we\'ve had have said for these
first two protocols, yes, there is. Then we create the charge for the
blending team based on the results of the protocol and how it can
address critical needs in the treatment field.

The blending team is then headed by our colleagues at ATTC and SAMHSA.
It involves three of the key members from the CTN who were involved in
the research. But really it is the ATTC who are going to develop the
products for dissemination. In fact, so far we have done a couple of
products. I think I have the next slide here.

We have done one for bup awareness. We call it the buprenorphine
treatment, which is really for the non-physicians. So we call that bup
awareness. We are doing one also on Addiction Severity Index. Again,
these were two that didn\'t come out of the CTN, but these were things
that we had on the shelf and were ready for dissemination. We got one of
them out on the street already, and the ASI is coming out soon.

The CTN protocols, as I said, the short-term, the motivational
interviewing, is one that it improves retention in stimulant abusers
entering treatment. The buprenorphine detoxification here. In fact what
this is telling you, and this is a Walter Lynnism, who was the principle
investigator here, you have to treat 5.44 patients with clonidine to get
the same effect of treating one patient with buprenorphine and naloxone.
So it shows the efficacy and the effectiveness of buprenorphine versus
something like clonidine.

High acceptability. Many drug-free clinics have already adopted it in
terms of detox, and they participated in some of the early studies. We
got very excited when some organizations that before would never in fact
use methadone or some of the other medications stepped up to the plate
and said we want to participate in these studies. Now, for a number of
them it is actually standard operating procedure. So we think that that
is a great success in moving forward evidence-based practices.

Motivational interviewing. Again, this is very interesting. This is a
very simple protocol that was studied. Again, it is this particular
protocol. It is 20 minutes on the assessment intake battery, 20 minutes
of motivational interviewing in the beginning, and 20 minutes at the
end. Forty minutes at the beginning had an effect 30 days later. Go
figure. There was a 25 percent increase in retention in these treatment
programs. That says a lot about what we can learn from this.

The last one is motivational incentives, low cost incentives are
effective. This is the fishbowl approach to motivational incentives in
promoting treatment, retention, and abstinence successfully introduced
to the community. Positive reinforcement versus punishment.

We have also collaborated with CSAT on a number of blending conferences.
We had a meeting in Portland, Maine at last year\'s NASADAD meeting with
our colleagues at CSAT. That was, I think, very well received.

Ken, I\'ll reserve judgment on that.

We have been trying to work much more closely with NASADAD in all of
these dissemination efforts. You guys blew me away when you did this,
Ken. When we were up in Portland, Maine, they told us that they were
going to collocate the NASADAD annual meeting this coming June just
before our blending conference in Miami. So we are very excited about
that potential for collaboration. So we\'re going to be doing some stuff
there.

Again, we cosponsored a similar meeting in Denver and Detroit, and as I
said, we\'ll be doing it in Miami in 2004, and we\'ll be having this
NASADAD preconference.

Future directions. Well, we need to continue with what are the
characteristics of interventions that can reach the large number of
people, be broadly adopted in different settings, be consistently
implemented by staff with moderate training expertise, and produce
reliable and long lasting effects. Also things in fact that can be
reimbursed at reasonable cost. Our partnerships are essential to making
this all happen.

With that, I\'ll say thank you for your attention and hope that was
useful.

(Applause.)

DR. CLARK: Any questions for Tim?

MR. DeCERCHIO: Just a quick comment. I had 15 years in the community
substance abuse before going into a state job. In the community, I
don\'t ever remember a single NIDA study or NIAAA study kind of
filtering down and saying okay, we\'re going to change our practice as
an agency as a result of it. I got to the state and they said, we have a
\$90 million block grant, and we\'re evaluating its progress.

I said gee, what is the connectivity to all this research over here? How
come that is not helping us decide what we should be buying in terms of
all of our special initiatives under the block grant? So that doesn\'t
seem to make sense. You guys have made sense of it. Alan started it, and
you and Nora continue it.

The last five, six years, seven years between the Clinical Trials
Network, the connectivity to providers and the connectivity to states,
the support has been really remarkable in terms of the overall change.
It is affecting our providers in a positive way, the direct
relationships. It is affecting helping how we do business in the state.
It is very exciting.

I remember the IOM report. It was like this is a big gap, how do we get
our arms around it. Through a lot of what NIDA has done in relationship
with SAMHSA and CSAT, it has been very rich. I think it is having an
impact in creating a culture change around the adoption.

DR. CONDON: Dead on arrival?

(Laughter.)

MR. DeCERCHIO: The embracing of good science and good practice where it
is available. I think it has been a very important and a very positive
initiative, and certainly you all should be commended for that work,
frankly.

DR. CONDON: Thanks for that feedback, Ken. I appreciate it.

DR. CLARK: Frank?

DR. McCORRY: I would also like to commend NIDA for realizing that they
have partners in states and among providers. There is just a tremendous,
tremendous culture change, Ken said, taking place. I think we realized
it on the SAMHSA side that we needed you, but to see NIDA recognize how
much you needed us for your work to be effective is just terrific. It
holds a tremendous opportunity for positive results in terms of the care
delivered to people.

Two issues. One, in terms of science to service, as you said making it
up, I work for a state agency. We are making it up, too. We are part of
a couple of the NIDA initiatives to continue to look at delivery
mechanisms to promote the adoption and sustaining evidence-based
practices.

We are learning that everything from training, for example, focusing on
an individual practitioner versus a program since public sector funding
is often program related, even though there are separate credentials for
it, doesn\'t make the kind of change that you perhaps want. That seems
to be supported by the literature as well that you want to introduce
motivational interviews, and you\'ve got to get your staff together, not
get a couple of clinicians go to a central site for three days to learn
about it.

So to continue to look for states and providers to understand the
dynamics, the facilitators and inhibitors to change in terms of
evidence-based practice.

The second issue is more one of concern than the first one, which I
think is more a research question. That is I like the way you said CTNs
as a platform for effectiveness studies. That is the way I view them.

We do a lot of work in New York with the Clinical Trial Networks trying
to partner with them in terms of trying to have evidence-based practices
adopted. We view that as a tridirectional process of setting the
priorities for Clinical Trial Networks and Wave 5 studies.

That involves policy folks like state folks, practitioners, researchers,
and of course other folks would say consumers is as well as a fourth
partner in that. That kind of caldron of competing priorities that kind
of yields a research agenda that somehow can be bought into by all of
those parties we see as a process. We think NIDA probably should be the
one driving that process.

NIDA should be kind of requiring, insisting, and looking for input from
those other stakeholders when they are creating studies. So while it is
great that we\'re studying prescription opiate misuse, I\'m not sure
that that would be something that from my viewpoint I would say is a
priority. But that doesn\'t mean that it isn\'t, that just means from my
viewpoint.

I think if we\'re going to transform the culture, the state culture, the
research institute culture, the provider culture, it is necessary for
all of us to kind of work through these issues on how we set priorities
around the work we do. So I just encourage NIDA to not be bashful in
that, even though it might be a difficult process, to continue to see a
research agenda develop that might have to in some ways react to outside
forces and outside influences saying have you thought of this direction
to go in.

DR. CONDON: Thank you for your comments. On the last point, I couldn\'t
agree with you more. One of the things, and we haven\'t done it in the
last couple of years, but we have done it on almost a yearly basis, or
every other year, is we started this, actually Alan Leshner started this
about 10 years ago. That was we would have a constituent conference
where we brought together all the stakeholders.

I would tell you we\'re going to have another one this year budget
permitting, but I\'m pretty sure we\'re going to have one. I would tell
you if I looked out over the audience, if you will, who would be invited
to that, a lot of the stakeholders would have changed. Certainly
everybody that you talked about at the state level, at the community
level, would be a part of that.

I\'ll tell you how successful that was. In the first couple of years we
did that, we were genuine about this. Tell us what we\'re not doing. We
got all these requests and we looked at them and thought gee, what are
we going to do now? We actually systematically looked and went through
it and by the second year, we gave them a report card about how we had
done.

I won\'t speak for all of them, but I\'ll tell you, it was so well
received that NIDA would pay attention to this, would actually implement
things, a lot of it to be honest, were things we were already doing,
they just didn\'t know about. But we did this, this is a good idea. All
the good ideas just don\'t come from the NIDA staff, although lots of
them do, and we recognize that.

We got As on those first couple of report cards, so I have talked to Dr.
Volkow about reenergizing that. With that said, these are all the
priorities. Priorities in the flat budget years are going to be real
tough, and there is going to be a lot of competing interest.

So that is really not asking the questions and getting the input, but
trying to really be responsive is going to be a great challenge in the
coming years.

DR. CLARK: All right. We need to get back on schedule.

I want to thank you, Tim, and I hope Nora\'s illness is brief. We
appreciate your comments.

Thanks, Jack, for accompanying him.

DR. CONDON: Thank you so much.

DR. CLARK: Thank you.

(Applause.)

DR. CLARK: All right. So we\'re now going to move to the next discussion
involving Joe Gfroerer, who is going to present information from the
National Survey on Drug Use and Health. Joe is the point person for
NSDUH and is relied upon by many and all.

Thank you, Joe.

MR. GFROERER: I\'m happy to be here and to present some data from the
National Survey on Drug Use and Health. What I\'m going to do is present
primarily the most recent results that we released in September from the
2003 survey, and talk a little bit about some of the future plans we
have for this year for other analyses and reports.

First of all, a little bit about the design of the survey. It is
represented nationally and within each state. It covers the civilian
non-institutionalized population age 12 and older. Data are collected
with a face-to-face interview using a computer, a laptop computer, that
all the interviewers have with them. Most of the questions, particularly
the sensitive questions on substance use, are answered by the respondent
by keying in the response, they are self-administered questions.
Questions come up on the screen and they key in the answers, so the
interviewer doesn\'t know what the answers are.

We had about 67,000 respondents in 2003. One of the things that affects
some of the analysis we can do is the changes we made in the survey in
2002 that disrupt the trends. So basically what we have is a two-year
trend. Here, we can compare 2002 data to 2003, and that\'s the main
focus of the report in September.

First some of the findings on tobacco use and alcohol use. These are the
overall rates of tobacco use. About 30 percent of the population has
used some tobacco product within the past 30 days. Most of these
estimates are a reference period of the past 30 days. That\'s driven by
the cigarettes, which is 25 percent of the population.

You can see there is virtually no change between 2002 and 2003.

Now looking at youth cigarette use, here again there is really no
significant change overall among 12- to 17-year-olds. The rate is about
13 percent on average, plus you can see there is quite a wide range
across the age group from less than 2 percent among 12-year-olds, up to
26 percent among the 17-year-olds.

You can see a little bit of a decline there at each age. Only the
13-year-old trend was significant. There was also a statistically
significant decline in youth cigarette use among females, female 12- to
17-year-olds.

For alcohol, we have three measures that we look at, within the past
month again, all of these. Any use within the past month is what we call
current alcohol use. Then we have binge use, which is having five or
more drinks on at least one occasion within the past month, and then
heavy use is having at least five binge occasions within the past month.
About half the population, or 119 people 12 and older are current
drinkers, 23 percent with binge use, and 7 percent with heavy use. These
numbers are virtually identical to what we saw in 2002, so there is no
changes going on in alcohol use.

Looking at underage drinking, again breaking it up by age group, and
also by the different levels of use, you can see the wide range from 4.5
percent up to 51 percent in the 18- to 20-year-olds. That\'s for current
use. You can see that the majority of the underage drinkers are binge or
heavy drinkers. That isn\'t the case for older adults. But for the
underage drinkers, it is primarily binge and heavy use.

Let me move onto the illicit drug use data. Now here, looking at any
illicit drug use within the past 30 days, the overall prevalence is
about 8.2 percent. Again, no change between 2002 and 2003. Most of this
is marijuana use at 6.2 percent. You can see the other drugs.
Psychotherapeutics is basically prescription-type drugs, but only used
non-medically within the past 30 days.

We did look at the data a number of different ways and did find some
interesting changes between 2002 and 2003. For example, hallucinogens.
When we look at the number of people using hallucinogens within the past
12 months, past year of prevalence, we do see significant declines,
particularly with ecstacy and LSD. Ecstacy went down from 3.2 million to
2.1 million. So these are pretty significant drops.

On the other hand, the one area where we see possibly an increasing
trend is among the non-medical use of pain relievers. These numbers
represent the number of lifetime users in millions. You see 31 million
people have used at sometime in their life a pain reliever

non-medically.

We can break this down by the specific drug categories. You can see
Vicodin, Lortab, and Lorcet, significant increases for all of these
specific categories. OxyContin is from 1.9 up to 28.8 million.

Another decline that we found was when we broke it out by geographic
areas. We find that in rural areas, overall illicit drug use did go down
between 2002 and 2003. Also among youth, even though the overall illicit
drug use rate, and even the marijuana use in the past month rate didn\'t
change between 2002 and 2003, there are indications of decline.

The lifetime use that is ever having used marijuana in a lifetime went
down from 20.6 to 19.6 among youth. That was statistically significant.
The other estimates were past year and past month. It declined a little
bit, but they\'re not statistically significant.

Also when we look at youth marijuana use by how frequently they use, and
we focus on the almost daily users, whether over the past 12 months, 300
or more days within the past 12 months, or within the past month, 20 or
more days, there are significant declines in heavy marijuana use among
youth.

At the same time, looking at the attitude data, this is perceived great
risk. Proportion of youth who think that there is great risk in using
these different drugs. Here we see an increase in the percent of youth
saying that smoking marijuana is risky, from 32.4 to 34.9. No
significant change for any of the other drugs. Same things for
cigarettes and alcohol, no changes. Just the marijuana.

Let me move onto dependence and treatment data. What we do in this
survey is we have a series of questions related to symptoms of
dependence and abuse, basically the DSM-IV criteria. Based on those
responses, we classify people as having dependence or abuse on each of
the substances. This is what the estimates look like. In 2002 and 2003,
these are the estimated numbers in millions. Basically 22 million people
with dependence or abuse. It is primarily alcohol. There is no change
between 2002 and 2003.

Now, looking at the specifics within the illicit drugs, these are the
rates for that same measure within the illicit drug category. This is
any illicit drug dependence or abuse. Marijuana is the primary drug here
with 4.2 million, and then you have cocaine and pain relievers, and then
all the other drugs with less than half a million.

Now, this is some new data that we\'ll be putting out in a couple of
weeks in our state report based on the 2002 and 2003 surveys using our
model-based estimation methodology. What you look for here is the red
states have the highest states of use, the white states have the lowest
rates of use, so you can see the pattern. It is those northern states.
Now, this is alcohol dependence or abuse. Northern states generally have
the highest rates, also Arizona and New Mexico. Southern states
typically have the lowest rates. This is a pattern that we have been
seeing in the data since 1999 when we started the state estimation.

Now, it is a little different pattern when you look at illicit drug
dependence or abuse. Those northern states fall in the lowest category
pretty much. North Dakota, Minnesota, Wisconsin are all in the lowest
category for illicit drug, and some other states kind of show up in New
England, Louisiana, State of Washington, and Arizona and New Mexico are
still in there in the top for illicit drug dependence or abuse.

I wanted to present this data here. This is from a study we did last
year relating to older adult substance use. This is a study where we did
projections based on the aging population, age 50 and older, trying to
guess what the rates would look like and the numbers would look like in
2020. Here we show that because of the population increase, a 50 percent
increase in the population, a 70 percent increase in the rate of
dependance or abuse, we would expect about 150 percent increase in the
number of 50 and older persons with dependence or abuse on alcohol or
drugs.

Now moving into the treatment. This looks at the people who need
treatment, which is primarily the dependence and abuse population, but
it also includes an additional set of people who receive treatment. Here
you can look at the people who have received treatment among those who
needed treatment. So the yellow part of that bar is the treated
population. That is any treatment within the past year at a specialty
facility. This is drug or alcohol.

What we have here is basically no change in the treatment need, but we
did have a decrease, statistically significant decrease, in our estimate
of the number of people who have received specialty treatment, from 2.3
million to 1.9 million. We don\'t have a good explanation for that, but
that is the estimate that we see. It seems to be concentrated more on
the older adult population. There was not a decrease among the 25 and
under population.

Now, if you take that 22 million people who we estimate needed treatment
based on the criteria collected in the survey, the 8 percent who were
treated, that\'s the same 1.9 million from the last slide. Now here we
break it out by their responses to some other questions. Basically do
they feel they need treatment? Perceive need for treatment? The
respondents, even though they have reported that they have all these
symptoms that allow us to classify them with dependence or abuse, 87
percent of them say they didn\'t feel a need for treatment within the
past 12 months.

Five percent, or about an estimated 1 million people do report that they
felt a need for treatment, but they didn\'t get it. Out of that 1
million, about 26 percent in a follow-up question reported that they
tried to get treatment, made an effort to get treatment, and didn\'t get
it.

So for those people who say they needed treatment but didn\'t get it, we
asked them, why didn\'t you get it. These are the responses to that
question. The number one response is that they\'re not ready to stop
using the drugs. The cost and insurance barriers account for about
one-third of these people, and stigma is about 20 percent.

Now, here we have among those people who did get treatment, we are
looking at the substances that they reported that they received the
treatment for. The interesting thing here that is not obvious from
looking at this is that it is very consistent with the treatment data,
the TEDS data that Deb will be talking about.

If you look at any drug involved in the treatment episode, treatment
admission, the distributions are very similar to this. About 65 percent
for alcohol in TEDS data and 35 percent for marijuana, so it is very
consistent.

Now, we also asked respondents who have received treatment how they paid
for their treatment. These are the responses that we get. About half,
almost half report that they used some of their own savings or earnings.
Only about one-third said that they used private health insurance, that
private health insurance paid for their treatment, any part of their
treatment. Then we have public assistance other than Medicaid, and
Medicaid and all the other categories there.

Now, a little bit of data on the mental health characteristics. We
created this estimate of serious mental illness based on a scale of six
questions that we have in the survey. You classify all the respondents
as having serious mental illness, which is defined as having any mental
disorder, plus having some impairment in the past year. The prevalence
in 2003 was about 9 percent. This is only asked among adults.

Now, here is what it looks like when you cross the SMI, serious mental
illness, with substance dependence or abuse, showing the comorbidity.
Among those with SMI, 21 percent have an alcohol or drug disorder. Among
those without SMI, only 8 percent have a drug or alcohol disorder. Now,
that 21 percent represents about 4.2 million people, and that\'s a
population that we call the co-occurring population in some of our
reports.

I should point out it is not really the full co-occurring population,
because we are only talking about serious mental illness here, not any
mental disorder. But still it is a population that definitely has a
mental health problem and a substance abuse problem. So we look at those
people, whether they got treatment, and here, you can see it is about
half, 49 percent got no treatment at all in the past 12 months.

Only about 7.5 percent received treatment for mental health problems and
for substance abuse problems. Forty percent received the mental health
treatment, but no substance abuse treatment, and another 4 percent just
got substance abuse treatment. This is among that 4.2 million
co-occurring population.

I want to talk a little bit about some of the reports we have coming up
this year. In a few weeks we should have the state report coming out
from 2002 and 2003. I showed you a couple of maps from that. The report
will have maps just like that for about 20 different measures and for
different age groups.

Another project that we have that we expect to be releasing a report on
this year is our substate estimation project. I\'ll say a little bit
more about that in a minute. We also have a report on immigrants and
substance use where we have taken our sample of the foreign-born
population and looked at their substance use by specific country of
birth, compared that to the

U.S.-born. Then around September we expect to release the national
findings from the 2004 survey, and we\'ll have an additional year to
compare with the last two years all these charts and data points to see
what has happened over the past three years, and the trends.

We have some methodological reports coming out. One is on assessing and
improving methods of various studies that we\'ve done to look at survey
methods and experiments that we\'ve done to test new methods. Then of
course there will be these very short reports, probably 20 or 30 of
those over the next year on various topics.

I just wanted to say a little bit about the substate estimation project.
This has been something that has been a collaboration between our
office, the Office of Applied Studies, and CSAT. The way this is coming
out is that our first step was to basically determine the substate
regions. How do we break up the states into different areas? We
certainly can\'t with our sample make an estimate for every county in
the country, so we have to come up with some boundaries. We have been
working on that. It is a very difficult process.

Through CSAT and working with state representatives, we have finally
come up with a set of boundaries. So that is basically completed and we
are now into the next phase where we are starting to do the modeling and
the estimation to produce these results. We are using the 1999 to 2001
data for this project. Once that is done, we\'re hoping we get some
feedback, see how it works, and then we\'ll be revising it as needed,
working with the states to give them something useful, and then run the
same estimation procedure through the 2002 to 2004 data and hopefully
we\'ll have that sometime next year.

Just to give you some examples of what some of the states look like and
how we\'ve broken them up, this is what Delaware looks like, just the
three counties in Delaware. Florida has quite a few areas. We have a big
sample in Florida, so we\'re breaking it up. You can see those numbers
are the sample size. Every single one of these areas that we\'re making
estimates for, we do have sample in those areas. So it works pretty
well.

This is Ohio, which I think has over 20 different regions where we\'ll
have estimates. South Carolina, South Dakota, and finally Texas.

That\'s it. Thank you. Any questions? I\'d be glad to answer.

(Applause.)

MR. DeCERCHIO: Real quick. The state level samples are representative
based on actual surveys, they\'re not extrapolations or synthetic
estimates at the state level?

MR. GFROERER: That\'s right. The substate estimates are not synthetic.
That\'s why I said every one of the substate areas that we make
estimates for will have a sample of at least 275 basically was our
cutoff. So it is a combination of the direct estimate and the model
based on the national data.

DR. CLARK: Melody?

MS. HEAPS: On the decreasing number of people who had access to
treatment, is there any program to really look at what that was, or why
that was?

MR. GFROERER: Yes, we actually did a lot of follow-up analysis on that
to try to come to an explanation, which we really didn\'t come up with a
good answer, other than that it was concentrated more on the older
adults and not in the younger population. But certainly when we get to
2004 data, we\'ll look more closely. We\'ll have three years. It may
have just been a sampling issue or a blimp in the data.

MS. HEAPS: Thanks.

DR. CLARK: Francis?

DR. McCORRY: The slides, by the way, I have used the slides that you
sent out, that package. It is just terrific to have this PowerPoint on
my computer. I use the slides all the time on presentations, when you
start off a presentation in epidemiology.

A quick question on the K6. I remember looking at those questions, but I
haven\'t looked in awhile. They didn\'t seem like seriously mentally ill
questions. But if that thing was piloted, I don\'t know if it was
validated, but what is the degree of confidence that SMI estimate off of
those K6 questions?

MR. GFROERER: Well, what it is based on is a study that we did in Boston
on about 150 respondents taken from the general population, it wasn\'t a
treatment sample. It was a general population sample where we
administered a whole series of questions related to serious mental
illness.

There were three or four different scales. K6 was one of them, and there
were some others.

DR. McCORRY: Another one is I think the CIDI.

MR. GFROERER: Yes. And this was done in a household-type interview.
Actually, it was done in an office setting. No, it was in a household
setting. But it was done with our exact same questionnaire using our
methodology. Then a clinical interview was done on these people
afterwards to match it up. So it is kind of a validation. It is more I
guess I\'d call it a calibration. So we calibrated the K6 to the results
of the clinical interview to match it as closely as possible to what
that clinical interview showed.

DR. McCORRY: And what was considered SMI? Is there a standard?

DR. CLARK: It\'s not diagnosis-specific.

MR. GFROERER: Well, it is basically any diagnosis, any disorder plus
having an impairment within the past 12 months. The questions don\'t
actually measure all diagnoses, but statistically in terms of the way we
did that study, it matches pretty well.

DR. McCORRY: And the impairment was like a functional impairment?

MR. GFROERER: Right.

DR. CLARK: One last question, Gregory.

DR. SKIPPER: How do you define the

non-medical use? How do you define that?

MR. GFROERER: Well, its use is not prescribed by a doctor or ‑‑

DR. SKIPPER: So it doesn\'t count people like a neighbor that took it
for a headache.

MR. GFROERER: No.

DR. SKIPPER: Like if somebody got drugs from somebody else for a medical
problem, would that be

non-medical use?

MR. GFROERER: Yes. It has got to be prescription drugs. It is only
prescription drugs.

DR. SKIPPER: To them.

MR. GFROERER: Used without your own prescription.

DR. SKIPPER: Without your own prescription.

MR. GFROERER: Yes.

DR. SKIPPER: Okay. So it wouldn\'t necessarily represent, all of those
wouldn\'t be abuse necessarily?

MR. GFROERER: No.

DR. CLARK: Although theoretically it is illegal. Or actually technically
it\'s illegal to use somebody else\'s controlled substance.

Thank you, Joe. Once again, that was a great presentation.

We move to our next speaker. We will have a presentation overview of
residential treatment by Deborah Trunzo, also from the Office of Applied
Studies.

MS. TRUNZO: Good afternoon. Today I\'m going to be talking about some
results from the Drug and Alcohol Services Information System, otherwise
known as DASIS, with some findings on residential treatment.

There are basically two kinds of data as part of the DASIS data sets.
The first is facility data that comes from our National Survey of
Substance Abuse Treatment Services, or the N-SSATS. The second is

client-level data from the Treatment Episode Data Set.

First I\'m going to describe some findings from the N-SSATS survey for
you. It is conducted annually, and it is actually a census of all known
substance abuse treatment facilities. That is all the treatment
facilities in the nation that we\'re able to identify from a variety of
sources.

It includes public and private facilities, freestanding facilities, and
specialty units within other organizations, such as hospitals or mental
health centers. The survey collects data on facility characteristics,
services offered, and the number of clients in treatment on the survey
reference state. So in effect what it provides is a snapshot of
treatment resources in utilization on a particular typical day in the
treatment year.

Now for some of the data. I\'m going to be presenting data from our most
recent survey, which was conducted March 31st of last year. 13,454
facilities responded, saying that on that date they were actively
providing substance abuse treatment services.

As you can see, the vast majority, 81 percent, provide outpatient care,
27 percent said they provided non-hospital residential treatment, and
only 8 percent provided hospital inpatient care. You might notice that
this adds up to more than 100 percent. That is because some facilities
provide more than one level of care.

This slide demonstrates that this distribution of treatment services has
remained pretty much unchanged since 1997. That is the year starting in
which the survey was conducted in a more or less consistent manner, so
I\'ve only gone back that far. But it is an amazingly stable trend.

On March 31st a year ago, there were about 1,080,000 clients in
treatment at all of the 13,000 plus facilities. The distribution of
these clients by type of care received more or less mirrors the
distribution of types of care offered by the facilities that I just
showed you. Facilities reported that almost 90 percent of clients were
in outpatient treatment, while about one-tenth that many were in
residential care. Again, this picture has remained pretty much unchanged
for the past six years.

Now I\'m going to take a look at the residential services in particular.
There were 3,680 facilities that reported that they offered residential
services. Most of these, over 80 percent, offered

long-term residential treatment, that is a treatment program lasting for
30 days or more. About half as many offered short-term treatment
programs lasting less than 30 days, and about one-fourth offered
detoxification services.

This slide shows the distribution of the 102,000 clients receiving
residential treatment on March 31st, 2004. Again, this parallels the
results shown in the previous slide with most clients in long-term
treatment, and about one-third as many in short-term programs.

In the survey, we asked facilities to indicate whether they are owned or
operated by a private or government organization. About three-quarters
of all the residential facilities reported that they were private,
not-for-profit entities, and just 12 percent claimed to be private, for
profit. A much smaller percentage of residential facilities said that
they were government owned, either local, state, or federal, and just 1
percent claimed tribal ownership.

This result surprised me, because it is quite different than the pattern
for outpatient facilities. Outpatient facilities report being 55 percent
private

nonprofit, and 30 percent private for profit. I know that there is some
interest here in faith-based treatment. We can\'t say for certain how
many of these residential facilities are what you might call
faith-based. One reason that we can\'t is that there really isn\'t a
definition that we can use in our survey when it is sort of precise
enough. But we do ask facilities if they are affiliated with a religious
organization. I don\'t have that result for 2004, but in 2003, about 8
percent of the residential facilities said that yes, they were
affiliated with a religious organization.

We also asked facilities to tell us what they considered to be their
primary focus. Most residential facilities of course report that
substance abuse treatment is their primary focus, but not all. Fourteen
percent say that their focus is equally divided between substance abuse
treatment and mental health services, and 3 percent say that mental
health services is their primary focus.

We are asked a lot of questions about treatment capacity. In an attempt
to answer these questions, we asked a question that is shown here on our
survey on March 31, 2004, how many of the residential beds at this
facility were specifically designated for substance abuse treatment.

Amongst the facilities that provided an answer to that question, they
reported about 125,000 residential beds, which works out to an average
of 39 beds per facility. So when we divided the number of residential
clients in treatment on March 31st by the number of beds, we get a
utilization rate of 77 percent on that particular day.

Now I\'m going to move onto the Treatment Episode Data Set, which is not
a survey. It is a

client-level database on treatment admissions. It is collected by the
state substance abuse agencies from the facilities that they monitor or
fund. So these are largely facilities that are receiving public funds,
including federal block grant funds.

The states then convert their own unique data into a standard format,
which they then submit to us, and we aggregate it and then are able to
analyze it on a national level. It is a huge data set. We get about 1.9
million records annually at this point.

One thing to keep in mind when I show you some of the data is that TEDS
counts admissions, it doesn\'t count individuals. So some individuals
can be admitted to treatment more than once in any given year. So it may
be that these numbers reflect multiple admissions for a certain
proportion of the clients.

The TEDS data elements include date of admission, client demographics,
their drug use history, and treatment variables that describe the
treatment services that the client is being admitted to.

In 2002, the most recent year for which we have complete TEDS data, 34
percent of all admissions were to residential treatment. Like the survey
results, TEDS paints a remarkably steady picture. This 34 percent has
been the case since 1992, which is the first year for which we have TEDS
data. There has been very little change.

This slide shows clients primary substance of abuse at the time of
admission by the three major service categories. Here we can see how
primary drug differs for outpatient versus residential versus hospital
inpatient admissions. The residential admissions are more likely to
report alcohol and opiates as primary substances than outpatient
admissions, but less likely than the hospital inpatient admissions.

Also marijuana, that\'s the pink bar in the middle, is less likely to be
the primary drug of abuse for residential admissions than it is for
outpatient admissions.

MR. DeCERCHIO: This is adults and adolescents?

MS. TRUNZO: Yes, it is. I\'m trying to remember. Of that 1.9 million
admissions in 2002, I\'m trying to remember the portion that are for
adolescents. I think it is somewhat less than 9 percent.

DR. SKIPPER: (Inaudible.)

MS. TRUNZO: This is primary drug. TEDS gets primary, secondary, and
tertiary. This is just primary.

In terms of gender, there are only slight differences between the three
types of service. A slightly higher proportion of residential admissions
than outpatient admissions.

Here we can see that residential admissions tend to be somewhat older
than outpatient admissions, but younger than hospital inpatient
admissions. The little blue bar represents clients under 18, and the
purplish one on the right represents clients 45 and over.

I\'m looking at race and ethnicity. Residential admissions are slightly
less likely to be white, and more likely to be African American and
Hispanic than outpatient admissions. American Indian and Alaska Natives
represent about 4 percent of all residential admissions. That\'s the
little yellow bar. Asian and Pacific Islanders, about 1 percent.

Looking only at residential admissions, in 2002, just over half were for
detoxification services, and the rest were equally divided among long
and short-term residential rehabilitation. Again, long term was defined
as over 30 days, and short term as 30 days or less. Once again, there
has been very little change since 1992 in this distribution.

Looking at primary substance for just residential admissions, you can
see that the pattern differs according to service with detox having a
much higher proportion of alcohol and opiate admissions, which wouldn\'t
be surprising. The short term and long-term rehabilitation having higher
proportions of marijuana, cocaine, and stimulant admissions.

Here is gender for residential treatment services. The detox admissions
tend to have a higher proportion of males. The long-term treatment
admissions have a slightly higher proportion of females. Age, the detox
admissions are a little bit older. There are very few detox admissions
under the age of 18, and about one-fourth of the detox admissions are 45
and over.

Looking again at race and ethnicity, long-term treatment admissions are
somewhat less likely to be white, and more likely to be African American
or Hispanic than other residential admissions.

I think a lot of these demographic differences are in fact driven by the
affect of primary drug, and that the age, gender, race, and ethnicity
differences are more determined by patterns and primary drug, which
I\'ll show you in a minute.

Here we do have residential admissions by race and ethnicity by primary
substance. You can see that each of the race and ethnicity groups shows
quite a different pattern. Over 70 percent of American Indian and
Alaskan Native residential admissions are for primary alcohol abuse,
whereas only 35 percent of Asian and Pacific Islander admissions
reported alcohol as the primary substance. This is limited to just
residential admissions.

On the other hand, Asian and Pacific Islander admissions are the most
likely to report stimulants as their primary drug, if you look at the
yellow bar there. In looking at the sort of tealish, aqua-colored bars,
you can see that Hispanic residential admissions are the most likely to
report opiates as the primary drug.

To finish, I\'m going to give you a preview of some of our data from the
2002 TEDS discharge data set. The bar on the left represents total
discharges from all treatment services. In looking at the yellow area,
you can see that 42 percent of all discharges completed treatment, and
another 8 percent were transferred to another level of treatment.
Combined, this is 50 percent, and represents what you might call a
positive end to the treatment episode.

The remaining 50 percent were divided between those who dropped out of
treatment, that is represented by the pinkish segment, those whose
treatment episode was terminated by the facility, that\'s the purple
color, and then the little blue segment at the top is represented by
death, incarceration, and other reasons.

If you compare this total bar to the bars on the right for the three
types of residential service, you can see that discharges from
residential short-term treatment have by far the highest treatment
completion rate, at 65 percent. But discharges from long-term
residential treatment do only half as well, with only 33 percent
reporting that the treatment episode was completed. Also among
discharges from long-term treatment, the dropout rate equals the
treatment completion rate.

That\'s all the numbers that I have for you this afternoon, but our
report on all 2002 discharges that has an incredible amount of detail is
going to be released in about another month. So when it is, I encourage
you all to have a look.

Yes?

MS. JACKSON: On this last slide, you said the other was by death or
incarceration on that blue?

MS. TRUNZO: Yes.

MS. JACKSON: Wouldn\'t it be more appropriate to somehow detail that
closer to the completed transfer, since there is no control there, and
keep the dropped out terminated as the top two? Since everybody
interprets completion so seriously and wants to have a higher completion
rate, the ones that there is no control over, it seems a little unfair
to classify that with the terminated and the dropped out.

MS. TRUNZO: Yes, I can do that the next time I present the slide. That
other also includes sort of unknown, records that we get without reason
for discharge where we don\'t know what to do with them. So it is kind
of a mixed bag.

MS. JACKSON: Yes.

MS. TRUNZO: But certainly I can stack them in order.

MS. JACKSON: But if it is indeed, because we do have a certain number of
people who end up being incarcerated or something like that, then that
is a

non-control issue.

MS. TRUNZO: Another thing I might do next time is actually split those
out.

MS. JACKSON: Split that out, yes. Thank you.

DR. SUCHINSKY: Do you have any data on the percentage of all patients
who are in treatment who receive a residential period of treatment
during the year? Obviously it would be more than 10 percent, but do you
have any data which imputes that number?

MS. TRUNZO: No. Not all the data that we get has the unique client ID.
We\'d have to be able to link treatment episodes and figure that out. We
haven\'t even attempted that yet. We are just starting to look at
whether or not the ID that we get with the data would permit that. But
that would be something we\'d like to do eventually.

DR. SUCHINSKY: The other question I have is on the occupancy rates of
the residential programs, do you have any data on the number of programs
that had occupancies of 90 percent or above?

MS. TRUNZO: Yes. Yes, I had a slide on that and I took it out because I
thought I was going to be going on for too long. I can\'t remember what
the result was.

But if you look for the 2003 survey, that data is out on the web. If you
look at the SAMHSA website under statistics and data, and then under
N-SSATS, the 2003 report will have the utilization rate in categories of
90 to 100 percent, I think, and then it is 51 to 90 percent and so
forth. Anyway, it will provide some insight on that.

Yes?

DR. MADRID: One question. Do you all have any data on success at
follow-up on treatment completions versus dropouts?

MS. TRUNZO: No, we don\'t.

DR. McCORRY: I think this follows up on Richard\'s question. That 77
percent utilization rate, have you run that data dropping out the detox
beds? It looks like the system is overbedded.

MS. TRUNZO: Unfortunately, the way we collect the data, we can\'t just
distinguish the detox beds from other residential treatment beds.

DR. McCORRY: How are you able to compute the other statistics then?

MS. TRUNZO: We asked for the number of clients in detox in long term and
in short term on March 31st. But then when we asked for the number of
beds, it is for all the residential clients in the facility. I mean, for
the entire facility. So we don\'t ask them to tell us their number of
detox beds.

DR. McCORRY: Because I\'d hate to be delivering a message that we have
28 percent, 23 percent underutilized in residential if essentially it
might be a problem of not closing inpatient detox beds, which tends at
least in New York, tends to still be overbedded, because they are pretty
good cash producers.

MS. TRUNZO: Right. No, our instrument is not that precise. However, we
are doing a redesign in 2006, so I\'ll take into consideration your
comment, because we want the data to be useful.

DR. CLARK: Last question, Melody.

MS. HEAPS: I would more than strongly urge you to do that. I think
Frank\'s comments are important. I think there is a bit of a devastating
impact that that number will have. We are dealing with treatment waiting
lists in Illinois.

If someone got hold of that, if Congress got hold of that, I think it is
a very, very serious question that people would say, what is the problem
here? You are underutilizing it, and it will have economic impacts.

The other thing, I mean, I have to tell you I have some concerns about
what I\'m seeing. I think that we ought to be concerned about it. I\'m
not suggesting the data is not good, I think it is, but the successful
completion of long-term residential when so much of our money is going
into long-term residential, clearly these are harder clients, I
understand that. But I\'d like to look at that, if you could look at
that, because that is another piece of data that when it gets out there,
gets interpreted in ways which say long-term residential care does not
work. That is what the data shows.

So I hope you are thinking in those terms about now it may be that we
need to look at that issue. I\'m not saying we shouldn\'t look at it.
But a 33 percent success rate compared to the others is not a good
success rate. Even though I know it, even though I could have told you
that, it is still not good. We need to look at that.

DR. CLARK: All right.

Val, you\'re the absolute last one.

MS. JACKSON: I\'ll be quick. Following up, though, I think Melody made a
very important point. The question would be in your redesign to look at
what is the completion rate. How are you measuring the completion rate?
Go ahead.

MS. TRUNZO: Yes, the data on completion doesn\'t come from the survey,
it comes from this Treatment Episode Data Set. That is the
administrative data that we get from the states. So it isn\'t really
subject to redesign, in that that is what the state sent us.

MS. JACKSON: Okay. We do our completion rates in Florida, and they are
certainly not even close to what you\'re reporting. I mean, they are
much higher, the completion rates.

MS. TRUNZO: Yes. This is an aggregate of all the states that are
reporting. It varies from state to state.

MS. JACKSON: But if the states are only reporting by, for instance, X
number of days or when there was graduation day, I mean, it is so
complex, it is so much more than that. We are giving a very misleading
picture.

MS. TRUNZO: This was just one piece of the data. We have other
information on average length of stay, median length of stay in terms of
days in treatment. So there is a lot more to balance out and round out
the picture. That will be in this upcoming report.

DR. CLARK: Thank you, Deborah.

(Applause.)

DR. CLARK: We were supposed to have a break. We\'ve got two more
presentations. What is the will of the council? All right. Let us
proceed.

Our next speaker will be Joan Dilonardo, Dr. Joan Dilonardo from
Division of Systems Improvement Organization and Financing Branch. She
will give us an overview of residential treatment in CSAT\'s
discretionary portfolio.

DR. DILONARDO: So I heard in using science, bridging science, I heard
that the things that you practice when you\'re younger stay with you
when you\'re older. So I\'m recovering from some foot surgery, and I\'m
practicing the use of a cane. I expect when I\'m 85 and I need a cane, I
will be really, really good at this.

What I\'m going to talk to you about today is what we know about
residential services in the discretionary portfolio that CSAT funds. My
folks who run the data system for us, for the discretionary grantees,
put this presentation together for me. That\'s Deepa Avula, Kevin
Mulvey, and Pat Roth. Pat is going to work the slides, and Deepa is
going to answer the technical questions.

MS. HEAPS: Joan, do we have copies of these yet?

DR. DILONARDO: Do you have copies? They\'re in the book. I think we
added one, so that one is just coming out.

I\'m going to try to go through this quickly. I don\'t think there are
any big surprises. I know that this is in response to the interest that
the council expressed before in terms of what are we doing about
residential treatment within the discretionary portfolio.

Let me first remind you of a couple of things. The discretionary
portfolio are sort of a variety of announcements, mostly under the
rubric of Targeted Capacity Expansion, which for the most part, and that
is what is represented in these data, are for people to apply for grants
to serve underserved populations.

Now, sometimes it may be a population that is rural, sometimes we may
change it and shift it to like we have an announcement out now as part
of TCE, one of the populations is college students. So to a certain
extent, the people that are in our portfolio are a result of what we put
out in the announcements, and also a result of who applies and wins.

We don\'t have enough data to really start looking at trends and
differences over time. We expect to do that later on, but I\'m just
telling you, so it is not representative of anyone, but who applies to
and when CSAT grants.

The other thing I want to point out to you is although we are certainly
beginning to work on bringing our data together across SAMHSA, the kind
of data that I\'m presenting to you are different than what Deborah
presented to you from TEDS where she talked about what TEDS has is
mostly admissions. We don\'t have admissions, we have people. We are
actually moving to getting both people and admissions, so it is somewhat
different.

For those of you who aren\'t aware of this, this particular system is a
web based reporting system, grantees who get our money to provide
services or best practices activities have certain kinds of GPRA data
that they have to report. The data is supposed to be in the system
within seven days of the person being seen. So it is a live, active
system. The numbers change each day. It is what it is.

Currently we have in the whole portfolio, 508 discretionary services
grants. So those are the grants providing services to people. The grants
are funded to target varying populations, generally populations which
are underserved and vulnerable, including adolescents, minority groups,
women, pregnant, postpartum and parenting women, homeless individuals,
those affected with HIV or AIDS, those with co-occurring mental health
substance abuse disorders, persons in recovery, or other underserved
groups.

Our grants go to a wide variety of people. Sometimes they go to a state,
county, or city, and then onto providers. Some of them go directly to
providers. In the end, the services that are provided are a wide variety
of things, including outpatient treatment services, intensive outpatient
services, outreach, methadone maintenance, recovery support, as well as
residential treatment services. So residential treatment is just one of
the kinds of services we fund through our discretionary portfolio.

Currently there are two programs at CSAT which require grantees to
provide residential treatment services. The first of those was a grant
announcement that focused on adolescent residential treatment and
supports residential treatment services for

substance-using adolescents. There are currently 17 grants in that part
of the portfolio.

Another portfolio which requires residential treatment be provided is
the pregnant, postpartum, and parenting women portfolio, which support
residential services for pregnant women. That program currently funds 20
grants.

Then we have all of the other kinds of grants where people write in and
say, to serve this part of the population, I want to provide this kind
of a service. I\'m getting ahead of myself. We have people that provide
just residential services, and then we have people that provide
residential services as well as other kind of services.

We have some grantees that come in and propose sort of a service with
residential stepping down to something else. We have people who provide
services, say intensive outpatient and residential. They take patients
in and they assign them to what is needed.

So for the residential services only, we have besides the two
portfolios, the 37 grants that are adolescent and the pregnant and
postpartum women grantees, we have a couple of other grantees who are
providing residential services only. That totals only about 9 percent of
all the grantees in the discretionary program. The other ones are sort
of all over the map. A couple of HIV programs, a couple of TCE general
programs, and some homeless programs.

Then as we go onto the grantees who provide a combination of modalities
that include some residential treatment, we have another 115 grantees
who provide residential treatment in addition to one or more other
modalities. So those grantees compromise about 23 percent of all of our
grantees in the discretionary portfolio.

So about one-third of our grantees are providing some residential
services.

For the people that are combining residential with something else, the
most requested thing that it is combined with is outpatient treatment.
But we also have people providing residential with intensive outpatient,
and then also outreach and then residential.

The residential programs are located all over the country. This is the
piece of paper you just got today. The highest number is in California,
and you\'ll see substantial numbers of residential programs also in
Florida, Massachusetts, Texas, the larger states, as well as nine
residential programs.

Now I\'m going to switch gears a little bit and talk about the patients.
Our data show that only 12.2 percent of all the patients served under
our discretionary grants have received residential treatment services.
Targets, that is the number of people to be served, which are proposed
by grantees in their applications providing residential services, are
generally lower.

So if we have grants for \$500,000 and you come in and you apply for
outpatient services, the likelihood is that with that money, you\'d be
proposing to serve a larger portion of patients, whereas typically
people who are proposing residential services propose to serve a smaller
number of people relating to the larger costs for residential services.

In general, we looked at how many weeks of residential services the
patients in our portfolio are getting. Unfortunately, we didn\'t look at
treatment completion, although after listening to Deborah\'s
presentation, that\'s something we\'d certainly want to go back and do.

We don\'t use distinctions in our portfolio like short and long term.
These data represent actual lengths of stay, not planned lengths of
stay. You can see that if you want to use the rubric that long term is
more than 30 days, that we have a large portion of patients who are
staying in residential treatment for long term. Only about 30 percent
are exiting residential treatment within one to five weeks.

The other lack of comparability in the data that Deborah was presenting
to you from TEDS and these data is that we have very few detox of any
things going on in the discretionary portfolio. Generally we don\'t get
a ton of applications proposing to provide detox, and so we don\'t fund
it. We might have maybe one in the entire portfolio of 508.

So we see patients that are staying quite a length of time. I was
pleased when I saw this. If you look at the research, people that are
staying in treatment longer than 90 days have a better outcome, so I\'ll
be interested in looking at that. I didn\'t bring the outcome data
today, but we can certainly look at that if you all are interested in it
next time.

In addition to receiving these weeks of residential service, about 70
percent, just slightly more than 70 percent of all these folks who get
some residential services also get case management services, and then
about 20 percent of them also get outpatient services, and then it goes
about 10 percent get outreach in addition to their residential services.

We did look a little bit at the demographics and drug use
characteristics of the people getting residential services within the
discretionary portfolio. A surprise to me, more men than women. I
thought it might be largely populated by pregnant and postpartum women,
but that is not the case. We looked at why that was. Was it mostly
criminal justice, GFAs, or other kinds of announcements contributing to
that? The answer is no, it is just no across the board.

In terms of folks getting residential treatment in terms of their race
or ethnicity, you see that these are really not that different than the
overall sort of race and ethnic profile of our discretionary portfolio
period. There is one difference in that there is a larger percentage of
American Natives and American Indians getting residential treatment. But
largely really not that different, which I thought was a good thing to
see.

MR. DeCERCHIO: But it is different than the other slides on other
presentations in terms of the overall TEDS data. So the fact that this
is targeted capacity targeting certain populations, it is 42 percent or
48 percent, which is like 32 and 26 percent before.

DR. DILONARDO: Right.

MR. DeCERCHIO: So in that respect, it is very different.

DR. DILONARDO: It\'s very different than the national benchmarks. It\'s
very different from TEDS. It is also very different from what was the
sample developed in the alcohol and drug services survey, a nationally
representative sample. I have that slide in a couple of slides.

This slide represents the age distribution of folks getting residential.
Again, 15 percent of adolescents, but it is not 50 percent adolescents,
it is 15 percent. It somewhat mirrors what you normally see or often see
as a distribution.

Speaking to the point that Ken just brought up, what this slide shows is
the comparison of the demographic characteristics of folks in the
discretionary portfolio who get some residential and the folks in the
discretionary portfolio who don\'t get residential. So all the other
people in our discretionary portfolio get outpatient or something other
than residential, as well as TEDS. And then also the distribution in
ADSS for residential. So it is a little bit different. But still, you
see significantly our residential doesn\'t look that different from our
non-residential. We are basically serving the same kinds of people
within the discretionary portfolio and residential, except that we\'re
serving a larger proportion of American Indians and American Natives,
and a slightly smaller proportion of blacks. But it is hardly
remarkable.

The differences between the discretionary portfolio and who is served by
the discretionary portfolio in terms of their demographic
characteristics are significantly different than what we see in the TEDS
data, and also significantly different than what we see in the ADSS
data.

Lastly, I\'m going to go onto this slide. This is not the primary drug
abuse kind of variable that Deborah showed you in the TEDS data. This is
we asked people, we take them through a long, lengthy lists of drugs.
You can just see for discretionary residential, alcohol is the first
drug most frequently mentioned, cocaine is the second, onto marijuana.
Whereas there is a little bit of difference in the discretionary

non-residential clients who mention alcohol most often, marijuana most
second, and cocaine shortly after marijuana. There is a slight change in
the ordering in that.

So if you can take home anything from this, in the non-residential
portion of the CSAT discretionary portfolio, we are seeing more people,
slightly more people, with marijuana than you see in the other sort of
distributions. People with problems with cocaine are more likely to be
in residential treatment in a discretionary portfolio than in the
non-residential part of the discretionary portfolio.

So basically going the same place we went before, which is that in the
discretionary portfolio, CSAT\'s residential portfolio, we are basically
treating very similar kind of populations that we treat in the rest of
our discretionary portfolio. But the population is more diverse and more
minority than seen in TEDS or ADSS.

We are also serving more women in the discretionary portfolio than you
see in TEDS or ADSS. We are serving more Hispanics, and in general, more
minorities.

As we go down the road with these data, and as our data become better
and better, we actually want to look at sort of a predictive model to
look at what is the contribution, what are the things that get you into
residential treatment, what are the things most likely to get you into
residential treatment in our portfolio, and then also look at and try to
follow up on what Deb was talking about before in terms of how treatment
completion does or doesn\'t predict outcome, and how that relates, what
the treatment completion outcome looks like in the discretionary
portfolio in comparison to the TEDS portfolio would be a really
interesting comparison I think to make.

Comments? Questions?

MS. HEAPS: It seems to me that you are doing what you are supposed to be
doing. The data shows that you\'re doing what you are authorized to do.
So congratulations.

DR. DILONARDO: And we all said look at this, isn\'t this great.

MS. HEAPS: Congratulations. It doesn\'t always happen.

DR. DILONARDO: Thanks. Well, and also recognize that we have these data
because our grantees, although we require them to do this, they actually
collect and send the data to us. So I would also like to recognize all
of the work that all of our grantees do in sending the data in and in
dealing with us about data issues, questions, and problems.

The grantees have really come around and have made a tremendous number
of changes in a short period of time. So without that, we wouldn\'t be
here.

DR. CLARK: Thank you.

I\'d also like to acknowledge the staff of DSI who work with the
grantees to we make sure we get the data in. I periodically look at the
SES data and harass people about why is this program performing so
poorly, yada, yada, yada.

DR. DILONARDO: And he occasionally does sprinkle in a positive. I\'m
glad to see these grantees really doing well.

DR. CLARK: But the key issue is we have a mechanism by which we can do
near real-time monitoring of performance, and so we don\'t have to wait
six months before we discover whoops. That\'s the key issue.

We\'ve got one more presentation. That is Joe Faha, who has graciously
consented to return. We were supposed to hear from him earlier, but
because of the scheduling, he was unable to present. He is going to give
us a legislative update.

MR. FAHA: Good afternoon. Cynthia asked me on the way down here, she
asked me if I would give her a small bio. So I provided one, but they
didn\'t use it. They said basically he\'s tall, dark, handsome, able to
jump tall buildings with a single bound, faster than a speeding bullet.
They chose not to use that.

(Laughter.)

MR. FAHA: I also am pleased ‑‑ although I was supposed to present this
morning, unfortunately the calendar got a little stretched, so I wasn\'t
able to do it. But George Gilbert was kind enough to give me a call and
say, \"Can you show up at 3:15. They were unanimous in wanting you to
come and talk.\" I said, \"Thank God, because if somebody objected, I
would not have come.\"

(Laughter.)

MR. FAHA: My role here today is to just give you a flavor as we start
the 109th Congress about what is currently going on on the Hill. First
I\'m going to do a little bit of discussing about how the personnel
members are shifting and what is happening with regard to various
committees. We\'ll talk a little bit about that and what the
repercussions are and share with you the current state of lack of
resolution of what the assignment is going to be. Then maybe a couple of
issues, and if you have any questions, by all means, feel free.

Melody, you and I have met over a hearing in which you testified, along
with Charlie. I don\'t believe I\'ve had the opportunity to meet
everybody else, but hopefully before the end of the day, and certainly
before you leave this council.

Let\'s start with appropriations, because that is always the most
important it seems to me. We have a lot of discussion about
authorization and policies and what we can and cannot do. The push is in
the appropriations. So I want to give you first a breakdown as to what
is happening on the various committees.

First of all, Mr. Stevens from Alaska has resigned as chairman of the
Appropriations Committee in the Senate, largely because he has been in
that seat for six years, and the Republicans adopted a six year and then
out along with their Contract with America back in 1994. He gave up his
seat in favor of Mr. Thad Cochran from Mississippi. So you will start
seeing in our budget discussions in the future less money going to
Alaska, and more money going to Mississippi.

(Laughter.)

MR. FAHA: Be assured of it.

Over on the House side there was a considerable debate over three people
potentially taking over the chairmanship from Mr. Young from Florida,
who also served his six years out. Ken I\'m sure knows him very well, in
that he served his six years, and instead is now going to become
chairman of one of the subcommittees.

It was between three people. Ralph Regula, who has been our chairman of
our Labor-HHS-Ed Subcommittee and Appropriations, Jerry Lewis, who had
been the chairman of the Defense Appropriations, and Harold Rogers, who
was Homeland Security chairman. The end result was that the leadership
chose to give it to Jerry Lewis from California.

Is there anybody here from California? Anybody particularly from San
Bernardino area? No?

MR. DONALDSON: Los Angeles, Orange County.

MR. FAHA: All right. If you know anybody in San Bernardino, they\'re
important to us. That is his district. That is who he represents.

I\'ll talk about organization right now, and I\'ll explain to you why it
is that they have not made a lot of decisions. Mr. DeLay put in a
proposal as part of the Republican leadership in the House to reduce the
number of subcommittees from 13 to 10. Now, you have to understand this.
There is a lot of logic to this.

Programs that are of like mind are finding themselves being brushed
aside because they\'re not the most important program. His interest was
in NASA, as an example, and NASA was not being considered appropriately,
he felt, in the subcommittee in which they were assigned to. So he set
out to suggest and recommend.

What that meant was that they referred to them as appropriation
cardinals, very powerful positions in the House and in the Senate, were
going to lose their jobs. So this became a real political concern. There
was enough push back that he has basically abandoned that. However,
there is a commitment on Jerry Lewis\'s part, and I can only assume that
it was part of the deal to get him to become chairman, that there would
be a reorganization. He is currently going through a discussion with all
of the 13 cardinals about what moves can happen from one subcommittee to
another subcommittee in a hope that he will either reduce, that is one
possibility, reduce the number of subcommittees, but certainly rearrange
responsibilities.

Now, this is going to cause a lot of havoc because the Senate, Mr.
Cochran, has already said he\'s not interested in changing. So in the
political process, you run into a problem where you have a subcommittee
on the House side that is going to deal with example, Commerce, Justice,
Labor-HHS, but a subcommittee over on the Senate side that only deals
with Commerce and Justice, and they are supposed to sit down with each
other. One has a bill that covers Commerce and Justice, the other one
has a bill that covers commerce, Justice, Labor-HHS, and they have to
conference those.

So it causes some future problems politically for them, and they\'re
going to have to work this out. In the meantime, that means that the
chairmanships of all the subcommittees have not been decided yet. So
while Mr. Regula is the probable chairman of Labor-HHS-Ed, it has not
been decided yet. Nor have we found out whether or not his subcommittee
will lose jurisdiction over certain programs, be added, or have
additional responsibilities.

So all of that is up in the air. Until that\'s resolved, they can\'t
move ahead, they won\'t move ahead. I\'m talking in terms of hearings.

Continuing with the House. Given that, Mr. Lewis has promised to have
all the bills done on the floor by June, which would be huge. Just to
tell you that the Labor-HHS bill didn\'t pass last year in the House
until September. So that means that they\'d have to do a hell of a lot
of work about a bill that has an enormous amount of implication, very
costly, very controversial, being done roughly in three and a half
months. That is quite a challenge.

In the Senate side, they are less prone. Mr. Cochran has said, you know,
I kind of like things the way they are, and we\'re going to leave this
alone. Which would mean Mr. Specter and Mr. Harkin will continue as
chairman and ranking member of our subcommittee on Appropriations, and
both of whom have been very generous to SAMHSA in the past, and we would
hope would continue to be generous to us in the future. But we have to
wait for all of this to settle down.

Hearings in the appropriations process only occur on the House side. The
Senate gave up jurisdiction of holding hearings a long time ago when Mr.
Harkin was chairman and he was running for President, and all of a
sudden we didn\'t need all these hearings because he needed the time to
be running. When they gave it up then, they never pulled it back. So
there are no Senate hearings typically. They occur in the House. Staff
in the Senate come over and listen to the debate.

This year it is very likely that our hearing will be late March or early
April. It will also probably be similar to the one we had last year
where Charlie appeared with the Directors of NIMH, NIAAA, and NIDA. That
hearing was probably one of the best appropriation hearings I have ever
gone to. If any of you were here for it, you would have heard
considerable and intelligent conversation about substance abuse and
mental health issues, both prevention and treatment, and the interplay
between science and services. It really was probably the best hearing I
have been to. Therefore, it is likely it will be repeated.

What is our outlook this year? If anybody listened to the news or read
the paper this morning, you\'ll see that the federal government has
declared there was a deficit in \'04 of \$412 billion, and that the
projected deficit in \'05 is \$427 billion, \$412 billion having been
the highest deficit that we have ever run in one year, and now we\'re
closing in on this year being \$427 billion. That\'s just the deficit,
it is not the debt. The debt is well over several trillions of dollars
that we owe.

The President is getting an enormous amount of pressure from
conservatives to pull back. Let\'s conserve, we need to cut. In
addition, he is coming forth with a bill for another \$80 billion for
Iraq and Afghanistan. So I\'m just laying the work here that every year,
and again this year, we are going to face some monumental mountains that
we\'re going to have to get over from a funding standpoint.

So you can probably expect that the \'06 budget is going to reflect this
concern for all agencies. This is just a general comment. You\'re going
to see Congress and Mr. Lewis, especially, be very conservative about
funding opportunities for \'06.

Any questions about that before I move onto the other side of our Hill
responsibilities?

(No response.)

MR. FAHA: Such uplifting information, wasn\'t it? I figured as much.

With regard to authorization, now the other side of the picture with
regard to the Hill is that they also give us the authority to do what it
is that we do. I need to put this in context.

General Motors is free to do what it wants to do unless the law says
they can\'t. The federal government is only free to do what the law says
it can do. So the law is very important to us, because it defines who we
are. We try to make sure through our authorization process that we have
the statutory language that permits us to do what we want and need to
do.

If it gave us authority to make ice cream, we could make ice cream. But
we can\'t make ice cream right now. We\'re not authorized to make ice
cream. If they gave us authority to make ice cream with chocolate
sprinkles, we can make ice cream with chocolate sprinkles, but we can\'t
put strawberry sprinkles on it.

So that is the kind of thing that we have to be very careful about in
dealing with the authorizors. In that case it is the Senate Health,
Education, Labor, and Pensions Committee that has jurisdiction over our
programs. In the House, it is the Committee on Energy and Commerce.

The Health Committee is now being taken over by Senator Mike Enzi from
Wyoming, as opposed to Judd Gregg from New Hampshire. This is quite a
shift. Mr. Gregg was against any kind of legislative action. There were
very few mark ups in his tenure as committee chair, and he refused
basically to have any discussions about health policy and health
legislation unless it was desperately needed, and he needed to be
convinced that it was desperate. So there wasn\'t any casual
conversations about bills to pass to do this, that, or the other thing.

Mr. Enzi is being joined on the Republican side by several new members.
Mr. Frist will continue to serve, Mr. Alexander from Tennessee will
continue, Mr. Gregg will still be on that committee, and Mr. DeWine from
Ohio will continue to serve on that committee. Mr. Roberts from Kansas,
Mr. Sessions from Alabama, and then Mr. Ensign from Nevada. Then we have
three new members who are taking the places of Senators Warner, Bond,
and Graham. Mr. Hatch returns to the Health Committee, Mr. Hatch being
from Utah, and Mr. Burr, Richard Burr, a new Senator just elected from
North Carolina will be on that committee, along with Mr. Isakson from
Georgia will serve on that committee.

The Democrats will remain the same. They lose one seat on that
committee, but that seat was held by John Edwards who has resigned, as
we all know. That seat will not be filled because they in essence lost a
percentage. They have been reduced from what is it, 49 to 45 percent,
and as a result, they lose a seat on that committee. That, just to
remind everybody, includes Senators Kennedy, Dodd, Harkin, Mikulski,
Bingaman, Murray, Reed of Rhode Island, Clinton from New York, and
Jeffords as an independent sides with the Democrats.

They have reorganized the committee. Mr. Enzi has reorganized it
completely. There were four subcommittees. There still remains four
subcommittees, but the Subcommittee on Substance Abuse and Mental Health
is gone. It has been taken away. Instead we have four subcommittees,
basically one on bioterrorism and public health, another one on aging
and pensions, one on education and early childhood development, and a
fourth on labor.

Historically the chairmanships of subcommittees have gone to senior
members, yet two freshman Senators will be chairing two of these four
subcommittees. Mr. Burr from North Carolina will chair the Subcommittee
on Public Health. Mr. Isakson is taking over the one on labor. They are
both freshmen. Highly unusual.

However, one would assume that our issues, and all public health issues,
would fall under Mr. Burr\'s jurisdiction. No, not quite. Mr. Enzi has
decided that all public health issues will reside in the authority of
the full committee, not the subcommittee. So that all hearings about
public health issues will happen before the full committee, not the
subcommittee. That includes substance abuse and mental health.

You should be aware that when he sent out his summary of
responsibilities for the full committee and all of the subcommittees,
mental health and substance abuse were not mentioned at all. So it tells
you where substance abuse and mental health are in priority listings.

Do we know what their agenda is going to be? No. We\'ll get to some of
our hopes in a second. In the House, Mr. Barton, Joe Barton from Texas,
is now the chairman of the Energy and Commerce Committee, having taken
over from Mr. Tauzin when he left to become a lobbyist. Mr. Barton is
thinking seriously about redoing a lot of the organization of that
committee. So that where we had a Subcommittee on Health, which is where
we were for jurisdictional purposes, he is seriously thinking about
changing the subcommittees and changing the scope of responsibilities.
Those decisions have not been made yet, so we\'re still up in the air.
Nevertheless, who will continue as chairman and ranking members?

So structurally you can see what kind of disarray we currently have
right now in terms of trying to understand what is going to happen in
Congress. If you don\'t know who the players are and what their
interests are, then you can\'t figure out where to go.

So let me set that aside, unless somebody has a discussion about that,
and talk about some things that I know will happen.

MR. DeCERCHIO: What\'s the time frame? Is SAMHSA\'s reauthorization
overdue and you want an extension? Or is that coming up?

MR. FAHA: Yes, that\'s exactly where I was going to go. So unless there
is an organizational question from anybody else, let\'s go there, let\'s
start there.

SAMHSA seems historically to get a three year reauthorization every 10
years. We were authorized from 1992 through 1995, and then we were
unauthorized until 2000. Currently our programs are unauthorized as of
the end of fiscal year 2003. So we are entering 2005, which is our
second year without authorization.

What does that mean? This is not critical, folks. Despite the fact that
we were not authorized, we still got a lot of money in \'04, and we got
a lot of money in \'05. What it basically means technically is that
every authority, regardless of which one you look at, let\'s say the one
for pregnant and postpartum women, Section 508 of the Public Health
Service Act, the last section of it says authorization of appropriation.

It says they are authorized to be appropriated for fiscal year 2001,
\$10 million, and such sums for fiscal year 2002/2003. Reauthorization
means you say they are authorized to be appropriated for fiscal years
2005, \$10 million, and such sums as are needed for 2006, 2007. When you
have done that, you have reauthorized the program.

So from a technical standpoint, it doesn\'t mean much. However, you need
to appreciate it is the only time that you get to have a policy
discussion with Congress around those policies that you need to talk
about so that you can do what you want to do.

So reauthorization should not be looked at from a budget/appropriation
perspective. It is not needed. We don\'t need it. What we do need is if
we want to move ahead in a direction that the current statute limits us
from, we want to have that discussion with Congress so that we can get
the authority to do it. That\'s what reauthorization presents us with.

From a political perspective, if you do not have an agenda, if you do
not have policy concerns, then politically you are better off staying
out of the fray, because you may get something you don\'t want.
Guaranteed you\'ll get something you don\'t want.

So if you don\'t have an agenda, if you don\'t have a need, then
politically you just kind of pull back and let them set the agenda. You
don\'t push it, you let them have it, and just hope that you remain
safe.

MS. BERTRAND: The Substance Abuse Subcommittee that you talked about a
minute ago that you said was taken away, can you talk about that a
little bit? Is that the same committee that Congressman Jim Ramstad
developed, or is that different?

MR. FAHA: You\'re talking about two different things. Let me just finish
this thing on reauthorization. Let me finish this story, and then get
right back to your question, if that would be okay. Notice I call it a
story.

So the question is does SAMHSA have a tremendous need. As of right now,
no. We have a lot of things that we would be able to change, but I
don\'t know that there is something flagrant out there of what I refer
to as critical mass that would generate a need to have reauthorization.

Having completed that, is it going to happen in the Senate? Not clear.
Until Mr. Enzi sets his priorities, I have no clue. We do know that in
the House, Mr. Barton feels it very important that he reauthorize the
agencies under his jurisdiction. So we are on the queue on the House
side. However, we are behind several others. Notably, NIH, which is
expected to be first on the queue, and then Ryan White. So as I said, we
are in the queue, we just don\'t know if and when it is going to come
up.

To get to your question. The Subcommittee on Substance Abuse and Mental
Health, which was a subcommittee of the Senate HELP Committee, full
committee, was chaired by Mr. DeWine and several other Republicans, Mr.
Reed, and several Democrats were on that subcommittee.

They focused purely on substance abuse and mental health issues. That is
a subcommittee of the full committee.

What Mr. Ramstad has set up, along with Mr. Patrick Kennedy, is a
caucus, which is basically a group of members of the House who are
interested in substance abuse issues. That is what that is. They have no
power. It is just those of like mind who get together to talk about,
discuss, plan, see if they can coordinate efforts on substance abuse
issues.

I don\'t mean to belittle it. It is important. Mr. Ramstad, the last
time we gave a presentation on a National Household Survey, he stayed
for the whole hour and a half personally asking us questions, showing
his commitment to this issue. Unheard of that a member of Congress
spends that much time and energy on this issue. I hope that explains the
difference.

Other issues that are going to come up. Buprenorphine and getting rid of
the 30-patient limit for group practices. Unfortunately, they started an
effort to do this and eliminated it six months ago, and it still hasn\'t
been done. One would wonder why it is that it is not done since it is
not so controversial.

Part of the problem was a personality issue between, to be quite frank,
two staff people on the House side. There was a pissing contest going on
and it got held up. Then at the last minute, Mr. Sensenbrenner, who is
the chairman of the Judiciary Committee, decided that he wanted to hold
hearings on an issue that nobody objected to. I have no clue as to what
the problem is, because there is no force out there that we know of that
is objecting to the issue of releasing the limit on group practices.

But that should come back up. In fact, I know Jackie Parker from Mr.
Levin\'s office was putting together the language. She sent me a copy of
it yesterday to make sure that is what was needed, and they were going
to introduce it.

You can expect monitoring, an electronic monitoring bill to come back.
Here we have Mr. Harold Rogers of Kentucky initially set up a program
through the Department of Justice. Kentucky started an electronic
monitoring system, along with I believe 19 or 21 other states that have
such systems in some capacity.

Mr. Harold Rogers is still firmly supportive of the fact that this
should stay at Justice. Mr. Rogers is a member, as I just mentioned, who
was running for chairman of the Appropriations Committee.

Mr. Whitfield, another member of Congress from Kentucky, wants it to
come to the Department of Health and Human Services.

MS. HEAPS: Electronic monitoring?

MR. DeCERCHIO: Prescription monitoring.

MS. HEAPS: Not a bracelet.

MR. FAHA: Oh, no, no. I\'m sorry. I made an assumption. So Mr. Rogers
has said no money will be appropriated to such a program if it in
essence goes to the Department of Health and Human Services. You figure.

There is a lot of support in both chambers for such a system. There is a
lot of support in SAMHSA, there is also a lot of discussion in SAMHSA
about whether or not that is something that we think is appropriate.

Finally, there is an enormous amount of interest in methamphetamine. At
2:00 today, Mr. Talent from Missouri, along with Ms. Feinstein and
others, indicated that they were introducing a bill on methamphetamine
that had changes to criminal statutes, to treatment and prevention, and
that should be available for everybody to see. It is not a startling
bill, but it shows you a great deal of support for methamphetamine, both
from a law enforcement, treatment, and prevention perspective.

That having been said, are there any other questions?

MR. DeCERCHIO: Any discussion around child welfare and substance abuse?
The legislation about two or three years ago, is that dead?

MR. FAHA: It has not been reintroduced so far, and I have heard no
discussion. I know what you\'re talking about. It set up a block grant
for folks, kids who were involved in the child welfare system.

To be very honest with you, it is going to have an appropriation issue
to it. The bottom line is it is nice to have an authority. We have over
20 authorities that have never been appropriated right now. If indeed
this one were authorized, it would have to compete with the SAPT block
grant for funds.

So you in essence get into this battle. Yes, that looks nice. If it is a
block grant program, then you\'ve got to have some size to it, or else
what states in essence get would buy a postage stamp to submit your
application and then all the paperwork SAMHSA would require. You
understand where I\'m coming from.

Any other questions? I think I\'ve run over my time. Yes?

MR. DONALDSON: Frank, go ahead.

DR. McCORRY: Thanks, David.

What was the group that recommended NIDA and NIAAA being merged? Is that
part of the NIH reauthorization?

MR. FAHA: No. The NIH reauthorization is primarily going to focus on too
much independence of the individual institutes to pull together their
own professional budgets. Its major achievement, if Congress has its
way, would be to give more authority to the Director of NIH to stipulate
what those budgets are going to be, and to keep these professional
budgets to a minimum.

DR. McCORRY: So it is not an organizational reorganization?

MR. FAHA: No, and the NIH is not proposing a reorganization to
incorporate NIDA and NIAAA.

David?

MR. DONALDSON: So glad you came back this afternoon. Fascinating. We
have a government relations office, and I just want to present this. We
may be able to help you.

Pam Pryor, I don\'t know if you worked with her, she was the chief of
staff for J.C. Watts and is good friends with Jerry Lewis.

MR. FAHA: Good.

MR. DONALDSON: So if we can be of support there.

MR. FAHA: I didn\'t bring a card. I\'ll give you my phone number.

MR. DONALDSON: Also, you may have heard that there is a faith-based
caucus called the Community Solutions that we\'ve helped develop with
Harold Ford and Tom Green. They are looking for different pieces of
legislation that tie back to community-based efforts. So that might be
one horse to saddle.

MR. FAHA: I need to cleanse my spirit here and let you know that we
cannot encourage anyone to lobby on our behalf. But I want to let you
know that I am always available to provide technical assistance.

MR. DONALDSON: That\'s exactly what I was thinking.

DR. CLARK: For the staff and the audience, pay attention to those words.

MR. FAHA: Any other questions?

DR. CLARK: All right.

MS. HEAPS: You said methamphetamine was Feinstein and who else?

MR. FAHA: Talent. Mr. Talent. In fact, I thought maybe I brought a copy
of that bill with me. No, I guess I didn\'t. Yes, I did. So if you want
a copy, or do you want to make copies of this, we can get copies made.

Thank you very much for your attention. I\'m sorry if I kept you from
going asleep. I hope that you got something out of it.

Thank you very much.

(Applause.)

DR. CLARK: Now we\'re in the penultimate part of the day, the council
roundtable. It is during the council roundtable that council members get
to articulate areas of interest should they desire, or to further pursue
concerns.

Dr. Skipper?

DR. SKIPPER: I wanted to bring up an issue about buprenorphine.

DR. CLARK: Buprenorphine.

DR. SKIPPER: Probably everybody knows, and maybe I\'m right on this, but
buprenorphine, the law that allowed physicians to prescribe
buprenorphine in their practice occurred in about 2001, was it? I think
it was about 2001.

DR. CLARK: Two-thousand.

DR. SKIPPER: Two-thousand. The year 2000. And so SAMHSA has maintained a
website that lists all those physicians that have gone through the
process of training and obtaining a waiver. That is good. However, I
have received numerous calls, and it seems like increasingly, of
patients unable to find a doctor that will prescribe buprenorphine for
them.

So I have directed them, early on I was directing them to the website,
and now I\'m getting a lot of comments that nobody on the website will
prescribe for them. You know, I\'ve gone through every doctor on the
list, and nobody will prescribe.

DR. CLARK: Is there anyone from DPT here? Oh, Bob.

Bob, do you want to comment on that?

MR. LUBRAN: Bob Lubran with DPT, and I had a chance to talk to Greg
during one of the breaks.

The issue has several parts to it. One is that we only have about 70
percent of the physicians listed on that locator to begin with because
we have to ask each physician for permission to list their name. So
there are some physicians who don\'t even appear on that list.

Secondly, we know that there are more people in need of treatment and
seeking treatment than there are physicians in many communities who are
authorized to provide it. Our primary goal really from day one has been
to expand the capacity and expand the number of physicians who are
authorized to provide that treatment.

So in 2005, there are over 60 trainings being planned by the five major
medical organizations in the United States throughout the country to
expand that number. So we hope that the number of physicians which
currently is around 4,000 who have a SAMHSA waiver is going to almost go
up by 70 or 80 percent by the end of the year.

Thirdly, there are some patients who are interested in detox, and only
detox, and there are some physicians who would rather not provide that
service. Likewise, there are some patients who would like long-term
maintenance on buprenorphine, and physicians who may not be prepared to
do that. So getting that right mix in any community requires some work.

Last year we funded a project called the Clinical Support Network with
ASAM, American Society of Addiction Medicine, in collaboration with the
other medical groups to provide support to primary care doctors in
communities who may be reluctant to take on patients, or who may not
want to provide maintenance treatment in order to educate them, provide
them assistance, and if necessary, additional training in order to get
them to be more comfortable with that whole effort.

So that said, we would love to work with you, with ideas you might have
to address the problem, which we recognize is there. So please feel
free, or any other council member who has experienced that problem in
your own state, to be in touch with us, and let\'s try to work out some
other solutions.

MS. BERTRAND: So Bob, you and I discussed the trainings are great. I\'m
wondering if, as you and I discussed, if we could somehow get
information from docs that are prescribing buprenorphine to get a sense
of their satisfaction, and use that as advertising to get others to do
it.

MR. LUBRAN: Actually, that\'s something we discussed. I did want to
explain that we have a series of surveys that we\'re conducting,
starting with a survey of physicians, roughly 1,000 physicians from
October of 2002 to October of 2003. We did get those results. They are
available through our website, and we\'ve made presentations on that.

The second survey was a survey of 400 patients who have been on
buprenorphine to try to get a sense of their experience and some of the
things that they liked and didn\'t like.

Finally, we just started last week with another survey of 1,833
physicians randomly selected. I asked Greg if he got a survey, which it
turns out he didn\'t, probably because you weren\'t in the pool, but we
randomly selected over 1,800 physicians, and we\'re going to ask them a
whole set of questions along the lines of what you talked about. I hope
based on that survey that it is going to give us some insight into some
other areas we can follow.

Lastly, I did want to pick up on the comment that Joe Faha made about
the legislation to remove the cap on group practices. We know already
that that is a serious problem that has restricted both physicians and
patients from getting care. So we have been working with Joe in terms of
consulting with Congress, and also with Dr. Clark and the administrative
office in terms of looking at perhaps a regulatory fix to address the
problem.

So yes, there are some things from the surveys from physicians that are
going to help us a good deal. We\'re going to be presenting that at some
of the national meetings coming up this year.

DR. SKIPPER: I\'m wondering about identifying certain areas that may be
quite deficient. Like, for example, in Alabama, I have yet to find a
physician that will prescribe buprenorphine for maintenance therapy in
the entire state. None of the methadone programs will.

I wonder if we could identify areas like that that are real needy and do
some kind of further promotion, other than trainings.

MR. LUBRAN: Yes. I think through the physician surveys we are going to
discover a good deal about the practices and where there are gaps, and
through the ASAM project. So one of the things that I would again
encourage you to do is to share with us some of those ideas. We\'ll get
back to ASAM and some others, and to you, and work together on trying to
improve that system.

DR. SKIPPER: I\'m kind of wondering if we\'re going to see in areas that
are underserved by physician/patient ratios as in Alabama, Mississippi,
and other places where they are already too busy that they may not be
very interested in taking on a further patient load. So I don\'t know
how to get around that.

MR. LUBRAN: Well, one of the activities that we have is a plan to invest
in four rural areas in the United States, starting in March. We are
going to be going to Huntington, West Virginia, Lexington, Kentucky,
Jackson, Mississippi, and St. Louis, Missouri. Four areas that serve
somewhat of a regional population.

We found that in those states, particularly in the three states of West
Virginia, Kentucky, and Mississippi, there is a shortage of physicians
who have signed up for buprenorphine. We think that in working through
the public health system and working through some of the migrant
services in the rural communities, that we\'ll be able to educate a lot
more physicians. We know there is going to be some trainings in those
communities as well.

DR. SKIPPER: And then finally you and I talked about trying to get a
website or something that does detail what service is provided by those
physicians so that patients are so frustrated that they call everybody
on the list and find that nobody is prescribing it.

MR. LUBRAN: Right. We are going to look into that. Right now we collect
data from the physicians who are applying to us. It is very limited in
terms of what we collect. Some of the things that you mentioned to me,
we just don\'t collect that data. So we\'re going to go back and look at
what would it take in order to expand our notification form where we
collect data.

If not, we\'ll look at some other options, including the medical groups
who may be willing to add that information. Greg was asking, for
instance, if physicians offer detox services or maintenance services.
That information is currently not available on our website. But we\'ll
look into it and see what is involved and consult with you down the
road.

DR. SKIPPER: Thank you very much.

DR. CLARK: Frank?

DR. McCORRY: Just a quick point. Would it be possible to get the slide
presentation today electronically? Is that possible? I\'d appreciate
having sets that I\'d be able to look at and pull. Thank you.

DR. CLARK: Anybody else?

MR. DeCERCHIO: Before we leave, I wanted to talk quickly on today\'s
discussion, or this morning. I think you alluded to maybe coming back to
it. Maybe at a future meeting we could have an update or presentation.
It is such a big issue, the status of those performance domains and
where we are with indicator development. It is such a big issue that
resonates down to the state level, and down to providers at that level.

And then of course in terms of our whole collective stake in terms of
being able to depict success of what we collectively do. Maybe we could
agenda that for a future meeting and have a discussion around that.

DR. CLARK: That\'s the purpose of this roundtable, so we\'ll put that
there.

Val?

MS. JACKSON: Yes, I also had a request. That was at a future meeting if
we could talk a little bit about the development of the topics for the
RFAs for discretionary funds.

I know that that is kind of within the realm of us being able to give
suggestions as an advisory council. I appreciate all of the information
that we were given today. I think it was really a very good day in terms
of learning. So I wanted to thank you for that also.

Then I just wanted to say I\'m only going to be on the phone a little
bit tomorrow because I\'m going home to help my daughter have a baby.

DR. CLARK: Thank you.

Any other questions?

(No response.)

DR. CLARK: After this, we will tour the building. So given that there
are no questions for today, I\'ll entertain a motion to adjourn. We\'ll
reconvene in the morning. Is there such a motion?

DR. FLETCHER: So moved.

MS. HEAPS: Second.

DR. CLARK: It\'s been moved and seconded that we adjourn for today and
reconvene tomorrow.

(Whereupon, at 4:03 p.m., the meeting was recessed, to reconvene at
10:30 a.m. on Thursday, January 27, 2005.)