***[The Road to Recovery 2008]{.underline}***

**Real People, Real Recovery:**

**Effectively Delivering Recovery-Oriented Systems of Care**

*[Shoot Date]{.underline}: TBD [Air Date]{.underline}: July 2, 2008*

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**Abstract**: In 2006, an estimated 22.6 million persons aged 12 or
older were classified with substance dependence or abuse in the past
year. Of these, only 4 million received some kind of treatment for a
problem related to the use of alcohol or illicit drugs.\* Luckily, a
host of services exists for those who need them. From 12-step programs
to in-patient and out-patient treatment and from recovery-oriented
housing to sober recreational activities like those celebrated each
September during *Recovery Month*, there's an entire network of
treatment and support services available for those dealing with
substance use and mental health disorders. This program will examine
some of those services and explore ways to increase awareness and better
deliver these services to those who need them.

\* Source: Substance Abuse and Mental Health Services Administration.
2007. *Results From the* *2006 National Survey on Drug Use and Health:
National Findings.*

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**[Panel #1---Recovery-Oriented Systems of Care]{.underline}**

**[Key Questions]{.underline}:**

1.  **What is a "recovery-oriented system of care"?**

2.  **What are the goals of recovery-oriented systems of care?**

3.  **How do ROSCs deliver appropriate and effective treatment better
    than traditional acute treatment models?**

**Reasons for not Receiving Treatment *(2007 NSDUH)***

-   Among people who felt they needed treatment for illicit drug use but
    did not receive it (based on 2004-2006 combined data), reasons cited
    for not receiving treatment were:

    -   No health coverage and could not afford cost (35.1 percent)

    -   Not ready to stop using (31.8 percent)

    -   Not knowing where to go for treatment (14.7 percent)

    -   Concern that neighbors/community might have negative opinion
        (13.5 percent)

    -   Possible negative effect on job (12.8 percent).

**Definition of "Recovery"**

-   Recovery from alcohol and drug problems is a process of change
    through which an individual achieves abstinence and improved health,
    wellness, and quality of life.

**Definition of "Recovery-Oriented Systems of Care" (ROSCs)**

-   ROSCs support person-centered and self-directed approaches to care
    that build on the strengths and resilience of individuals, families,
    and communities to take responsibility for their sustained health,
    wellness, and recovery from alcohol and drug problems.

-   ROSCs offer a comprehensive menu of services and supports that can
    be combined and readily adjusted to meet the individual's needs and
    chosen pathway to recovery.

-   ROSCs encompass and coordinate the operations of multiple systems,
    providing responsive, outcomes-driven approaches to care.

-   ROSCs require an ongoing process of systems improvement that
    incorporates the experiences of those in recovery and their family
    members.

**Philosophy Behind ROSCs**

-   Treatment is part of recovery

-   End point of treatment = absence of symptoms of clinical disorder

-   End point of recovery = holistic health

-   Recovery support services are grounded in a strength-based approach
    that focuses on wellness and a reengagement with the community

-   Recovery support services build on capacities that already exist
    within communities

**Overall Goal of ROSC**

-   Create paradigm shift from acute treatment model to
    recovery-oriented system of care.

**Aims of Recovery-Oriented Systems of Care**

-   Reach those in need of services.

-   Develop culturally appropriate evidence-based interventions.

-   Build and sustain a qualified workforce.

-   Support systems-level changes.

-   Integrate substance use disorder services into the public health
    paradigm.

**How Recovery-Oriented Systems of Care Intend To Meet Those Aims**

-   Support person-centered and self-directed approaches to care that
    build on the strengths and resilience of individuals, families, and
    communities to take responsibility for their sustained health,
    wellness, and recovery from alcohol and drug problems.

-   Offer a comprehensive menu of services and supports that can be
    combined and readily adjusted to meet the individual's needs and
    chosen pathway to recovery.

-   Encompass and coordinate the operations of multiple systems,
    providing responsive, outcomes-driven approaches to care.

-   Require an ongoing process of systems improvement that incorporates
    the experiences of those in recovery and their family members.

**ROSC Encompasses and Coordinates the Operations of Multiple
Systems...**

-   Child welfare and family services

-   Social services

-   Housing system

-   Faith community

-   Indian health services

-   Health insurance

-   Veterans affairs

-   Criminal justice system

-   Vocational services

-   Primary care system

-   Mental health system

-   Addiction services system

**... To Provide a Comprehensive Menu of Services**

-   Family/child care

-   Education

-   Housing/transportation

-   Spiritual

-   Financial

-   Legal

-   Case management

-   Peer support

-   HIV services

-   Physical health care

-   Mental health

-   Vocational

-   Alcohol/drug services

*[Note]{.underline}: These services and supports can be combined and
readily adjusted to meet the individual's needs and chosen pathways to
recovery.*

**End Results of Providing Responsive, Outcomes-Driven Approaches to
Care**

-   Evidence-based practice

-   Cost effectiveness

-   Perception of care

-   Retention

-   Access/capacity

-   Social connectedness

-   Reduced homelessness

-   Reduced crime

-   Increased employment

-   Abstinence

**Summary of ROSC**

-   Begins with the individual, family, or community.

-   Presented with a comprehensive menu of services, the individual,
    family, and/or community can access systems of care that lead to
    recovery, wellness, and health.

**ROSC Maintenance**

-   Maintaining ROSC requires an ongoing process of system improvement
    that incorporates the experiences of those in recovery and their
    family members.

-   ROSCs require collaboration, partnership, and non-duplication of
    services.

-   ROSCs must be community-based, client-focused, cost effective,
    efficient, competency-based, and outcomes-oriented.

**[Panel #2---Prevalence of Substance Use Disorders and Benefits of
Recovery]{.underline}**

**[Key Questions]{.underline}:**

1.  **How prevalent are substance use disorders and how can they be
    treated?**

2.  **How does recovery benefit not only the individual but society as a
    whole?**

3.  **Why does treatment need to be personalized?**

**Substance Use Statistics *(Source: 2007 NSDUH)***

-   In 2006, among persons aged 12 or older, an estimated 22.6 million
    (9.2 percent), were classified with substance dependence or abuse in
    the past year.

-   Heavy drinking (classified as five or more drinks on the same
    occasion on each of 5 or more days in the past 30 days) was reported
    by 6.9 percent of the population aged 12 or older, or 17 million
    people.

-   In 2006, an estimated 20.4 million Americans aged 12 or older (8.3
    percent) had used an illicit drug during the month prior to the
    survey interview.

**Psychotherapeutics, i.e., "Prescription Drug Abuse" *(Source: 2007
NSDUH)***

-   Psychotherapeutics include the nonmedical use of any
    prescription-type pain relievers, tranquilizers, stimulants, or
    sedatives.

-   The number of persons aged 12 or older who used psychotherapeutics
    nonmedically for the first time within the past year rose from
    647,000 in 2005 to 2.6 million in 2006.

-   Among persons aged 12 or older who used pain relievers nonmedically
    in the past 12 months, 55.7 percent reported that they got the pain
    relievers they most recently used from a friend or relative for
    free.

**Prevalence of Treatment**

-   In 2006, 4.0 million persons (1.6 percent of the population) aged 12
    or older received some kind of treatment for a problem related to
    the use of alcohol or illicit drugs.

**The Benefits of Treatment and Recovery to the Individual and Family**

-   In addition to reducing alcohol and/or drug use, treatment can:

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-   Improve mental and physical health.

-   Reduce personal health costs.

-   Increase productivity in the workplace.

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-   Treatment allows individuals to improve relationships with family,
    peers, and coworkers.

**The Benefits of Treatment and Recovery to Society as a Whole**

-   Research suggests that treatment can *(Source: NIDA)*:

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-   Reduce criminal activity up to 80 percent.

-   Reduce arrests up to 64 percent.

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-   Effective treatment reduces harm, such as in physical/sexual
    assaults and motor vehicle crashes, to the general public by the
    behavior of those who are dependent on alcohol and/or drugs.

-   Recovery is associated with a 19 percent increase in employment and
    an 11 percent decrease in the number of clients who receive
    welfare.[^1]

**The Effectiveness of Treatment and Recovery**

-   Treatments for drug use disorders are just as effective as
    treatments for other chronic conditions such as high blood pressure,
    asthma, and diabetes.[^2]

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-   Standard treatments have been shown to produce significant
    reductions in drug use and in drug-related problems of crime, family
    violence, unemployment, and welfare dependence. *(NIDA*)

-   Following treatment, alcohol- and drug-related medical visits
    decline 53 percent.

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-   CSAT's Discretionary Services Program reported the following, from
    intake to 6-months past intake *(CSAT)*:

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-   Abstinence from substance use disorders increased 63.3 percent.

-   Employment and school attendance increased 33.5 percent.

-   Those reporting having stable housing increased 20 percent.

**Personalizing Treatment and Recovery (SAMHSA)**

-   Treatment should be tailored to the individual's needs, substances
    of misuse, demographics, and available options, and it should
    incorporate a cohesive group of services.

-   An individual's treatment and services plan must be assessed often
    and modified to meet the person's changing needs.

-   Just as substance use disorders can affect people regardless of
    their age, race, ethnicity, class, employment status, or community,
    treatment services also should respect these unique characteristics.

**Importance of Treating Co-Occurring Disorders Simultaneously**

-   The treatment of both mental health and substance use disorders can
    help prevent the exacerbation of other health problems, including
    cardiac and pulmonary diseases.[^3]

-   Ensuring that treatment is available and accessible for both
    disorders is essential to providing a successful path of recovery.
    *(TASC)*

-   Although not readily available, specialized therapeutic community
    "mentally ill chemical abuse (MICA) programs are promising for
    patients with co-occurring mental and addictive problems. *(TASC)*

**[Panel #3---Recovery Support Services]{.underline}**

**[Key Questions]{.underline}:**

1.  **What are "recovery support services"?**

2.  **What kinds of recovery support services are available?**

3.  **How can various recovery support services work together to support
    an individual's recovery from addiction to drugs and/or alcohol?**

**Recovery Support Services (RSS)**

-   Are a key component of ROSCs.

-   Are non-clinical services that assist individuals and families to
    recover from alcohol or drug problems.

-   Include social support, linkage to and coordination among allied
    services providers, and a full range of human services that
    facilitate recovery and wellness contributing to an improved quality
    of life.

-   Can be flexible stages and may be provided prior to, during, and
    after treatment.

-   May be provided in conjunction with treatment, and as separate and
    distinct services to individuals and families who desire and need
    them.

-   May be delivered by peers, professional, faith-based and
    community-based groups, and others.

**Employee Assistance Programs (EAPs)**

-   Of the 20.6 million adults classified with dependence or abuse in
    2006, 12.7 million (61.5 percent) were employed full time. *(2007
    NSDUH)*

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-   An EAP can help people find a treatment program and provide
    confidential problem identification, short-term counseling, and
    followup services to help resolve the problem.[^4]

-   The benefits of EAPS include:

    -   Less absenteeism and fewer accidents

    -   Decreased use of medical and insurance benefits

    -   Savings in workers' compensation claims

    -   Fewer grievances and arbitrations.[^5]

**Residential Therapy *(Source: ONDCP)***

-   Short-term residential treatment provides intensive but relatively
    brief (3- to 6-week) residential treatment based on a modified
    12-step approach.

-   Treatment is usually followed by extended outpatient therapy and
    participation in a self-help group, such as Alcoholics Anonymous.

-   Long-term residential therapy provides care 24 hours per day,
    generally in residential, nonhospital settings ("therapeutic
    communities" or TCs), for planned lengths of stay of 6 to 12 months.

-   The typical long-term resident has more severe problems, with more
    co-occurring mental health problems and more criminal involvement.

-   TCs focus on the \"resocialization\" of the individual and use the
    program\'s entire \"community,\" including other residents, staff
    members, and the social context, as active components of treatment.

-   Many TCs are quite comprehensive and can include employment training
    and other support services on site.

-   Research shows that TCs can be modified to treat individuals with
    special needs, including adolescents, women, those with severe
    mental disorders, and individuals in the criminal justice system.

**Counseling and Outpatient Therapy**

-   Counseling and therapy help people to:

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-   Address issues of motivation and improve problem-solving abilities.

-   Build skills to resist substance use.

-   Replace substance-using activities with constructive behavior.

-   Develop interpersonal relationships and the ability to function in
    the family and community.

-   Work through mental health and co-occurring issues.

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-   This type of program does not require individuals to take time off
    from work, leave their families, or enter a hospital as an
    inpatient. *(Illinois Institute for Addiction Recovery)*

**Support Groups and Aftercare**

-   Participation in self-help support groups during and following
    treatment is often helpful in maintaining abstinence.[^6]

-   Encouraging people in recovery to seek out aftercare following their
    initial treatment will help them sustain their path of recovery.[^7]

-   Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) and other
    12-step-like programs are self-supporting entities that are not
    allied with any sect, denomination, politics, organization, or
    institution. \[*AA, NA, and Dr. Hoffman*\]

-   Al-Anon holds regular meetings for spouses and other significant
    adults in an alcoholic's life, while Alateen is geared to children
    of alcoholics. \[*NIAAA*\]

**Jail Diversion Programs**

-   Jail diversion programs divert people with serious mental illnesses
    (often with co-occurring substance use disorders) from jail by
    linking them to community-based treatment and support services.

-   The key to jail diversion is identifying individuals with
    co-occurring disorders as early as possible in their processing by
    the justice system.[^8]

-   Studies have shown that jail diversion results in positive outcomes
    for individuals and communities, and is effective in reducing time
    spent in jail and results in lower criminal justice costs.[^9]

**Drug Courts**

-   Drug courts help to actively intervene with and break the cycle of
    dependence on alcohol and/or drugs. [^10]

-   There are more than 1,600 planned or existing drug courts in the
    United States that provide job/skill training, family and group
    counseling, and other resources that help individuals and their
    families cope.[^11]^,^ [^12]

-   Juvenile drug courts are intensive treatment programs established
    within and supervised by juvenile courts to provide specialized
    services for eligible drug-involved youth and their families. *(RM
    2003)*

-   The National Association of Drug Court Professionals and the
    National Drug Court Institute promote and advocate for the
    establishment and funding of drug courts. For more information,
    contact 703--575--9400 or visit their Web sites at www.nadcp.org and
    www.ndci.org, respectively.

**Retention in Treatment and Remaining in Recovery**

-   Recovery can be a long-term process and may require multiple
    episodes of treatment.

-   In 2004, only 40 percent of people discharged from treatment
    programs had actually completed treatment.[^13]

**[Panel #4---Working Towards ROSC]{.underline}**

**[Key Questions]{.underline}:**

1.  **What are some organizations/programs that deliver effective
    treatment services?**

2.  **How damaging is stigma, and what can be done to minimize or
    eradicate it?**

3.  **What are the benefits of investing in treatment?**

**Substance Abuse Prevention and Treatment Block Grant**

-   About \$1.76 billion per year

-   Forty percent of funds managed by the Single State Authority

-   Supports 10,500 community-based prevention and treatment
    organizations

-   Set-asides for Primary Intervention---20 percent; early intervention
    services for HIV--- 5 percent

-   Requirements for pregnant women and women with dependent children,
    IV drug abuser, TB services, coordination of services, and
    continuing education

**Access to Recovery (ATR)**

-   ATR is a 3-year competitive discretionary grant program funded by
    the Substance Abuse and Mental Health Services Administration
    (SAMHSA), Center for Substance Abuse Treatment (CSAT). 

-   ATR is a presidential initiative that provides vouchers to clients
    for purchase of substance use disorders clinical treatment and
    recovery support services. 

-   The goals of the program are:

    -   To expand capacity

    -   Support client choice

    -   Increase the array of faith-based and community-based providers
        for clinical treatment and recovery support services. 

**Faces and Voices of Recovery
([www.facesandvoicesofrecovery.org](http://www.facesandvoicesofrecovery.org/))**

-   Faces and Voices of Recovery (FVR) is a national campaign of
    individuals and organizations joining together with a united voice
    to advocate for public action to deliver the power, possibility, and
    proof of recovery.

-   FVR supports local recovery advocacy by:

    -   Increasing access to research

    -   Policy

    -   Organizing and technical support

    -   Facilitating relationships among local and regional groups

    -   Improving access to policymakers and the media

    -   Providing a national rallying point for recovery advocates.

**Treatment Alternatives for Safe Communities (TASC)**

-   TASC is a not-for-profit organization that provides behavioral
    health recovery management services for individuals with substance
    use disorders and mental health disorders.

-   Through a specialized system of clinical case management, TASC
    initiates and motivates positive behavior change and long-term
    recovery for individuals in Illinois\' criminal justice,
    corrections, juvenile justice, child welfare, and public aid
    systems.

-   TASC provides direct services, designs model programs and builds
    collaborative networks between public systems and community-based
    human service providers.

-   TASC\'s purpose is to see that under-served populations gain access
    to the services they need for health and self-sufficiency, while
    also ensuring that public and private resources are used most
    efficiently.

**Screening, Brief intervention, Referral, and Treatment (SBIRT)**

-   SBIRT is a comprehensive, integrated, public health approach to the
    delivery of early intervention and treatment services.

-   Primary care centers, hospital emergency rooms, trauma centers, and
    other community settings provide opportunities for early
    intervention with at-risk substance users before more severe
    consequences occur.

-   A key aspect of SBIRT is the integration and coordination of
    screening and treatment components into a system of services. This
    system links a community\'s specialized treatment programs with a
    network of early intervention and referral activities that are
    conducted in medical and social service settings.

-   [Screening]{.underline} quickly assesses the severity of substance
    use and identifies the appropriate level of treatment.

-   [Brief Intervention]{.underline} focuses on increasing insight and
    awareness regarding substance use and motivation toward behavioral
    change.

-   [Referral to treatment]{.underline} provides those identifies as
    needing more extensive treatment with access to specialty care.

**Connecticut Community for Addiction Recovery (CCAR)**

-   CCAR is a recovery community membership organization that promotes
    recovery through advocacy, education, and service.

-   Its RCSP project uses a peer-based social support model to build
    recovery capital throughout Connecticut.

-   CCAR's definition of recovery capital is "individual, relational,
    and community resources that support sustained recovery."

**Oxford House
(**[www.oxfordhouse.org](http://www.oxfordhouse.org/)**)**

-   An Oxford House is a democratically run, self-supporting and drug
    free home.

-   The number of residents in a House may range from 6 to 15; there are
    houses for men, houses for women, and houses that accept women with
    children.

-   Each house represents a remarkably effective and low cost method of
    preventing relapse, and this purpose is served in over 1,200 houses
    in the United States today.

**Recovery Month**

-   The *Recovery Month* effort aims to promote the societal benefits of
    alcohol and drug use disorder treatment, laud the contributions of
    treatment providers and promote the message that recovery from
    alcohol and drug use disorders in all its forms is possible.

**Barriers to Treatment *(Source: 2007 NSDUH)***

-   In the past year, 21.1 million persons (8.6 percent of the
    population aged 12 or older) needed treatment for an illicit drug or
    alcohol use problem but did not receive treatment at a specialty
    substance use disorders facility

-   The five most often reported reasons for not receiving illicit drug
    or alcohol use treatment among persons who needed but did not
    receive treatment at a specialty facility and perceived a need for
    treatment included:

    1.  Not ready to stop using (37.2 percent)

    2.  No health coverage and could not afford cost (30.9 percent)

    3.  Possible negative effect on job (13.3 percent)

    4.  Not knowing where to go for treatment (12.6 percent)

    5.  Concern that might cause neighbors/community to have negative
        opinion (11.0 percent).

**Stigma**

-   In 2001, 19 percent of people in recovery surveyed by Faces and
    Voices of Recovery were afraid of being fired or discriminated
    against if they entered treatment.

-   An estimated 22 to 23 percent of the U.S. population experiences a
    mental disorder in any given year, but almost half of these
    individuals do not seek treatment. *(U.S. Department of Health and
    Human Services \[HHS\])*

-   Embarrassment and shame often are listed as the second most common
    barriers to recovery.[^14]

-   Stigma is a barrier. Fear of stigma, and the resulting
    discrimination, discourages individuals and their families from
    getting the help they need.

**The Benefits of Investing in Treatment**

-   A 2006 study by *Health Services Research* in California has shown
    that treatment in general has a benefit-to-cost ratio of 7:1, with
    substance use disorder treatment costing \$1,583 per person on
    average, yielding a monetary benefit to society of nearly \$11,487
    for each person treated.[^15]

-   Another study conducted in Washington State clinics discovered as
    much as a \$23 return for every dollar spent on treatment.[^16]

-   On a societal level, for every \$1 invested in opioid treatment, \$4
    is recovered in social costs. *(NCCHC)*

**[Additional Resources]{.underline}**

-   **The U.S. Department of Health and Human Services (HHS)**

[www.hhs.gov](http://www.hhs.gov/)

-   **The Substance Abuse and Mental Health Services Administration
    (SAMHSA)**

[www.samhsa.gov](http://www.samhsa.gov/)

-   **The Center for Substance Abuse Treatment (CSAT)**

[csat.samhsa.gov](http://www.csat.samhsa.gov/)

-   **National Institute on Alcohol Abuse and Alcoholism (NIAAA)**

[www.niaaa.nih.gov](http://www.niaaa.nih.gov/)

-   **National Association for Children of Alcoholics (NACoA)**

[www.nacoa.org](http://www.nacoa.org/)

-   **Alcoholics Anonymous (AA)**

[www.alcoholics-anonymous.org](http://www.alcoholics-anonymous.org/)

-   **Narcotics Anonymous (NA)**

[www.na.org](http://www.na.org/)

-   **Al-anon/Alateen**

[www.al-anon.alateen.org](http://www.al-anon.alateen.org/)

**[Sources Cited]{.underline}**

[^1]: Center for Substance use disorders Treatment. 2004. *National
    Treatment Improvement Evaluation Study (NTIES), 1992--1997.*
    Computer file. Rockville, MD: U.S. Department of Health and Human
    Services, Substance use disorders and Mental Health Services
    Administration.

[^2]: Kleber, H.D., O\'Brien, C.P., Lewis, D.C., and McLellan, A.T.
    October 4, 2000. "Drug dependence, a chronic medical illness:
    Implications for treatment, insurance, and outcomes evaluation."
    *Journal of the American Medical Association* 284 (13), p. 1689.

[^3]: *Report to Congress on the Prevention and Treatment of
    Co-Occurring Substance use disorders Disorders and Mental Health
    Disorders.* Rockville, MD:  U.S. Department of Health and Human
    Services, Substance use disorders and Mental Health Services
    Administration. 2002, p. ix.

[^4]: U.S. Department of Labor Web site:
    [www.dol.gov/asp/programs/drugs/workingpartners/dfworkplace/ea.asp](../www.dol.gov/asp/programs/drugs/workingpartners/dfworkplace/ea.asp),
    section entitled "Employee Assistance." Summary of p. 1. Accessed
    October 31, 2006.

[^5]: *What Works: Workplaces Without Alcohol and Other Drugs*. U.S.
    Government Printing Office 282-148/54629. Washington, DC: U.S.
    Department of Labor. October 1991 (reprinted 1994), p. 11.

[^6]: *Principles of Drug Addiction Treatment:  A Research-Based Guide,*
    p. 5.

[^7]: Lash, S.J. and Blosser., S.L. "Increasing adherence to substance
    use disorders aftercare group therapy." *Journal of Substance use
    disorders Treatment*, 16(1), pp. 55--60.

[^8]: "Definition." The TAPA Center---Jail Diversion Web site:
    [http://gainscenter.samhsa.gov/htmltapa/jail%20diversion/definition.asp](http://gainscenter.samhsa.gov/htmltapa/jail diversion/definition.asp)*.*
    Accessed August 28, 2006.

[^9]: *What Can We Say About the Effectiveness of Jail Diversion
    Programs for Persons With Co-Occurring Disorders?* Rockville, MD:
    U.S. Department of Health and Human Services, Substance use
    disorders and Mental Health Services Administration, Center for
    Mental Health Services, Center for Substance use disorders
    Treatment, The National GAINS Center for People with Co-Occurring
    Disorders in the Justice System. April 2004, pp. 5, 7.

[^10]: Huddleston, C., Freeman-Wilson, K., and Boone, L. *Painting the
    Current Picture: A National Report Card on Drug Courts and Other
    Problem Solving Court Programs in the United States*. Alexandria,
    VA: U.S. Department of Justice, National Drug Court Institute, May
    2004, p. 1.

[^11]: "Facts on Drug Courts." National Association of Drug Court
    Professionals Web site:
    [www.nadcp.org/whatis/facts.html](../www.nadcp.org/whatis/facts.html).
    Accessed August 27, 2006.

[^12]: Rempel, M., Fox-Kralstein, D. Cissner, A., Cohen R., Labriola,
    M., Farole, D., Bader, A., and Magnani, M. *The New York State Adult
    Drug Court Evaluation: Policies, Participants and Impacts*. New
    York: Center for Court Innovation. 2003, p. 25.

[^13]: *Treatment Episode Data Set (TEDS):  Discharges from Substance
    use disorders Treatment Services.* DHHS Publication No. (SMA)
    06-4207, DASIS Series S-35. Rockville, MD:  U.S. Department of
    Health and Human Services, Substance use disorders and Mental Health
    Services Administration. 2006, p. 2.

[^14]: Peter D. Hart Research Associates, Inc. October 2001. *The Face
    of Recovery.* Washington, DC: Peter D. Hart Research Associates,
    Inc., p. 10.

[^15]: Ettner, S., Huang, D., Evans, E., Ash, D.R., Hardy, M.,
    Jourabchi, M., and Hser, Y. January 2006. "Benefit-cost in the
    California treatment outcome project: Does substance use disorders
    treatment pay for itself?" *Health Services Research* 41(1), p.
    192--213.

[^16]: French, M. T., Salome, H. J., Krupski, A., McKay, J. R., Donovan,
    D. M., McLellan, A. T., and Durrell, J. 2000. "Benefit-cost analysis
    of residential and outpatient addiction treatment in the State of
    Washington." *Evaluation Review* 24(6), p. 609--634.