SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Thursday,

May 19, 2005

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

P.O. Box 360833

Strongsville, Ohio 44149

Kenneth A. DeCerchio, M.S.W.

Director

Florida Department of Children and Families

Substance Abuse Program

1317 Winewood Boulevard

Tallahassee, Florida 32311

David P. Donaldson, M.A.

CEO

We Care America

44180 Riverside Parkway, Suite 201

Lansdowne, Virginia 20176

Bettye Ward Fletcher, Ph.D.

Professor

Jackson State University

1120 Andrew Chapel Road

Brandon, Mississippi 39047

IN ATTENDANCE:

Valera Jackson, M.S.

CEO

Village South/West Care Foundation, Inc.

3180 Biscayne Boulevard

Miami, Florida 33137

Chilo L. Madrid, Ph.D.

CEO

Aliviane NO-AD, Inc.

7722 North Loop Road

El Paso, Texas 79915

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

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

Assistant Medical Director

Stormont-Vail HealthCare

901 Garfield

Topeka, Kansas 66606

Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 340

Crandon, Wisconsin 54520

[Ex Officio Members]{.underline}

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders

and Psychiatric Rehabilitation

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

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

PAGE

Welcome

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

Director, CSAT 7

Consideration of January 26-27,

2005 Council Minutes 7

Introduction of Council Members 9

Director\'s Report

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 13

Discussion 31

CSAT Hispanic Workgroup Briefing

Chilo L. Madrid, Ph.D.

NAC Member 37

Ruth Hurtado

Public Health Advisor

Division of Pharmacologic Therapies, CSAT 39

Discussion 49

SAMHSA\'s Data Strategy

Stephenie Colston, M.A.

Senior Advisor to the Administrator

Office of the Administrator, SAMHSA 55

Discussion 66

Public Comment 78

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

PAGE

State Performance Measurement and Management

Efforts Under the Block Grant

Anne M. Herron, M.S., C.R.C., CASAC, NCACII

Director

Division of State and Community

Assistance, CSAT 81

Discussion 92

Screening, Brief Intervention, and Referral

to Treatment (SBIRT)

Tom Stegbauer, M.B.A.

Lead Public Health Analyst

Organization and Financing Branch

Division of Services Improvement, CSAT 94

Discussion 106

Access to Recovery (ATR) Update

Andrea Kopstein, Ph.D.

Branch Chief

Practice Improvement Branch

Division of Services Improvement, CSAT 112

Discussion 121

Addressing Women\'s Treatment Needs

Sharon Amatetti, M.P.H.

Coordinator, CSAT Women and Families

Coordinating Committee

Office of Program Analysis and Coordination, CSAT 129

Discussion 140

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

PAGE

Partners for Recovery Workforce

Development Update

Karl White, Ed.D.

Public Health Analyst

Practice Improvement Branch

Division of Services Improvement, CSAT 161

Donna Cotter, M.B.A.

Partners for Recovery Coordinator

Office of Program Analysis and Coordination, CSAT 172

Discussion 179

Treatment for Persons with Co-Occurring Disorders

Charlene LeFauve, Ph.D.

Branch Chief

Co-Occurring and Homeless Activities Branch

Division of State and Community Assistance, CSAT 181

Discussion 195

Council Roundtable 213

[P R O C E E D I N G S]{.underline} (9:13 a.m.)

DR. CLARK: I want to say good morning. I want to welcome you to the 42nd
meeting of the CSAT National Advisory Council. I know that it\'s
difficult sometimes to make it to these meetings, and so I really
appreciate people, especially Council members, being able to do that,
and I appreciate your being here.

Our first item of business on the agenda is to vote on the minutes from
the January 26th and 27th meeting, and they were forwarded to you
electronically for your review and input, and hopefully you gave Cynthia
your comments. So I\'ll entertain a motion.

DR. MADRID: I so move that the minutes be adopted.

DR. CLARK: A second?

DR. VOTH: Second.

DR. CLARK: Is there any discussion on the minutes?

(No response.)

DR. CLARK: Then all those in favor of approving the minutes?

(Chorus of ayes.)

DR. CLARK: All right. Anybody opposed?

(No response.)

DR. CLARK: Okay, the minutes are adopted.

Again, I want to thank you for being here, now that we\'ve got the
minutes out of the way. I can\'t overemphasize the importance that I
place and that Mr. Curie places on the National Advisory Council input.
Your advice is critical. You\'re all familiar with the problem of
substance abuse and its complications. We look at our Household Survey
data from 2003, we know almost 20 million people, 19.5 million age 12
and older are current illicit drug users. This represents a large number
of people in the population, at 8.2 percent. We know that we have a
large number of people who have problems with misuse of alcohol. We also
know that there\'s a growing problem with pathological gambling.

We know that there has been an historical and persistent problem with
nicotine addiction, and even though SAMHSA is not the principle entity
that addresses that ‑‑ in fact, that is more addressed outside of
SAMHSA. Within SAMHSA, CSAP has the responsibility for Synar-type
activity and not CSAT. Nevertheless, we are concerned about the impact
of these issues on our society. We all have to be willing to work
together to facilitate recovery, make recovery a reality. As you know
from our matrix, building resilience and facilitating recovery is an
important construct for us here.

Your expertise and the expertise of the people who will be presenting is
very, very important. I want to take a couple of minutes now to go
around the table, now that we\'re all here and settled, to have people
introduce themselves. We\'ll start off with our recorder on the left.

MR. FRIEDMAN: I\'m Alan Friedman, your court reporter.

DR. CLARK: Thank you.

DR. VOTH: Eric Voth, internal medicine and addiction medicine specialist
in Topeka, Kansas, the center of the United States, equally far from
everywhere.

(Laughter.)

MS. BERTRAND: Good morning. I\'m Anita Bertrand from the Northern Ohio
Recovery Association, located in Cleveland, Ohio.

DR. MADRID: Chilo Madrid, Aliviane, El Paso, Texas.

JUDGE WHITE-FISH: Eugene White-Fish, judge for the Forest County
Potawatomi Tribal Court in Crandon, Wisconsin.

DR. McCORRY: Good morning. Frank McCorry from the State Office of
Alcoholism and Substance Abuse Services in New York.

MS. GRAHAM: I\'m Cynthia Graham at CSAT.

DR. CLARK: And, of course, I\'m Westley Clark, the Director of the
Center for Substance Abuse Treatment.

MR. KOPANDA: Rich Kopanda, Deputy Director.

MR. GILBERT: I\'m George Gilbert, CSAT Office of Program Analysis and
Coordination.

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

DR. FLETCHER: Good morning. I\'m Bettye Ward Fletcher from Jackson,
Mississippi, recently retired professor of sociology after 30 years.

MR. DONALDSON: Dave Donaldson, president of We Care America.

MS. JACKSON: I\'m Valera Jackson. I\'m the chief development officer and
senior vice president for West Care Programs and the Village,
headquartered in Miami, Florida.

DR. SUCHINSKY: Hello. I\'m Richard Suchinsky, chief for addictive
disorders, Department of Veterans Affairs.

MS. GOLDSTEIN: I\'m Irene Saunders Goldstein, and I\'m writing your
minutes.

DR. CLARK: Very good.

In addition to Council members, we have a few new faces in CSAT. Is
Laura House here? Dr. House has joined the Division of Services
Improvement as a project officer with the evaluation team. She earned
her doctorate from Howard University, focusing on adolescent mental
health, resiliency and cultural issues, and did a post-doc with NIDA
from 2002 to 2004.

Is Ken Hoffman around? Dr. Hoffman began his duty on February 22nd.
It\'s the second medical officer in the Division of Pharmacologic
Therapies. He recently retired from the Department of Defense Office of
Health Affairs, TRICARE, where he worked in the Surgeon General\'s Drug
and Alcohol Office.

Any other new staff whose name I didn\'t mention?

We have a fellow from the Office of Global Health, Wendy Waddy. She
literally started this week. She is from Trinidad and is working in
DSCA, among other things, principally located in DSCA, working with John
Campbell and Anne Herron, but will be obviously working with others
within SAMHSA to get an overview of our delivery system and the issues
that are germane. I think you are interested, Wendy Waddy, in women\'s
issues and children\'s issues. It fits nicely on our matrix and in our
activity.

Anybody else whose name I haven\'t mentioned?

(No response.)

DR. CLARK: All right. We\'re also pleased to welcome the participants in
a dialogue for CSAT\'s Hispanic Task Force, who extended their stay to
join us today. Will those who are participants in the Hispanic Task
Force stand up? Too numerous to name. Thank you very much.

We\'ll be hearing from Ruth Hurtado later, delivering comments, and
members of the task force will be delivering comments on their
observations. Ms. Hurtado is the public health advisor in the Division
of Pharmacologic Therapies, and she\'ll be briefing us on the results of
that task force, and she worked with Chilo, who I\'m going to single
out. He agreed several months back to work in an advisory role with the
Hispanic work group, so today he\'s wearing two hats.

I think the issue for Council members ‑‑ some of you have been working
with specific issues. I know Val has been working with e-therapy. These
are the kinds of things that we like to tap Council members for, the
specific kinds of sub-issues that we have to deal with. Some of you are
available and others aren\'t, but the key issue is we see this role as
an important role, and you can be of assistance to us as we attempt to
address these issues, and to inform Mr. Curie so that he can make
whatever decisions of importance to SAMHSA.

We\'re grateful to the staff who have worked to organize this meeting,
the members of George Gilbert\'s team, starting with Cynthia Graham and
others.

Cynthia, do you want to acknowledge the people who are working with you?

MS. GRAHAM: Just George\'s office.

DR. CLARK: Just George\'s office? Julie, you\'ve become just George\'s
office.

(Laughter.)

DR. CLARK: Doug, where are you? All right. Well, we should do better
than that later. Just George\'s office. All right.

Can we put my slide show up?

So I\'m going to take this opportunity to address you today to start off
the meeting, of course. Clearly, it\'s important for us to recognize
that a lot of things happen between meetings. One of the most important
things that has happened between January and today is that our \'06
budget was released by the President. The \'06 budget, of course, is
what the President believes we should be spending. We will find out what
the Congress intends to do as it pursues its deliberations.

You\'ve received copies of the Director\'s Report, and it summarizes the
activities we\'ve been pursuing. You\'ll be hearing from members of my
staff, who will highlight specific areas of importance. So when we look
at the \'06 budget that was submitted by the President, you\'ll see that
there is a modest ‑‑ as soon as I can figure out how to make this thing
work. Oh, there\'s the \'06 budget. There is a modest increase in our
appropriations for the Center for Substance Abuse Treatment.

Maybe I should go to the podium. This doesn\'t work so well. It puts me
way over here. I feel alienated, estranged.

All right. So we\'re requesting for our block grant \$1.776 billion.
Ninety-five percent of this is distributed to states and territories by
formula. Formula is based on population, total taxable resources, and
cost of services. This formula is promulgated by the Congress. The
distribution of the money represents about 40 percent of all funds
managed by single-state agencies for substance abuse prevention and
treatment. It supports approximately 10,500 community-based
organizations. It includes set-asides for prevention. Twenty percent of
the funds are set aside for prevention. That goes to the Center for
Substance Abuse Prevention. There\'s a set-aside for women and HIV/AIDS.
There\'s a 5 percent set-aside for jurisdictions with HIV prevalence
rates of 10 per 100,000. So we have about 25 states that have a 5
percent set-aside for HIV. Then there are also priorities for women
injection drug users and tuberculosis.

These are our priority areas that the budget will support. Our modest
increase is primarily going to be directed toward our expanding
substance abuse treatment capacity through the Access to Recovery
program. This is, as you know, a voucher program that is currently
underway. Ken DeCerchio is the SSA from Florida and is working with us
in this area, knowing full well that this is an important thing. In the
past, state interest in ATR has been overwhelming. Some 66 states,
territories and tribal organizations apply for the \$99 million that we
had available in \'04. In August of \'04, we awarded 14 states and one
tribal organization ATR funds.

In \'06, the President has proposed \$150 million for ATR, and that will
support the 15 grants that we have and fund seven new ones. With the
addition of \$50 million in funds, an estimated 62,500 people will be
served.

The budget also proposes an increase in SBIRT by \$6 million, for a
total of \$31 million. Total Targeted Capacity Expansion grants are
proposed to be funded a little over \$33 million.

So we have \$30 million that is proposed for homelessness, with those
with substance abuse disorders. The budget will support \$29.6 million,
which is a slight decrease between \'05. For children and families,
it\'s \$33 million. It\'s a slight decrease. For HIV/AIDS and hepatitis,
we are proposing \$61 million for Capacity Expansion for outreach and
substance abuse for African Americans, Latinos, Hispanics, and other
racial and ethnic minority groups disproportionately affected by
substance abuse and HIV/AIDS.

We\'re proposing \$25 million to support programs that address the
treatment needs of adults and adolescents in the criminal justice
system, and this is a \$1 million reduction. The \'06 budget proposes
maintaining the substance abuse and treatment block grant at the same
level, which is, as I mentioned, just under \$1.7 billion.

So these are, as most people are very well aware, delicate times
budget-wise. I think we\'re faring quite well under the constraints that
we have to operate. Those constraints are dictated by a competing
national agenda. I think the President has treated us very favorably
given the hard choices that he\'s had to make. Clearly, not all programs
are going to fare well in this process, so we have to recognize that.

The Best Practices Programs which promote effective treatment through
the adoption of evidence-based practices will be supported by
approximately \$28 million. This is a reduction of approximately 41.6
percent. Our Best Practices help us to adopt evidence-based practices,
supports training and technical assistance, translates research to
practice, conveying the most up-to-date science-to-services models to
the field.

We know that with the diminution of \$20 million, affected programs will
be program coordination and evaluation activities, pharmacologic
activities, Addiction Technology Transfer Centers, women and children
and family activities, Knowledge Application Programs, Partners for
Recovery, and others, the SAMHSA Health Information Network and consumer
affairs activities and technical assistance.

At the appropriations hearing that Mr. Curie presented, the issue of our
workforce development surfaced, and it was clear that Congressman Regula
has a personal interest in making sure that we have sufficient
activities in the area of workforce development. So we\'ll just have to
follow what the Congress does. The President has had to make hard
choices and has done so. Nevertheless, as some of us are well aware,
there are activities going on in the community that have risen to almost
daily characterizations.

So most of us are familiar with Sudafed and methamphetamines. U.S. News
and World Report this week has a thing on gambling. It showed the
addiction disorders are demanding a lot of attention, and society is
having to make changes. Those of you who are familiar with the Sudafed
issue know that Wal-Mart and Target and K-Mart are pulling Sudafed
behind the counter. Oklahoma has a registry where you have to sign up if
you\'re going to get more than three grams of Sudafed. So they\'re
making real changes.

The paradox is that Sudafed is a medication used for the treatment of,
among other things, allergic rhinitis, nasal congestion. I reviewed the
literature on Sudafed, and it turns out that it\'s actually a very
useful medication. So what it represents, then, is sort of the conflict
between how do we deal with the methamphetamine problem, where Sudafed
is being diverted for misuse by making it a precursor to
methamphetamine, and how do we maintain the health of our nation. It
turns out that allergic rhinitis is responsible for at least \$5 billion
a year in health care costs. It has a disability load and it does
respond to a combination of antihistamines and decongestants, the major
decongestant being medications like Sudafed.

So the pharmaceutical industry is trying to do other things.
Nevertheless, our media is capturing what it is that I\'m talking about
in terms of the prevalence of our issues.

We won\'t be funding our National Alcohol Screening Day. We will be
eliminating funding for our conference grant program. CSAT has been able
to contribute to the minority fellowship program. We won\'t be able to
do that under the proposed budget as a result of having to make the
concessions that are necessary in order to keep a viable agenda.

We are also trying to get the message out to the Congress. The question
keeps being asked, well, what are you doing with your money? So
especially, as you know, personally when you\'re in tight budget times,
you ask yourself what am I doing with the money? What do I need? What
don\'t I need? What am I getting in return? So National Outcome
Measures, which we\'ll hear from Stephenie Colston and others, National
Outcome Measures are being pursued.

I want to highlight briefly that CSAT and state representatives met in
Minnesota on May 5th and 6th for the first of five regional meetings to
discuss implementation of these 10 domains. The discussion included data
from state data systems, admission and discharge data, unique client
identifiers, and timely reporting of data. This is intended to result in
the full National Outcome Measures reporting within three years.

Preliminary data from 2005. Our block grant applications show that 11
states are reporting admission and discharge data in the abstinence
domain, and all identify improvement in abstinence. Sixteen states
report data in the employment domain, and all identify improvements in
client employment. Eight states report data in the criminal justice
domain, and all identify a reduction in arrests. For the 13 states
reporting data in the housing domain, 12 of the 13 identify improvements
in stable housing.

So we are working with the states. This is a common agenda. In our
discussions with state authorities, it\'s quite clear that the state
legislatures, the state governments are asking the same kinds of
questions. We found that some states have been fortunate in generating
additional resources from their governor and from their legislature, and
it appears that being able to answer some of these questions assists
them in that agenda. So this is an important thing for us to pursue, and
Stephenie Colston will lead the discussion on that.

The substance abuse treatment block grant is very important to the
country, of course. More than 50 percent of the funding from the block
grant represents these states, which represent about a third of our
block grant recipients, acknowledge the block grant using 2002 data,
constituted greater than half of their public budget. So Alabama at 78
percent, Arkansas at 63 percent, Colorado at 59 percent, Florida at 52
percent, Georgia at 50 percent, Idaho at 62 percent, and you can see it
goes on and on. In some jurisdictions, like Wisconsin, it\'s 87 percent.

So if we can tell the story about how the money is spent, we will be
telling the story about the substance abuse delivery system within many
of these jurisdictions. There\'s a report back there on health
expenditures and substance abuse and mental health, and that report
makes it quite clear that for substance abuse, public dollars constitute
the major source of income for providers. It\'s a major source of
expenditure. So what we\'re doing in the block grant then becomes of
critical importance, and I really appreciate the efforts by single-state
authorities, NASADAD, and of course our staff to work collaboratively so
that we can tell the story to the Congress, and hopefully continue the
funding.

As I pointed out with the Sudafed example, we have these competing
interests that need to be mediated carefully, and we need to show that
we\'re spending the money wisely, that we\'re having a positive impact
on criminal justice and child welfare. Methamphetamine is raising a lot
of concerns about child welfare issues. Those of you who had experience
with cocaine in terms of \"crack babies\" recognize that we\'re simply
revisiting a critical issue, but we\'re revisiting it with alacrity and
dispatch.

Since we\'re dealing with pharmaceuticals, we recognize that the misuse
of pharmaceutical drugs is a major issue, particularly the opioids. On
February 9th, we convened an open dialogue with pharmaceutical
companies. Those of you looking at the slides, these are the companies
who were present, and they represent the major manufacturers of opioid
agents, opioid agents used for the treatment of pain. We\'re all very
much aware, particularly with an aging population, that the issue of
pain is a major one, and how to treat pain effectively and carefully is
a conundrum. It\'s not as simple as all of that. Some people are
undertreated, some people are overtreated, and we all have to work
together collectively to come up with effective treatment strategies.

I know, since we have a fitness center in this building, 1 Choke Cherry,
I\'ve been trying to work out in the fitness center. I\'m walking. I
can\'t run. I\'ve got bad hips. But I find after about an hour, the pain
goes away, but then later the pain comes back. So I\'m becoming real
sensitive. I mean, fortunately, I don\'t need to take medications other
than Motrin at the moment, but I\'m real sensitive about keeping my
options open. So I know when I poll the audience, nobody wants to
suffer. So I guess we\'re not all that stoic out there.

But this was an important meeting. They are looking forward to a
follow-up meeting which we will be having to discuss where else we can
go with what strategies should be pursued, and we have to work with the
DEA and the FDA. In fact, I just met with the chiefs of police last week
dealing with the issue of drug abuse, prescription drug abuse. Dr.
Hoffman and I met with Karen Tandy and the chiefs of police. They\'re
very much concerned with maintaining a proper balance. The continuum of
public safety and public health is an important one, and the chiefs of
police are not interested in creating a disconnect between the two
efforts, which was a refreshing thing. You tend to see cops as \"Let\'s
go get them.\" But, in fact, what they basically want is a safe
community and a healthy community, and working collectively and
together, I think we can achieve that without causing a great deal of
consternation by denying people access to legitimate medications for
legitimate medical purposes.

So the pharmaceutical company acknowledged our need to collect data, and
we had participants from our Office of Applied Studies to help us tell
the story using our Household Survey data and our DAWN data to point out
some of the problems. We need to develop specific strategies addressing
the source of each problem, and we need to plan for adequate evaluation.
We have in our country fairly rigorous rules on how medications can be
approved, so as some people said, well, why don\'t you just make a new
formulation? It isn\'t that easy. You just can\'t run out and make a new
formulation. Everything needs to be tested because there are negative,
unintended consequences which people then get upset with.

I was part of a delegation to the United Nations through the Commission
on Narcotic Drugs held in Vienna. This organization is comprised of 60
nations and meets annually to address the implementation of
international drug control treaties. At this particular meeting, we
focused on the control of precursors, such as clandestinely produced
amphetamine-type stimulants, which is a major issue not only in the
United States but also in Asia and other countries.

The CND meeting included also special thematic debates on drug abuse
prevention, treatment and rehabilitation, focusing on community capacity
building and preventing HIV/AIDS and other blood-borne diseases in the
context of drug abuse prevention. We\'ll hear from Dr. Voth tomorrow on
harm reduction. This was a theme that surfaced at this meeting, and it
was a theme that we addressed. Mr. Walters, who is the Director of the
Office of National Drug Control Policy, articulated the U.S. stand on
needle exchange programs and other harm reduction strategies and the
drug legalization issue.

I was fortunate enough to be able to present the U.S. position on drug
demand reduction and work with delegates with other nations in reviewing
proposed resolutions to assure that the resolutions were consistent with
U.S. drug control goals and policies. There is a major harm reduction
effort afoot, and again we\'ll hear from Dr. Voth about that. There\'s a
debate internationally about what strategies we should employ to address
the HIV/AIDS epidemic.

There was no difference of opinion about the need to address HIV/AIDS.
The only question is what\'s the best vehicle for that. So I think
that\'s an issue.

On April 6th, I participated in a briefing of the House of
Representatives\' Addiction, Treatment, and Recovery Caucus on
methamphetamine addiction and recovery. The House is very much concerned
about this issue. On April 11th, I briefed Senate staff on the
Subcommittee on Labor and Human Services, education-related agencies, on
methamphetamine and inhalant prevention programs.

We\'ve had a program continuing our activities on e-therapy. I think we
need to bring the substance abuse treatment community into the 21st
century. Val Jackson was a speaker at that meeting. This was at the
Lonny Mitchell conference.

Sheila Harmison. Is Sheila around? Sheila worked with Patrice Clark, one
of our interns. No relation. But it\'s a very useful discussion. We\'ll
hear from Sheila on this. She also presented to the Joint Work Group on
Telehealth at the Appalachian Regional Commission. Our SAMHSA News in
January/February devoted a top issue on our December E-Therapy,
Telepsychiatry, and Beyond Conference.

We\'re beginning to recognize that we have to upgrade not only our MIS
systems but our strategies and how we address the issue of increasing
access to care. No one is suggesting that e-therapy be a substitute for
face to face encounters or replace access to care from face to face
encounters. But what we are saying is that we have far too few people
who have access to face to face encounters, and we need to recognize it,
acknowledge it, and come up with strategies to deal with it. We met
yesterday, Mady Chalk and I and Fran Cotter, with representatives from
the Netherlands, and they have developed not only a bibliographic search
effort but also an online treatment for alcoholism, recognizing that not
everybody is ready to address their alcohol abuse problem in a face to
face manner.

We\'re working on Access to Recovery. We have a very access team. Can my
ATR team stand up? We\'ll hear about this later, but I want the ATR team
to stand up. That\'s two, only two. Mady, are you not a part of this?
Thank you very much, Mady. I have a bunch of bashful ATR
representatives. You can\'t do that. You have to be out there carrying
the message. Thank you. I want to tell you I appreciate your work.

ATR allows individualized pursuit of recovery, providing consumer choice
and increasing the array of treatment and recovery support services. We
are trying to reward performance by offering incentives to providers who
produce results. We\'re working with state entities. As I mentioned, we
have some 14 states. Florida, under the leadership of Ken DeCerchio, is
one of our grant recipients.

A key issue is client choice in recovery support services. We believe
that we underemphasize recovery support services in our delivery system,
and our ATR effort will assist us in facilitating that. This will allow
us to increase the array of faith- and community-based providers to
provide clinical treatment and recovery support services.

I will be visiting a number of jurisdictions. Our staff will be making
some site visits to several of our ATR grants. This is a high priority
for this administration. The problem with having a high-priority
activity is that everybody is watching you, and our hope is that we can
get past the old adage that you can\'t do anything right and you can\'t
please everybody. My team has been very actively addressing some of the
issues that have surfaced. A number of issues have surfaced, and we are
working closely with the states. I\'m sure some project officers think
we\'re working too closely with them, but our objective is to have a
smoothly operating Access to Recovery initiative that produces the best
results possible.

Some of you are familiar with our TIP 42. This is the revised TIP 9,
\"Assessment and Treatment of Patients with Co-Existing Mental Illness
and Alcohol and Other Drugs.\" It\'s not \"Substance Abuse Treatment for
Persons with Co-Occurring Disorders.\" The key issue is our first
printing has been exhausted at 27,000, and I\'ve had to request a second
printing of TIP 42 to 50,000. Those of you who are familiar with TIP 42,
this is a big document. For somebody my size, I get to use it for
strength training. It\'s that big. Yet people are requesting it, and
it\'s not just the substance abuse delivery system. It was a TIP that
was well done, and I want to again commend Mady\'s group.

I see Karl White is out there, and Chris Curry for coordinating this
effort. Chris is the lead on the TIPs. Are you out there, Chris? I
can\'t see you. Then, of course, we work with our co-occurring and
homeless branch, Charlene LeFauve and others. The co-occurring and
homeless branch is Charlene and Jim Herrell and George Kanuck. So we\'ve
been doing a lot in the area of co-occurring.

Just last week I attended a meeting with our COCE, which is our
co-occurring disorders technical assistance center, and their advisory
group met to talk about how we\'re going to deal with the issue of
co-occurring disorders.

Join the Voices for Recovery. Our theme for September of this year is
Healing Lives, Families, and Communities, and I think this is important.
We want to have Council members support us in our effort. I\'m fond of
saying this is not just for people in recovery. This is for the
community to understand that recovery is possible. If we don\'t have the
community believing that recovery is possible, if we don\'t have them
acknowledging that recovery is possible, then we don\'t get the
community support that we need, and recovery is not possible without
community support. You return people to bars and to crack houses and to
methamphetamine dens and you expect them to stay clean and sober, I
think you do them a disservice.

Ivette Torres has worked hard with her team to deal with this issue. Is
Ivette out there? Oh, there you are. Is Carol back there? So we want to
really stress the importance of this issue. Ivette\'s group has worked
hard, and it\'s a complex issue.

There are a lot of materials out there, activity kits, flyers, PSAs.
Ivette\'s group has managed to negotiate with TV and radio, \$3 million
in free time. We have a webcast series, \"Road to Recovery.\" We have
the Ask the Expert chat. Is Michelle out there, Michelle Westbrook? In
any event, some of these things are really complex, they take a lot of
time and a lot of energy, but we\'re getting results. We have 10 shows
aired in 160 cable markets, 450 events nationwide. We\'ve got over
940,000 people participating, 111 government proclamations, 8.5 million
hits on the site, with 5 million unique visitors. The website has won
six awards over the last year, and the PSAs have received honorable
mentions at the Addies. So we encourage you to look at
www.recoverymonth.com.

This is all a lot of work, and it raises awareness and gets the message
out. So I\'m extremely pleased by our efforts on Recovery Month. I, for
one, wind up doing mom and pop radio at 11 o\'clock at night, 6 o\'clock
in the morning, and guess what? I love it, because there are a bunch of
people hanging out out there at 11 o\'clock at night and 6 o\'clock in
the morning. It\'s a surprising thing.

(Laughter.)

DR. CLARK: I wake up. Whoa, I should be in bed. I was on one radio talk
show that was supposed to be from 11 to 12 at night, and the guy says,
well, can you stay until 12:30? We were getting calls from all over, so
I stayed until 12:30. But the key issue is that our issues are important
issues. So we\'ve got a lot of activity that we have to address, and it
takes time to address that. Our website, as all of you are well aware,
is www.samhsa.gov, and we have a bunch of sub-websites.

What I want to do is thank you for your attention and your participation
and your efforts and to see if Council members have anything to discuss
about my report.

MR. DeCERCHIO: Question. In the United Nations presentation, was there
any discussion, either online or offline, about prescription drugs and
Internet?

DR. CLARK: Oh, yes, that\'s the big thing. That was part of the effort,
how do we limit that, how do we address that. There are a lot of bogus
sites out there, a lot of offshore sites. People are receiving
medications in the United States. We\'re just trying to quantify some of
these things. Allegedly from Canada, people who are seeking legitimate
prescriptions are getting bogus prescriptions from offshore sites. It\'s
easy to route an address through Canada when it\'s not really in Canada.
So while Canadian pharmaceuticals might be on par with the United
States, the fact of the matter is if you do it on an anonymous website,
if you will, you don\'t know what you\'re getting, from where you\'re
getting. So that turns out to be an issue.

Kids are requesting precursors and drugs. Some drug deals, at least,
have been using the Internet to peddle hard-core known drugs, get your
cocaine online. There are some people who are using the Internet for
that purpose. You can get an anonymous box. You know, the old brown bag,
brown box used to refer to certain kinds of things. Now it\'s drugs. So
they\'re working on that.

Frank?

DR. McCORRY: Westley, the NOMs measures are in-treatment measures?
They\'re not post-discharge measures?

DR. CLARK: Oh, no, they\'re both.

DR. McCORRY: They\'re both?

DR. CLARK: Yes. We want to know what happens six months afterwards. I
mean, the fact that you got treatment ‑‑ remember the 28-day program?
You did 28 days, you were good for 28 days. But on the 30th day ‑‑ no,
we want to know what happened.

MS. JACKSON: I\'m really pleased that you\'re continuing with the
National Recovery Month in September. I\'m wondering what kind of work
are you doing with the states ‑‑ we have some state folks here, one of
my own ‑‑ in terms of getting the states to work across each state with
the communities so that we\'re building it and building it? I\'ve been
involved in Recovery Month for several years, and I feel that it\'s
really good. I don\'t know if I feel like it\'s ‑‑ I wish it would
become a household word, and maybe that\'s too much hope, but I\'d
really like to see that go. So anything that we could do on the state
level maybe would be more helpful, or is there any money that we can put
into that side of it?

DR. CLARK: Well, again, we have a limited budget. I think Ivette\'s
group is doing yeoman\'s duty, and we\'ll be working with the states. So
we\'ll just keep our activity up. I mean, that\'s basically all I can
say. I don\'t anticipate an influx of new funds. We just have to figure
out how to leverage limited funds, and Ivette and Michelle and Carol
have all worked hard to do that and will continue to do that.

MS. JACKSON: I just wanted to add that I do really love the materials
that you put out. I mean, they are great. So don\'t get me wrong on
that, because I think what you\'re doing is wonderful work. I would just
like to see it grow even greater. I\'m a big fan of it. Thank you.

DR. CLARK: Bettye?

DR. FLETCHER: First of all, I\'d like to thank you for an exhaustive
report.

I wanted to comment on the TIPs document. Recently, I encouraged the
adoption of those TIPs as a primary reference resource for a graduate
training program in substance abuse treatment. I was wondering if you
all collect any kind of data or information on how the TIPs are actually
used, in what populations and what settings they are being utilized.
It\'s a tremendous resource.

DR. CLARK: Karl, we have a study on the use of the TIPs, do we not?

DR. WHITE: Yes.

DR. FLETCHER: That would be great.

DR. CLARK: Well, thank you.

Dave?

MR. DONALDSON: Just to illustrate your comment about meth and the impact
that it\'s having on child welfare, I was in Springfield, Missouri last
week, and the front page talked about how 50 to 70 percent of the men
incarcerated are because of meth-related offenses, and how it\'s causing
them to shift their budgetary priorities to include dental, but more and
more to foster care, so much so that they\'re now having to go 90 to 100
miles out from Springfield to recruit parents for these kids.

DR. CLARK: Dr. Voth?

DR. VOTH: I think the meth efforts are phenomenal, and one of the
things, though, since we\'re right in the heart of it in Kansas, I keep
trying to keep at the forefront of the consideration is nobody gets to
meth by waking up one day and saying I\'m going to use meth. I mean,
they\'re virtually all starting with alcohol and marijuana. So we\'ve
got to not take our eye off the ball at alcohol and marijuana because
that is the entree to meth, even though all of the other precursor
efforts are wonderful. I just think we need to keep that heightened
awareness.

DR. CLARK: I just got called up to the Administrator\'s office, so I
will be leaving briefly and only for a short period of time. But before
I leave, I wanted to introduce the Hispanic Work Group. I alluded to the
newly-formed CSAT work group, and this group has met several times and
would like to share information with you from the work group. Briefing
us today is the chair of the work group, Ruth Hurtado, a public health
advisor in our Division of Pharmacologic Therapies, or DPT as we fondly
refer to it.

Ruth began her federal career with DPT after completing an internship
through the Hispanic Association of Colleges and Universities, called
HACU. In her current position she\'s responsible for the certification
process of new opioid treatment programs, OTPs nationwide, providing
technical assistance to treatment providers and maintaining an updated
database of over 1,000 OTPs. She also serves as liaison between the Drug
Enforcement Administration and the state methadone authorities
throughout the OTP process.

Joining Ruth for the briefing is Council member Dr. Chilo Madrid.
Chilo\'s experience in the field of chemical dependency spans back to
1966, when he performed an internship at the Arizona State Psychiatric
Hospital\'s Chemical Dependency Unit. While in the military service in
\'69, he again worked drug programs at different levels. Performing
graduate work at the University of Arizona, he worked as a chemical
dependency psychiatric technician at St. Mary\'s Hospital.

Chilo\'s recent publication titled \"The Table Model: A Replicable,
Seamless, Integrated Program Increasing Student Attendance in the El
Paso Independent School District\" is an out-of-the-box model that deals
with drug abuse and violence issues in schools, utilizing truancy courts
and intensive parental engagement. This model is already producing a 90
percent-plus success rate with young drug abusers and violent offenders.

Rich Kopanda is going to hold my end of the fort, and Ruth and Chilo
will give their presentations. Thank you.

(Applause.)

DR. MADRID: Muchas gracias y buenas dias. Thank you all very much, and
good morning to you all. I wanted, first of all, to thank the Council
members for giving us the opportunity and the time to appear before you
today and talk with you about some issues that are very, very close to
our hearts, issues that involve many, many people in our country. But
before we go into the presentation, I wanted to again thank the Hispanic
stakeholders that joined us yesterday. We did about one week\'s work in
one day, and I don\'t think I\'ve ever met and exchanged ideas with
people that are so bright. It was very, very stimulating to be.

I wanted to, first of all, recognize Dr. Rafaela Robles. Doctor, thank
you. Then we have Dr. Teresa Chapa. Teresa, thank you. Then we have, to
the right of Dr. Robles, we have Ambrosio from L.A. Ambrosio? And then
right behind or to the left of Dr. Robles we have our friend from
Chicago, Illinois that also we need to thank, Dr. Marco Jacome. Thank
you, Marco. Then we have, of course, my colleague from Texas, Dr. Rudy
Arredondo, who, by the way, also is a Council member for NIDA. He joined
us yesterday and shared a lot of his experiences. Then right in front of
him is our colleague from New York, Mr. Moises Perez. Moises, thank you.
Then right behind we have Dr. Mario De La Rosa from Miami, Florida.
Thank you. I believe that Dr. Pablo Hernandez ‑‑ is he here today? There
he is. Thank you, Pablo, very much.

I believe that covers everybody. Marcia Gomez ‑‑ is Marcia here? No,
she\'s not here, but she was also with us, these individuals and myself,
as well as some of the staff. As you all know, we have several staff
members with CSAT that assisted us from the very beginning. We have at
the very, very back, dressed in gray and black we have George Samayoa.
George, thank you very much for your help. Then to his right we have
Ivette Torres, who facilitated the meeting yesterday, did excellent
work. Ivette, thank you so very, very much.

Then we have Ques. Where is Ques? There she is. She\'s also been with us
from the very beginning. As you know, the CSAT staff has been meeting
regularly as this task was given to them, and we have a couple of other
CSAT staff members that are no longer with us. Richard Lopez, who was
with us at the beginning, I believe he went to work at another federal
agency. Then we had an intern. Bernadine Hernandez from New Mexico, who
is no longer with CSAT. These individuals worked real hard, a lot of
hours, on top of their jobs that they\'re already doing. I want to
personally thank them for all the fine work that they did.

So again, Dr. Clark, thank you. Council members, thank you. I\'m going
to turn over the presentation, the formal presentation, to the
individual that was selected as chair, who has worked many, many hours.
I don\'t think she slept last night because we gave her a lot of
homework, as we have for the last several months, and that is none other
than Ruth Hurtado, who was selected as the chair of this particular work
group.

So, Ruth, take it away. I will be joining Ruth at the end to answer any
questions. The Hispanic stakeholders are here also to help us with any
questions that you all might have.

So, Ruth, again, thank you so very much for all the fine work that you
did.

(Applause.)

MS. HURTADO: Well, good morning. I wanted to thank the Council members
and Dr. Clark for giving the work group the opportunity for us to
present this information to all of you today. Again, thank you to all
the work group members who have contributed to this effort as well.

Just to begin, I wanted to start with some figures to let you know what
the Hispanic population looks like today. We have about 40 million
Hispanics who live in this country today, which makes up about 13
percent of the population. We\'re the largest minority group, and we\'re
growing very rapidly. We have about a 9.5 growth rate compared to the
regular 2.5 growth rate of the rest of the population. About two-thirds
of our population is 25 years or younger. So we\'re a very young
population. We are expected to be the largest minority group within the
next 25 years. So that just gives you an idea of how significant our
population is and really allows us to think about the unique issues that
we need to address also when we\'re talking about substance abuse
issues.

The work group was appointed by Dr. Clark in October of last year, and
when we first met with Dr. Clark he wanted us to begin by doing an
internal assessment of the activities that were occurring within the
Center. So we began working as a work group and meeting pretty much on a
bi-weekly basis to work on Dr. Clark\'s recommendation, and also to
develop some goals and tasks for ourselves as a work group.

Some of the goals that we had for the work group was, number one, to
assess the level of services that were being offered through the CSAT
grantees and Spanish-speaking communities. We also wanted to focus on
workforce development of Hispanics in the field of substance abuse. We
wanted to identify and prioritize recommendations for services
improvement. We also wanted to work on materials development in Spanish.
We wanted this to be a cross-center collaboration, and so we did invite
the other centers to participate in the dialogue that we had yesterday
with the stakeholders, which was a very productive meeting and a very
successful meeting.

So some of the tasks that we\'ve worked on so far, we\'ve identified
some of the current data on Hispanics and substance abuse from the
National Survey on Drug Use and Health, as well as the National Council
of La Raza. We\'ve also identified the current CSAT grantees that are
located in areas with a high Hispanic population. We\'ve taken these
grantees and verified the availability of Spanish language services
within these providers. We\'ve also done an inventory of the CSAT
Spanish language publications. Finally, we\'ve convened the Hispanic
stakeholders meeting, which took place just yesterday.

Just to start, this is some figures from a statistical brief that was
developed by the National Council of La Raza. They did a report on
Latinos in the federal criminal justice system, so I thought it would be
relevant to include some of these figures since the criminal justice
system is one of the SAMHSA priority areas. Under the adjudication
portion, they found that Hispanics were more likely to be convicted for
drug offenses and least likely to be convicted for violent offenses. In
1999, they found that offenders convicted for drug offenses were ‑‑ 42.6
of them were Hispanic.

Under their sentencing report, they found that, in 1999, 94.4 of the
offenders sentenced to prison were drug offenders, and only 11 percent
of the Hispanic in prison received any type of substance abuse
treatment.

Then to go through some of the National Survey on Drug Use and Health
data, this is past month illicit drug use among youths age 12 to 17,
just to show how the Hispanic population is with respect to the other
groups. This is from 2002 to 2003. There was an increase for the
Hispanic population.

This is also illicit drug use, but for ages 12 or older. Again from 2002
to 2003 there\'s an increase of about 0.8 percent. Current binge and
heavy alcohol use among those age 12 or older, it seems like the binge
use is one of the bigger concerns here. Also, when we\'re talking about
the co-occurring issues, serious mental illness among Hispanics, about 9
percent.

Another recommendation that Dr. Clark had given us was to develop some
geomaps to display the areas of Hispanic population across the nation,
and then to see where our CSAT grantees were in these areas. So with the
help of Charles Reynolds, who actually works in the Center for Substance
Abuse Prevention, he helped us to develop some maps with this
information. This first map shows the concentration of Hispanic
population by county. The yellow is 12 percent to 29.9, and the pink is
30 percent or higher.

Then this shows the CSAT discretionary treatment grantees in respect to
the areas of the Hispanic population. So we found that there were about
250 grantees located in areas that had 13 percent or higher.

So what we did was we took these grantees and we verified the Spanish
language services that were available in these grantees. From this
verification, we found that about half of the grantees were offering
Spanish language services, and it was listed in the treatment directory.
There were also about 76 grantees who were offering Spanish language
services, but this information was not listed in the directory. There
were about 49 grantees who did not have Spanish language services
available.

So from this we can see that CSAT is sensitive to the issues, and we are
doing a really good job, but it doesn\'t prevent us from doing better in
this area. This is just showing the grantees who are not offering
Spanish language services.

Some of the key benefits from this verification, we now have more
updated information for the Helpline and facility locator. We also have
increased treatment referral options of Spanish language services. When
people call the Helpline, they have more options to turn to. Also, this
is the inventory that we did of CSAT Spanish publications, just a
listing of some of the ones we have here, and then I wanted to show you
some of them.

This one is \"Substance Abuse Treatment for Persons with Child Abuse and
Neglect Issues.\" This is the buprenorphine brochure that actually was
developed out of my office, the Division of Pharmacologic Therapies, and
it was printed last year in Spanish. This is a booklet for families on
what substance abuse treatment is. These are two pamphlets. The one here
is \"Good Mental Health is Ageless,\" which was a collaborative effort
between CSAT and CMHS, and also \"Aging, Medicines and Alcohol,\" which
was a pamphlet developed for the older population and making them aware
of the risks of prescription drug abuse and alcohol. This is the 2005
Recovery Month Spanish flyer out of Ivette\'s shop, printed in Spanish.

So yesterday, as we mentioned earlier, we had invited 13 key
stakeholders from the field who came together, and we really had a very
intense dialogue on the issues facing the Hispanic community. It was a
one-day meeting, and we did a lot of work, and out of this meeting the
stakeholders were able to develop some recommendations for CSAT.

Their recommendations pretty much fell into these categories: workforce
development, data and evaluation, systems, and capacity and financing.
Under the workforce development category, the stakeholders felt that it
was important to train new Hispanic service providers using models such
as promotores, which is a model of training for community health workers
to become proficient in addiction treatment service delivery, and it\'s
a model that\'s being used a lot in Hispanic communities. They felt that
this should be one of the recommendations.

Also, they wanted to develop some training opportunities for Hispanic
addiction treatment program administrators, as well as service delivery
staff. Also, the development of science to service finance systems and
license and certification training for Hispanic addiction treatment
service providers.

Also, the stakeholders felt that it would be useful to develop a toolbox
for Hispanic service providers to have this information available to
them. Also, they felt that it would be useful to have a leadership
development and mentoring program that could be done through local or
regional meetings. Also, they felt that it would be good to work with
Hispanic-serving institutions, as well as health professional schools to
attract more Hispanic students to the field of addiction treatment.

Still under workforce development, they felt that it would also be
beneficial to increase the SAMHSA CSAT Hispanic workforce. They also
really felt it was important to ensure that the CSAT grantees reflect
the communities that they serve in. They recommended a Center of
Excellence which would have a repository of Hispanic studies, reports,
books and other materials and resources that would be available to
students or Hispanic service providers as well.

Under data and evaluation, they felt that CSAT should work with the
Surgeon General to develop a comprehensive report that would help in
identifying some of the challenges and recommendations on addiction
treatment issues in the Hispanic community, and they also felt that
there was a need for uniform data collection on Hispanics by state and
local providers.

Under systems, they felt that they wanted to make every door a right
door for the Hispanic clients and their families. As we know, many
people enter the system through different mechanisms, and these are just
some of the ones that the stakeholders had mentioned here.

Again under systems, they felt that there was a need to promote system
integration at different levels, starting at the neighborhood, local,
state and federal for services including health services such as HIV,
hepatitis, behavioral health, prevention and intervention, drug courts
and schools, and they felt that it was important to have parental
engagement throughout these systems.

For capacity and financing, they felt that it would be useful to develop
a targeted Hispanic RFP that would address the service capacity and
workforce issues, as well as to mandate Hispanic staff integration for
all CSAT grantees operating in areas with high Hispanic service delivery
areas.

Also under capacity and financing, they felt that it would be a good
idea to collaborate with the Center for Medicare and Medicaid Services
to assist Hispanic providers with some of the issues facing the finance
structure, challenges regarding managed care, and possibly work with CMS
to develop a TAP publication. Also, they felt it was important to
include Hispanics in RFA review panels and to develop a Hispanic talent
bank.

Finally, for the recovery community, they felt that it would be a good
idea to assist and support the adaptation of CSAT\'s current recovery
program and adapt it to the Hispanic community.

So some of the next steps. We want to continue to work with our
partners, the stakeholders, and all of you in the community to identify
treatment service gaps for Hispanics. We want to continue to expand
these services by adopting the implementation that came out of
yesterday\'s stakeholders meeting based on budget and program
priorities. Finally, we want to work with the Center leadership to
really prioritize and then start implementing some of the stakeholders\'
recommendations.

Just to conclude, I\'m very happy to be working on this work group.
It\'s been a very positive learning experience for me, and I hope to
continue to work along with all of the work group members and the
stakeholders to continue in this effort. Here\'s just the contact
information if any of you have questions in the future and would like to
contact me or any of the work group members. That\'s it.

(Applause.)

DR. MADRID: Thank you so very much, Ruth, for a fine presentation.

We\'d like to open it up for questions if you all have any. As you\'ll
notice, one of the first recommendations was the development of a
promotore type of concept, which works very, very well in the Hispanic
community in other health areas, and that is the training of grassroots
people to do a lot of the outreach, a lot of the case management. It has
proven to be very, very successful. So we\'re looking at a lot of very
innovative ideas that hopefully we can develop in the future with the
support of the Council, Dr. Clark and the rest of the CSAT staff.

Any questions, or did we just give you too much?

MS. JACKSON: I just wanted to really commend you on a very relevant
subject. Living in Miami, where the majority of people living in
Miami/Dade County are of Hispanic origin, it obviously is something
that\'s of great concern to our agency and to our group of agencies. We
have a group known as the South Florida Provider Coalition, which has 30
different service providers that have come together as a coalition, and
that is one of the issues that we address. At our agency, we do have a
specific Spanish-speaking program.

I just wanted to say that in our history, prior to the time that we had
and developed the monolinguistic Spanish-speaking program, and we\'ve
been bilingual for a very long time, had groups, individual counseling
was never a problem to have it in Spanish in Miami. However, much of the
work was done in English, and somebody was trying to have to translate
that.

Our percentage of Hispanic population was less than 12 percent for years
and years and years, and when we implemented the companeros, which is
the Spanish-speaking monolinguistic program, we immediately jumped. I
hate to give a percentage right now because I haven\'t measured it
lately, but it was doubled the percent of Hispanic folks who were
accessing treatment at our agency. Not only that, but from the very
get-go we had a waiting list, and to this day we have a waiting list,
whereas before we were reaching out trying to find them. So if you reach
out and work at it, it really works. I\'m a testament to that. So I
really appreciate your concern, and I hope CSAT and SAMHSA continues to
really put an emphasis on this because it works if we put some attention
to it.

DR. MADRID: Thank you very much for your comments and for your
sensitivity to the Hispanic community in Florida. That says a lot for
you and for your program. Thank you, Val.

Yes, sir?

DR. McCORRY: Are there national provider organizations in substance
abuse that have Hispanic roots? Is there such a thing as a national
organization, as well as national counselor organizations for Hispanic
counselors? Have you given any thought to how that might be a force for
continuing to focus attention on the needs of the Hispanic community?

DR. MADRID: Our preliminary research seems to indicate that a lot of our
Hispanic community is having trouble with the standardized national
licensing exam. We\'re trying to develop different recommendations. For
example, the toolbox, a lot of workforce type of issues. There is no
Hispanic counselor association nationally. There is one, an overall
association, that a lot of counselors belong to. There are very few
Hispanics that are members of that association. So again, we\'re trying
to make headway there, but we need to train people, in the end get them
licensed, and then get them to join these associations that advocate for
the field.

So we\'ve got a long ways to go. National studies seem to indicate that
most of the counselors or the majority of the counselors are not ethnics
of color at this time.

I believe Dr. Robles has some comments to make. Dr. Robles?

DR. ROBLES: Yes. I would like to tell the people from Florida that we in
Puerto Rico have about 25 publications in Spanish funded by CSAP. We\'re
called the Caribbean and Hispanic ATTC. Also, CSAT, with the help of Dr.
Clark and Dr. White, helped to translate into Spanish the test. So in
Puerto Rico, we\'re giving the Hispanic test. We have a problem in
Puerto Rico because we train physicians in my school of medicine. I\'m
at the (inaudible) School of Medicine, and 61 percent of our physicians
come to the states because they are bilingual, and they are (inaudible).
We have a counselor Master\'s degree program, and we have already lost
25 of them because they are bilingual.

So in Puerto Rico you have a very good resource of Spanish-speaking and
English-speaking that you need, if you need. Thank you very much.

DR. MADRID: We\'re very proud of the work that Puerto Rico has done, and
Dr. Robles shared a lot of that work with us yesterday.

Also addressing us will be Mr. Moises Perez from New York.

MR. PEREZ: Perhaps the presentation was so full that it overwhelmed the
members of the advisory group. But I just want to communicate the sense
of urgency that sometimes gets lost in PowerPoint presentations of the
recommendations that we\'re making. Our community is growing by leaps
and bounds. There are tremendous gaps in the areas that we presented
here. They really do require some thinking, and they require strategies
that are dramatic.

The issues of workforce, the issues of the reflection of the community
in the programs that are funded ‑‑ we looked through the list of
grantees that was presented to us. In New York in particular, there was
only one Latino organization that I can identify there. The issue of
language is important, but it\'s not enough.

So I don\'t know that the sense of urgency in terms of the
recommendations that we made was properly communicated, and I hope that
you do have a chance to look at this data, the recommendations, to
digest them, and to maybe walk away with the same sense of urgency that
led us, I think in a very short period of time, to come up with, quite
frankly, recommendations that probably would have taken, as was pointed
out by Chilo, probably a week to pull together. We really are looking
for CSAT to feel this sense of urgency and to really help us create a
stronger presence organizationally, infrastructure-wise, workforce-wise,
in order to be able to deal with this tremendous problem in our
community. Thank you.

DR. MADRID: Thank you very much, Moises. We all echo your sentiment, and
we definitely agree with you.

Are there any other questions? Val?

MS. JACKSON: You know, I\'d like to just make one more comment. This
maybe comes from what I would perceive as the consumer\'s view, because
I was sitting here thinking about some of the statistics out of our
program, and I know that in the companeros program, the number of people
who have jobs when they leave treatment is lower in that program than in
our other programs. While I recognize that it\'s certainly much more
than a language issue, language is a key thing. You mentioned it, Dr.
Robles, about the physicians leaving because they\'re bilingual.

Well, if you\'re not bilingual, if you come to our program and we treat
you and we work in your culture and we treat you in the Spanish
language, we also try to teach you English. However, we have a very
short period of time to do that. It\'s a very difficult thing to do. It
is a huge barrier. Those people who are bilingual get the jobs. They
have an advantage. Those people who only speak Spanish really have a
hard time making a living and making it out of treatment, and therefore
they fail in treatment. We need to address that.

DR. CLARK: Because our next speaker is here, what I\'m going to do is
call for the break, and then we\'re going to have a public comments
period at 11:15 where we\'ll hear more, and then we can at the Council
roundtable revisit this issue.

So thank you, Chilo, and thank you, Ruth.

(Applause.)

(Recess.)

MR. KOPANDA: I\'d like to call us to order.

During the Council\'s January meeting, Dr. Clark read Mr. Curie\'s
report to the Council. One of the recommendations in the report was
regarding SAMHSA\'s data strategy, and the Council roundtable was to get
more information on the stated strategy and the outcome domains that Wes
referred to this morning.

So we\'ve invited Ms. Stephenie Colston, the senior advisor to Mr.
Curie, to further discuss the data strategy. Stephenie represents
Charlie on administration, departmental and SAMHSA-specific priorities
relating to substance abuse prevention and treatment. She works closely
with the center directors on a broad range of policy and program
matters. From August 2004 until April 2005, Ms. Colston joined the staff
of ONDCP as a director and senior advisor for demand reduction. She\'s
worked very closely with the data strategy work group here with the
agency, so we\'re looking forward to her recommendation discussion
today. You\'re invited to pick up her bio on the handout table and get
more detailed information on her.

So, with no further ado, Stephenie.

MS. COLSTON: Thanks, Rich.

Good morning. I want to talk a little bit about the development of the
SAMHSA data strategy and kind of where we are in the process. If anyone
is expecting a single piece of paper to emerge from the SAMHSA data
strategy, you\'re going to be sorely disappointed.

What the SAMHSA data strategy is is a series of efforts and priorities
and a very dynamic and fluid process. So happy to explain to you where
we are at this point in time.

Can you hear me okay in the back of the room? Okay.

And I\'ll answer any questions that you might have.

Just by way of background, I\'m not certain if we\'ve made a
presentation to the CSAT Council about the data strategy. So if I\'m
repeating things, forgive me.

The Administrator became concerned about a variety of issues relating to
data in the summer of \'03 and asked that we develop a data strategy
work group representing all of our centers and offices in July of \'03.
The charge of the work group was to prepare a strategy document to guide
the development and refinement of our data systems. So being good and
diligent federal employees, we hired consultants to engage in that
process, which turned out to be an interesting process. The consultants
basically interviewed dozens of SAMHSA employees and, of course, worked
with the data strategy work group, reported their findings to the data
strategy work group, established or recommended some data baselines, and
then in February of \'04 made a series of recommendations which I\'m
going to talk about in a minute, mostly findings.

The data strategy work group exercised its own discretion in terms of
how they responded to the recommendations of the consultants, which is
of course the federal government\'s prerogative.

One of the most valuable things that the consultants asked us to do is
to kind of think about a vision statement. As you see, supporting the
art of database management, policy, and programming is our vision
statement. I want to talk a little bit about the consultant findings and
then move pretty quickly into where we are in the process, because
you\'ll see, I think, the correspondence between the findings and what
we\'ve done as a result.

First, they indicated that SAMHSA lacks an enterprise model that
basically describes how we go about our business. For example, our bread
and butter is getting grants and contracts out the door. What kind of
data do we have that, for example ‑‑ I\'m sitting in the Office of the
Administrator. What kind of data do we have in the Office of the
Administrator that would provide early warnings to us about high-risk
grants or contracts, or timelines that aren\'t being met so that we\'re
not running around, so to speak, chasing our tails?

Second, that SAMHSA lacks IT infrastructure to support data collection
efforts.

Third, no big surprise to any of you who are community-based
organizations or states in the room, SAMHSA does not have standard data
definitions in all areas. We define housing any number of ways depending
on the center, depending on the office, depending on the program.

Fourth, SAMHSA lacks the ability to deliver data to its policymakers and
managers in a timely fashion. I\'m going to get to some of that in a
minute.

Fifth, there is significant overlap among SAMHSA centers ‑‑ boy, that
was a Freudian slip ‑‑ among SAMHSA systems. Every center has its own
data collection efforts, and there is considerable duplication and
lessons, frankly, and gems in every one of them. So we\'re right now in
the process of trying to do that analysis and kind of think through
where we want to be.

Sixth, SAMHSA in the past has not sufficiently been involved in national
data standard development and health informatics initiatives.

Seventh, SAMHSA conducts surveys and studies that don\'t justify the
high precision and cost.

Now, the consultants made a series of recommendations, but what the work
group decided would be the most efficient way to proceed is to take
those seven findings and develop some subgroups to work on implementing
them. For example, on development of enterprise model, we discovered
that Dr. Javaid Kaiser, who works for Anne Herron and Rich Kopanda and
Westley Clark in the Center for Substance Abuse Treatment, has a
considerable amount of experience in implementing enterprise models. The
enterprise model is important to SAMHSA not only because the consultants
recommended it but because the United States Department of Health and
Human Services is mandating that we implement an enterprise
architecture, and there\'s a whole federal enterprise architecture
statute and implementation model. So Dr. Kaiser is in charge of that
effort.

In addition, he\'s in charge of developing a technology architecture
plan, which is a little further down the road, and enforcing technical
oversight on IT projects.

The task of developing standard data definitions we asked the director
of our Office of Policy, Planning and Budget, Daryl Kade, to assume
responsibility for, and I\'m going to talk about that in a minute in
terms of our National Outcome Measures.

The task of adopting standard IT tools and platforms we asked the acting
director of our Office of Applied Studies, Dr. Charlene Lewis, to assume
responsibility for.

The task of consolidating our multiple client data systems we asked Dr.
Ron Manderscheid to develop a work group to work on.

Then Mady Chalk is in charge of engaging in behavioral health data
standards setting.

We did a gap analysis and asked some consultants that were working with
our IT folks on developing the SAMHSA enterprise architecture to do a
gap analysis for us. We asked every center to basically map their data
collection efforts to our National Outcome Measures, to our GPRA ‑‑
Government Performance and Reporting Act I believe is what GPRA stands
for ‑‑ and to our vision and mission statements. We discovered that we
have 33 data sets and information sources, that we\'re not quite ready
for an enterprise model, which is why we\'ve slowed things down a little
bit. There\'s an issue of the Office of Applied Studies and the efforts
that they\'ve been engaged with over a number of years. There\'s an
issue of three centers and the efforts that they\'ve been engaged with
over the past several years. So it\'s going to take us a while to work
through these internal kinds of processes.

In addition, our gap analysis revealed that our data informational
priorities kind of lack a context. We\'re not a data-driven
organization. That has become clear. We don\'t make enough management
decisions based on some good, strong, accurate, timely data. Next, our
corporate culture ‑‑ this kind of is the same issue ‑‑ doesn\'t require
data for decisionmaking.

So we kind of took a step back and said, okay, if an enterprise
architecture helps us define our business processes, then what does that
mean? Basically, this tells you ‑‑ and I\'m not going to go through
every single one of these things ‑‑ what is comprised of developing an
enterprise architecture in compliance with our federal requirements.

The outcomes of engaging in this process should be and will be more
efficient business processes, cost savings, reduced burden on states and
grantees. The Administrator has made it very clear that he wants
streamlined reporting at the community level that can be aggregated to
the state level, that can be aggregated to the national level. This will
also result in improved data quality and efficient and integrated IT
support.

Let me just kind of tell you what we\'ve done so far, and Mady and Anne
and Javaid, feel free to correct me if I miss something here. We\'ve
developed a baseline data reference model in a pretty brief period of
time, I thought. In doing so, that put us ahead of all other OPDIVs in
HHS. We actually went to the centers and instructed them, as I mentioned
earlier, we want you to map everything you\'re doing to National Outcome
Measures, to the goals of accountability, capacity and effectiveness,
and our vision and mission.

So we did that and, as you know, we have matrix data elements. We have
matrix action plans. So we asked that the centers map them to that. We
found that 44 percent, not surprisingly, of the data elements didn\'t
match to any of our National Outcome Measures.

Are you all familiar with the National Outcome Measures and kind of the
history there? Do you want me to go through that, anybody? That\'s good
news.

We also did not just work on programmatic. We didn\'t just go to the
centers and ask. We are now in the process of looking at our performance
measures of our administrative systems, getting back to the issue I
talked about earlier of getting grants and contracts out the door.

Now, we\'ve worked pretty hard on the National Outcome Measures.
They\'re a critical part of how SAMHSA is proceeding. They\'re a
critical part of the SAMHSA data strategy. As many of you in the room
may know, we\'ve just recently published a procurement that will be the
crux of how we intend to implement our National Outcome Measures, and
that\'s the State Outcomes Measurement and Management Systems
Procurement. I think it came out on May the 12th. We\'ve worked very
hard with NASADAD, over 10 years as I understand it, and NASMHPD, the
National Association of State Mental Health Program Directors, and
we\'ve reached agreement to phase in the National Outcome Measures in
all states in three years. This information is actually on the SAMHSA
website. I\'m not sure if we have the mental health information on the
website. I know we have the substance abuse information on the website,
and we have state profiles that are also on the website. We\'ve been
working very closely with single-state authorities for a good bit of
time.

Our plan is to collect National Outcome Measures across all funding
streams, all grant portfolios, all centers, everything we do, and
that\'s going to be another relatively significant challenge for us.
There are specific discretionary programs that need specific measures.
Again, remember that theme and that goal is to reduce the reporting
burden. We want everyone to report on the National Outcome Measures, and
we have to work out those additional kinds of measures. We don\'t want
50 measures per program. We\'re just not going to do it, okay?

We\'re also trying to look at every single data collection and analysis
contract that we have in this agency, no small feat, to look at how we
can better coordinate and where, if we can, consolidate to increase
efficiency and decrease waste.

Now, our next steps are to develop SAMHSA-wide performance outcome
measures, not just for programmatic efforts but, as I mentioned earlier,
for administrative functions. So now we\'ve managed to not only make the
centers extremely nervous, but all of our offices are extremely nervous.

Our second goal is to try to think about some entity, and I went ahead
and put this up here because we don\'t really know what that\'s going to
look like at this point in time, but we need to have some data control
board that\'s comprised of SAMHSA staff whose mission is primarily
greater participation of all SAMHSA centers and offices in our more
centralized Office of Applied Studies data collection sharing and
analysis.

We\'re working really hard. Charlene Lewis is doing a terrific job as
acting director of our Office of Applied Studies, under some fairly
tough financial situations, and we\'ve been working really hard with
Charlene to think about how to make OAS, and particularly the DAWN and
the Household Survey, which are massively large surveys, responsible and
accountable, and making sure that they meet the needs of our centers and
other offices.

We want to produce management reports for compliance and for oversight.
It gets back to that issue of using data to make management decisions.
We\'re just beginning the effort of identifying what kind of management
reports and technology we need. The acting deputy administrator, Andrew
Knapp, has asked that we identify high-risk grants and contracts. So I
now get an email, it seems like every day, but I\'m sure it\'s only once
a week, that identifies high-risk grants. It helps. It helps. It\'s just
a very basic thing, but we need to collect the data so that that becomes
fairly easy and isn\'t a paper reporting kind of mechanism.

We have directed the Office of Applied Studies to map the National
Household Survey ‑‑ I\'m sorry, I can\'t call it NSDUH. There\'s
something in my brain that just can\'t get there ‑‑ DAWN and DASIS,
which is the treatment episode data system within the larger DASIS
umbrella, it\'s the state substance abuse data collection system, to
SAMHSA program and management outcomes, and we\'re going to work on
realigning our SAMHSA resources, which means we have to focus on does
the data collection mechanism make sense for us, does it have functional
value, what does it cost, and what\'s the technology that drives it.

We\'re going to coordinate and consolidate as best we can our state data
infrastructure efforts across the Center for Substance Abuse Treatment,
the Center for the Substance Abuse Prevention, and the Center for Mental
Health Services. We\'re asking that given that we\'re moving into the
performance environment with the state, we\'re asking that they look
very, very carefully at prioritizing technical assistance so that states
can report on the National Outcome Measures. We have a three-year
window. We\'ve told Congress we will have all states reporting National
Outcome Measures in three years. We have to get going.

We have to identify IT solutions. Frankly, SAMHSA, as an operating
division of HHS, doesn\'t have a lot of independent authority here. HHS
has centralized its IT efforts. So where we\'re focusing on is what I
said earlier, the bread and butter issues of SAMHSA. So do we need to
think about changing the state data infrastructure grants? For example,
the contracts for cooperative agreements for greater SAMHSA involvement?
Don\'t know. We have to think that through as a group.

As I mentioned, we\'ve made state IT capability the highest priority in
providing data infrastructure assistance.

I\'m happy to answer any questions. Any questions?

Hi, Ken. How are you doing?

MR. DeCERCHIO: I just wanted to kind of compliment CSAT, and I\'m sure
you were involved in terms of the regional workshops and integrating
those. I know we\'re in Louisville next week and the southeast region,
and integrating CSAT and CSAP. They\'re important. We\'re constantly
doing a lot of work on measurement, a lot of work on data. It\'s a slow
process. We have issues in the state, but any time we look at either
changing measures or collecting data, at a minimum it\'s a two-year
process in terms of consultation and collaboration and engagement of all
the stakeholders and providers, and then beginning to test the
collection capability in year two. If all goes well, in year three
you\'re ready to kind of throw the switch.

I know that SAMHSA has been sensitive to that, and we kind of share that
responsibility in terms of that three-year target, and it\'s a
collective responsibility. So we\'re just going to have to keep plugging
at it and keep the communication going.

MS. COLSTON: I agree. It\'s not going to be resolved in a day. I think
just reaching agreement on the National Outcome Measures and rolling
them out in Access to Recovery, to getting some field experience with
some of these measures ‑‑ we know, for example, that the measure in the
Access to Recovery initiative on social connectedness, what Mr. Curie
calls that social glue, isn\'t quite what we would like it to be, and
I\'ve had several discussions with state directors about, well, it
isn\'t just about whether I attend an AA meeting. There\'s a factor
about am I isolated because of my substance abuse. So we\'re trying to
grapple with how you measure those, what is the measure, because again,
we do not want 10 measures for this.

So it\'s a goal, and we\'ll know more in a couple of years once we have
some experience.

Dr. Voth?

DR. VOTH: Hi, Stephenie. Good to see you.

MS. COLSTON: Good to see you, sir.

DR. VOTH: I work very closely in the electronic medical records process
nationally and locally, and one of the great challenges we have there,
which I think you\'re also going to face, is the phenomenal turnover of
hardware and software systems in terms of data collection. So I hope you
will all be very sensitive to that because state agencies don\'t have
any great excess of funds to be buying expensive systems and turning
that over and turning it over. I know in the medical arena, we\'re all
just pulling our hair out to try to find a central, workable thing, and
about the time you do, everything is turned over again.

MS. COLSTON: Well, not only that, but every state has a different
structure. I don\'t know if Missouri still has this, but Missouri used
to have a state chief information officer. So just like HHS, SAMHSA as
an operating division doesn\'t make IT decisions in a vacuum. In
Missouri, Michael Kootai doesn\'t make IT decisions. He\'s a division in
a state agency, one of many state agencies in Missouri. So it\'s a
complex issue.

Dr. McCorry?

DR. McCORRY: Thanks, Stephenie, and thanks for the presentation. It was
good to hear SAMHSA\'s overall plan, and I see in SAMHSA\'s draft, Mr.
Curie\'s draft strategy plan, that data strategy has become an important
element in it.

I have several issues that I just want to raise and get your comments
on.

MS. COLSTON: Sure.

DR. McCORRY: In my work for the Washington Circle, we\'ve struggled with
some of the same issues that SAMHSA is struggling with, and I just
wanted to raise some issues and just see what you might say about them.

One is this emphasis on outcomes versus processes of care. Of course,
everyone knows that outcomes are the crucial, final result of whatever
service is delivered, but we also know that it can be expensive to
collect. Things like case mix or gaming can make outcomes, or
self-selection or particular selection in terms of clients can lead to
outcomes that are really distorted from what the actual service is.

Washington Circle has taken something of a different approach in a
couple of different ways. One is this whole idea of a process of care,
kind of like a model of recovery. I was wondering how to look at that in
terms of these National Outcome Measures, that runs from prevention
through recovery support, prevention, recognition, treatment, and
recovery support or maintenance of effects, so that there\'s this
underlying kind of paradigm of what substance use as a chronic relapsing
condition is, and the model of care that kind of supports addressing
that.

In developing our measures, we looked in this process at prevention,
recognition, treatment. We went with three measures simply around
recognition or early treatment, identification, initiation, and
engagement, engagement being three or four services in the first 30 days
of treatment, and they could be considered early retention measures, but
you have to identify someone before you can worry about whether they
stay in care or not. We know that outside of the behavioral health
sector in primary care settings, the level of identification of people
with alcohol and drug problems is woefully low, in managed care
organizations woefully low.

So putting measures in that are predictive of outcome rather than the
outcome itself as the focus, knowing that if you identify someone,
you\'re more likely to be able to help that person get the help they
need to lead to recovery, and it\'s predictive. If you\'re able to hold
someone for 30 days, it\'s predictive of whether they\'re going to
recover. That\'s one issue.

I just want to raise a second issue and then get your comments on it.
The second is something of what might be kind of a disconnect between
the science-to-service approach, which I am very enthusiastic about ‑‑
I\'m really supportive of it. I do that work back home in New York ‑‑
and the emphasis on outcomes that SAMHSA is taking.

For example, use of medication as a measure. We have NIDA and NIAAA and
NIMH, but particularly I\'m talking about the substance abuse side,
spending a tremendous amount of research support to develop medications
to enhance the therapy delivered to folks in need. Yet, when you look at
our substance abuse service delivery system, the use of medication is
tremendously inadequate, and it\'s very difficult to move the field
towards accepting medication as an adjunct to counseling therapies.

So we have a disconnect somewhat in terms of not having measures that
would be considered process of care measures. When do you introduce the
notion of when someone should be offered the option of medication? Not
forced to take, but offered the option. Where does that fit in an
assessment or an early treatment plan which would fit as a performance
measure and would kind of correspond to NIDA and NIAAA\'s initiatives
and thrust but doesn\'t quite fit into what\'s been developed in terms
of outcome measures?

So wrapping up this kind of long monologue that I\'ve done here ‑‑

MS. COLSTON: I know there\'s a question there.

DR. McCORRY: There\'s a question. How can we move from outcomes to
process of care measures that are really more directly tied to
evidence-based practice, so that the measurement is around the evidence
base rather than some kind of global outcome of abstinence or however
they are listed here? How can we move from a kind of global outcome to a
set of measures that are very specific to processes of care that have a
strong evidence base in our field as being predictive of recovery?
Should we? Of course, I\'m advocating we would, but I\'d like your
comments on it.

(Laughter.)

MS. COLSTON: I think we should. I think it\'s a matter of priority and
moving forward with our outcomes first. We\'ve talked about this
internally and, frankly, struggled some. There\'s been a lot of
groundwork with the Washington Circle group. I can remember, I don\'t
know how many years ago, listening to Duane Simpson talk about the black
box and beginning to struggle with the process of treatment and how you
measure the process of care.

Where we are today has more to do with wanting to be able to demonstrate
results and be accountable for the expenditure of our federal dollars,
and also I think the state of the research to try to lead us in new
directions. So I would say that that\'s ‑‑ I know it\'s a very brief
answer to a fairly lengthy question, but that\'s Stephenie Colston\'s
personal opinion.

What frankly has driven the National Outcome Measures were a series of
lengthy, challenging discussions we had with researchers, practitioners
from the field in trying to think about the Access to Recovery measures.
We had a mandate from the White House to have outcome measures and to
ensure measurable outcomes, and to be accountable in addition to other
mandates, but that was right up there at the top of the list.

So what Mr. Curie has done is look at those outcomes, and having talked
to a lot of folks, he said these work across prevention, treatment, and
mental health services. So I think that\'s what\'s driving the National
Outcome Measures. No one disagrees with you about the process measures,
and I hope we get there soon, but we just ain\'t there yet.

DR. McCORRY: If I could just follow up, perhaps, as you said, I was
interested in noting that only 44 percent of the data elements can be
tied to outcomes.

MS. COLSTON: Kind of scary, isn\'t it?

DR. McCORRY: But in some ways it could have been worse, I guess.

MS. COLSTON: It could be.

DR. McCORRY: As you create these data elements, perhaps we can look at
them, we you kind of revamp your collection, to allow for data elements
that could be more directly tied to the evidence base or the process of
care so that we might be able to have the best of both worlds, be able
to know what ‑‑

MS. COLSTON: Once we know what that is, absolutely. Once we define
evidence base, absolutely.

DR. McCORRY: Very good.

MS. COLSTON: Dr. Suchinsky?

DR. SUCHINSKY: I was really impressed with what you\'re doing and what
you\'re attempting to do.

MS. COLSTON: I don\'t sleep much, sir.

DR. SUCHINSKY: Having been through something very similar in our
organization. A couple of questions occurred to me as you were talking.
First of all, has any thought been given to developing any sort of
interagency coordination group? Because I think what we\'re seeing is a
number of rather large governmental bodies all struggling to do
something very similar somewhat in isolation. I know the things that
you\'ve been discussing about process versus outcome and so forth is
something we\'ve been struggling with for years. In fact, we started
with doing outcome studies, and that was a disaster.

MS. COLSTON: Oh, that\'s good news.

DR. SUCHINSKY: We eventually decided that it would be better to do some
process measures, which we\'ve been much more successful in
implementing. But we\'re going to have to go back to outcome measures
because we\'re under the same pressures that you are to demonstrate the
worth of what we are doing. I was wondering whether it might not be
worthwhile to begin to set up some sort of mechanism for interagency
cooperation on this, because we don\'t have to all invent the same
wheel.

MS. COLSTON: Absolutely. When I was on detail at the White House Office
of National Drug Control Policy, that\'s actually why one of their
priorities is a drug data initiative. I\'m no longer there on detail,
but I represent SAMHSA on that group, and one of the things that both
Mr. Curie and myself have been emphasizing ‑‑ he\'s obviously at the
agency head group and I\'m obviously at the staff working group ‑‑ is
that we need common measures across federal agencies that deal with
substance use and abuse particularly, obviously. That\'s what ONDCP
would be dealing with.

So I think Mr. Walters hears that and, as you know, there used to be ‑‑
what was it called? Demand Reduction Working Group. I can\'t remember
the name of it. I\'m sure that with the drug data initiative, that kind
of effort will have to begin again. So hopefully we can start talking to
each other.

I actually participated in several conference calls while I was at ONDCP
with many VA centers talking about National Outcome Measures. So I\'ve
been talking with lots of VA folks for a long time.

Chilo?

DR. MADRID: Stephenie, I also want to congratulate you for the fine work
that you all are doing. I do have two very short questions.

Number one, in Texas, for the last four years we\'ve developed what we
call the BHIDPS system, behavioral health integrated data program
system, and it works real well. We perfected it. Everybody is happy with
it, providers, the state, other advocacy groups. So my two questions
are, your national outcome system, how compatible is that to the state
systems that are in effect at this time, and how friendly is it to the
providers that wrestle with these data systems on a daily basis?

MS. COLSTON: Well, let me answer the second question first if I could,
Chilo. The Administrator\'s goal is to streamline and reduce reporting
burden on community-based organizations, so it\'s very provider
friendly. That\'s a very important part of the vision. Secondly, in
terms of BHIDPS, lots of states have made great strides in having an
infrastructure in place for reporting process measures and outcomes. So
I would say that states like Texas, states like Florida, who have
slogged it through ‑‑ I remember one time going down for a review in
Florida and witnessing a legislative hearing and watching Ken have a
lively discussion with some senators about we want performance, we want
results.

So some states have, at the direction of their legislature, started on
this process fairly early. Now, he\'s got measures that are a little
different. I mean, the wording is a little different, and that kind of
stuff we have to work on. But I think BHIDPS would be one of the
strongest foundations. I\'m assuming that\'s why they got an Access to
Recovery grant. So you will know probably and should report back to this
group in a few months.

Has Texas started implementing its Access to Recovery yet, Mady? Not
yet. If and when they do, and they will by May 31st, then you\'ll know.
You\'ll be able to tell us.

Thank you all.

(Applause.)

DR. CLARK: Thank you, Stephenie.

We\'ll move to the next item on our agenda, which is public comment.

DR. DE LA ROSA: Good morning. My name is Mario De La Rosa. I\'m from
Florida International University in Miami, Florida, and I\'m a member of
the stakeholder groups. First of all, I\'d like to thank Dr. Clark for
his leadership in such an important issue as the one we discussed
yesterday.

There were many recommendations that were made, as you probably noticed,
and they probably will require some far-reaching discussions, and
probably strategies and changes in investments, and probably policy
changes and priority changes in CSAT and SAMHSA.

My question is ‑‑ and I think this is a question that the group
discussed after the meeting ‑‑ what comes next? I think this is a
question for Dr. Clark in relation to what are his thoughts and ideas
about where do we go from here, the process that we undertake, and an
idea in terms of a timetable and how those individuals who are here can
help in such an important endeavor? He knows and he\'s been truly part
of it.

DR. CLARK: In response to the comment from the work group, we will be
digesting the recommendations and trying to put them into a time
framework. The commitment is there, so the objective is only to make
sure that we can do things within the purview of the Center. Some of the
recommendations tend to be more global than others. Those that are more
global, of course, we will want to refer up the line. Those things that
we can do within the Center, we will want to focus on with dispatch.

Anybody else with public comment? Melissa.

MS. STAATS: I\'m Melissa Staats at the National Association of County
Behavioral Health and Developmental Disability Directors. We\'re an
affiliate of the National Association of Counties, and we have provided
written testimony before. I don\'t have any today. There are just two
things that I would like to raise that are on our association\'s agenda.

The first one, which we just had a presentation on, the data piece. I
just would encourage CSAT and SAMHSA, in their discussions with state
governments, to also consider county government. County government has
responsibilities in 22 of the states across the country, representing
over 70 percent of the population, and there is not a lot of
communication going out to county governments or to local authorities,
whether they\'re counties or their authority is in a board, about how to
go about collecting information to align their systems with the National
Outcome Measures. If you believe that it\'s expensive at the state level
for information systems, counties and lower local levels of government
are even further behind in the state. So I would just encourage CSAT to
reach out to our association and others to start getting information
out.

The other piece I just wanted to talk briefly about is methamphetamine.
The National Association of Counties has convened a work group, and
NACBHDDD participates in it, as well as others. We would, again,
encourage CSAT to do what it can to focus some of the activities in
methamphetamine on treatment and prevention. Right now it\'s really a
focus on criminal justice issues, and to help us with the message that
methamphetamine addiction is treatable and folks can recover.

Thank you for your time.

DR. CLARK: Thank you, Melissa.

Any other public comment?

(No response.)

DR. CLARK: No other public comment. All right.

We\'ve got another presentation.

MS. HERRON: Good morning, everybody. This is the first time I\'ve found
that being short is kind of helpful for these microphones. Maybe not.

DR. CLARK: Anne Herron is the director of CSAT\'s Division of State and
Community Assistance, and she\'ll discuss the state performance
management efforts under the block grant program. Anne has worked in
addiction treatment for over 23 years, joining SAMHSA as the director of
the Division of State and Community Assistance in March of 2003. In this
capacity, she is responsible for the management of the substance abuse
prevention and treatment block grants in the states and territories, and
she also has a branch that focuses on co-occurring disorders and
homelessness, and a branch that focuses on the data needs of CSAT in the
states.

Prior to that, Anne worked for the New York State Office of Alcoholism
and Substance Abuse Services as the director of treatment, responsible
for the development and improvement of over 1,300 treatment programs
throughout that state.

Anne?

MS. HERRON: Thank you very much, Dr. Clark.

It\'s my pleasure to be here and speak with you a little bit around
what\'s going on in the block grant program, how we\'re looking to
integrate some of the information that Ms. Colston just talked with you
about around the data strategy, and how we\'re implementing National
Outcome Measures. The last thing that I want to mention is some of the
work that we\'re doing in relation to performance management with the
states, which is one of the topics that\'s near and dear to my heart.

But to start, just to kind of give you a sense of the context for us,
CSAT-SAMHSA clearly has been involved in looking at data and reviewing
data for quite a while. You\'ve heard mentioned already and you\'ve
heard presentations in the past about a Government Performance and
Results Act. That really is looking at the relationship between CSAT,
SAMHSA, and our grantees. How are you spending the money? Are you
spending it effectively? Should we continue to give it to you? Those
kinds of questions.

Now, the performance and assessment rating tool asks those same kinds of
questions but asks them in a different context, really looking at
Congress to us, so looking at programs like our discretionary grant
programs, our block grant programs. How are we spending the money? Are
we spending it effectively, and should they continue to give it to us?

Well, one of the areas in our recent PART review, the Performance and
Assessment Rating Tool review of the block grant, was critical of the
fact that we didn\'t have performance data and we didn\'t look at data
in relation to the states\' use of the block grant money. Well, welcome
to national outcome demands. At the same time that we are being asked
these questions, again just to give a context, the states are being
faced with very, very similar kinds of questions and asked to provide
data on things around accountability, capacity and effectiveness.

State legislators, funders, other state systems, payers, all are asking
those same kinds of issues and questions of state systems. So they were
beginning to develop, look at and use data that they\'re collecting from
providers, counties, regions, et cetera.

Well, we all know treatment is effective. We\'ve gone down this road.
The research exists. We know that it reduces substance use. We know that
it reduces crime. We know that people who complete treatment become more
productive, responsible and stable members of society. That\'s not
always enough information. People want to know what\'s going on in my
state, in my county, in my district, in my programs. So again, the
importance of looking at and collecting data.

In the substance abuse prevention and treatment block grant, we\'ve been
asking for data for quite a long time. States submit admission data
through the Treatment Episode Data Set. You\'ve heard that mentioned
before. But most states collect more information and more data for their
own use than what they submit to us through TEDS. A subset of states
really are involved and becoming really quite elegant in their use of
that data in performance management kinds of efforts and initiatives.

Well, how do we bring this all together? This is where the National
Outcome Measures really play a major role for us. You had heard already
in December of 2004 there was a meeting between the states and SAMHSA
where we reached agreement on some guiding principles and the outcome
measures themselves. Ms. Colston mentioned the state outcomes
measurement management system, the concept that was proposed in the 2006
budget document, which really is the mechanism ‑‑ I\'ll mention a little
bit more about this later, but really is the mechanism that SAMHSA is
looking to use to collect and analyze and use the data from the states.

You\'ve heard that we are realigning our technical assistance resources
to support the states in their ability to report and use the national
outcome measure data, and we\'re making what data does exist more
public. There is the NOMs, the national outcome measure data available
on the SAMHSA website. What is available is what is currently accessible
to us.

You\'ve all heard about and seen the National Outcome Measures. They\'re
fairly intuitive when you look at what is expected to happen as the
result of a successful substance abuse treatment episode. I won\'t go
through them all. You\'ve seen them several times before.

But one of the things that I did want to mention are some of the guiding
principles of the agreements that we\'ve reached with the states around
the National Outcome Measures. One of the agreements is that for
treatment, the National Outcome Measures will be based on that data
that\'s already submitted to TEDS. For those measures where we don\'t
have TEDS variables, we\'re going to use the Access to Recovery program
to test out some other measures.

We\'re looking at data being collected at admission and discharge, so
two points in time. We\'re looking at a unique client identifier, with a
goal of being able to watch a client as they move through the system
from episode to episode; and again, the redirection of technical
assistance.

Even though those things are all in place ‑‑ we\'ve reached agreements,
we\'ve got the three-year time frame ‑‑ we don\'t have to wait until the
end of those three years to look at some of the data. In the substance
abuse prevention and treatment block grant application every year, there
is a section where we have asked states, if they are able, to report to
us voluntarily the data they have on some of these outcome domains. We
do have preliminary data available from a subset of states, and what
we\'re using it for right now is simply to look at those states who are
doing a really good job in collecting and using data so that we can
direct some technical assistance.

All of this fits into the GPRA and the PART process that I had very
briefly mentioned before. The National Outcome domains really is in that
area of looking at effectiveness. We\'ve mentioned the accountability
and capacity, very important measures, and efficiency. Those of you who
have heard the presentation, I believe it was a couple of meetings ago,
by the Division of Services Improvement, heard about the development of
cost bands for particular levels of care for individuals. The states in
their block grant applications used those same cost bands, and I\'m
pleased to say that all states report services within those cost bands.

Of the states who are reporting data to us, it\'s really good news.
Twelve of the states who report data in the abstinence domain, all of
them report improvements from admission to discharge. There are 17
states who report data in the employment domain. All of them report
improvements between admission and discharge. It\'s employment including
training and in-school, by the way. Thirteen states report data in the
housing domain. Twelve of the 13 report improvements. The one who
didn\'t report improvement has maintained the same level. So there was
no decrease. Then nine states report data in the criminal justice
domain, all of them reporting a reduction between admission and
discharge. So again, very good news.

Just to give you a sense ‑‑ this is my Easter map, I think, with all the
colors. To give you a sense of the range of reporting capabilities
across the country, what we did is we looked at states\' ability to
report in the five domains that are defined currently and identify those
states who can report in five, four, three, et cetera. So this just
gives you a sense that right now, there is a great deal of difference
among the states across the country with what they can report.

We mentioned already that the National Outcome Measures are on the Web.
There\'s other information that\'s on that website, including the
Household Survey and TEDS data, as well as the block grant application
data.

I did briefly want to mention some of the things that different states
are doing with this data, because they\'re all implementing performance
management in slightly different ways. In some ways, Frank, this goes to
your question earlier around performance management really being a
developmental process and kind of starting small and becoming more
elegant, if you will, as you spend more time in the system.

North Carolina, for example, has developed a fascinating consumer data
warehouse which looks not only at client outcome data but at
reimbursement data and marries those things around client outcomes and
program process. It\'s very, very interesting. They provide regular
reports to their providers, which in turn directs technical assistance
and support.

The State of Washington has gone in a little bit different direction.
Their data system is really very rich. They\'ve got administrative data
that they use in addition to data from their own providers, which means
going into the other state agencies to find data about the clients that
they\'re serving, and they\'ve spent a great deal of time and effort
developing marketing, public relations, educational material that really
have been used by a number of the other states, planning documents,
research papers, press releases. Very, very nice, very polished
documents and material based on their data.

The State of Connecticut, requiring all of their licensed providers,
regardless of funding source, to report data to the state. They, in
turn, provide monthly reports on performance to the providers. What\'s a
little interesting about Connecticut are the comparison groups that
they\'ve developed when they report that data back to their providers.
They look at like and similar programs either in terms of client
demographics, obviously level of care, location in the state, those
kinds of issues. So it provides a very interesting comparison process
for the providers to use in their own performance management.

The State of Oklahoma has developed really a very interesting integrated
provider performance management report which ties in performance data
from their providers with data from external databases, the
administrative data sets, and then provides that all in a comprehensive
report that they give to their providers, again directing technical
assistance and working with them to continually improve the service mix.

The State of Virginia has developed an automated data quality assurance
process, again looking at improving and trying to maintain the highest
quality data and information coming into the state so that the
information that it\'s used for is as solid as is possible.

In Virginia, instead of monthly reports, they provide quarterly reports
to their providers, but again using some comparison groups around
similar providers, regional, and then state averages. So each state is
doing this just a little bit differently, but you can see the themes are
quite similar.

Now, we mentioned earlier a little bit about the state outcomes
measurement and management as the mechanism that SAMHSA is proposing to
use to collect the data that we\'ve been talking about from the states.
We\'ve been working very closely with the Office of Applied Studies to
modify what is currently the TEDS system to be able to collect this data
at admission and discharge, and to collect it in a frequent way. Right
now there are differences in the time frames with which states report
the data. So looking to improve the timeliness of some of that.

One of the elements that is built into that particular program is an
expansion of the TEDS payment or the DASIS payment to states who are
able to report the National Outcome Measures data.

One of the other things that we\'ve been working with the Office of
Applied Studies fairly closely on has to do with that one submission of
data multiple uses. We\'ve been working to identify mechanisms whereby
we can use submissions to the TEDS process to prepopulate the block
grant application so that a state would not have to report data several
times during the course of a year. We think that would be very helpful
to the states.

We\'ve mentioned this, so I\'m going to skip right over this slide.

We have established a series of meetings with the states over the course
of this summer talking about all of these issues. We\'ve got a series of
five regional meetings ‑‑ one has been held already. The next one is
scheduled for next week ‑‑ where we talk about, jointly with our sister
center, the Center for Substance Abuse Prevention, the issues of the
National Outcome Measures, data outcomes measurement and management
system, and discuss more specifically some of the performance management
strategies and issues that the states are using, and their success with
those.

NASADAD, in turn, has been working with its member organizations to
encourage and support state-to-state technical assistance and, again,
the realigning of our technical assistance resources.

We\'ve got things to do over the next five years. There is no question
about it. Probably much longer than that, but your eyes start spinning
counter-clockwise if you talk much further. We\'re looking again at the
data on a state basis, looking at it nationally, establishing some
operational definitions, common data definitions, clarifying the role of
the state outcomes measurement and management system, and then applying
the National Outcome Measures both to the block grant, as well as our
discretionary grant programs.

So that\'s what we\'re doing. That\'s what we did on our summer
vacation, and that\'s what we\'re working on with the states and with
the block grant program.

I thank you very much for your attention, and any questions or comments
I\'d be happy to take.

MR. DeCERCHIO: Can you state the time frame again for ‑‑

MS. HERRON: The three years?

MR. DeCERCHIO: Yes. When did that start and when does it end?

MS. HERRON: It ends at the end of federal fiscal year 2007 or the
October 1 application for 2008.

MR. DeCERCHIO: Thank you.

MS. HERRON: Sure.

DR. CLARK: Any other questions? Richard.

DR. SUCHINSKY: What time frame do you use to assess outcome? In other
words, is this six months, 12 months, 18 months?

MS. HERRON: The way it\'s currently designed is really fairly
simplistic. It\'s between admission and discharge. So it\'s really
outcome at discharge.

DR. SUCHINSKY: At discharge. So if a patient does not improve over that
period of time, the program really has problems.

MS. HERRON: They\'ll certainly get a lot of questions from us, yes.

Thank you very much.

DR. CLARK: Thank you.

I want to acknowledge Anne\'s work and the data team with whom she\'s
working, her branch chief, Javaid Kaiser, and the others who are working
to provide assistance, Hal Krause. Is there anybody else from the data
team back there? I can\'t see. Javaid, Hal, Rich Thoreson. We\'re
working across centers to make sure we get this job done, working with
OAS, CMHS and CSAP. Thank you.

Any other issues? Any other questions?

(No response.)

DR. CLARK: Very good. Then why don\'t we adjourn for lunch, and we will
reconvene at 1 o\'clock. Thank you.

(Whereupon, at 11:56 a.m., the meeting was recessed for lunch, to
reconvene at 1:00 p.m.)

[AFTERNOON SESSION]{.underline} (1:08 p.m.)

DR. CLARK: I\'d like to not get too far behind again. So I\'d like to
start. Given our location, I know lunch is a hard thing to fix around
here, but we still need to get moving.

I\'ve included on the agenda a discussion of the Screening, Brief
Intervention, and Referral to Treatment, or SBIRT. Tom Stegbauer is the
lead public health analyst in the Organization and Financing Branch of
the Division of Services Improvement at CSAT. Tom has broad experience
in the development and organization of health delivery systems, along
with experience in the area of substance abuse treatment, as well as
mental health services and services for those with developmental
disabilities. He also has significant management experience, including
leadership of teams and working with federal grants to states.

Tom?

MR. STEGBAUER: Thank you very much. I appreciate the opportunity to
talk.

I had a chance to talk with Frank just for a minute before we started.
Frank, are you a Mets fan or a Yankees fan?

DR. McCORRY: Well, it doesn\'t matter. I\'m a Mets fan, but I took abuse
for the Yankees last year from the Boston contingent when the Yankees
lost. The day after the World Series I took serious abuse for it. So you
catch it, I guess, either way.

MR. STEGBAUER: Yes, I think so. As a Mets fan, you probably have a
little abuse coming. You\'re from Queens, right? You\'re a Queenie.

DR. McCORRY: National League.

MR. STEGBAUER: National League.

I appreciate the opportunity to talk with everyone about Screening and
Brief Intervention. This project is managed in the Division of Services
Improvement and in the Organization and Financing Branch. Joan
Dilonardo, Dr. Dilonardo, is our branch chief. Joan is not with us.
She\'s been injured, and she\'s out for a while, so I appreciate the
chance to talk with you.

We do a couple of other things in our branch, and I\'ll just have a
commercial here for a minute. We do the GPRA work for CSAT, and we also
are involved with a publication called \"The National Spending
Estimate.\" I see Rita Vandirvort is here, so make sure that you get a
copy of this. This is a real wealth of information. With that, we\'ll
continue.

People who need treatment for problems, it\'s well known, do not
recognize that they need treatment. If we go to a standardized measuring
tool like the AUDIT or the DAST, people tell us in huge percentages that
they do not need treatment, and these are people who score in ranges
that tell us they need to have treatment. In recent estimates, you see
that males, almost 80 percent of males who have illicit drug problems
scored by a repeatable instrument do not think that they need to have
any kind of treatment, and 87 percent of people with alcohol problems
that indeed pass the AUDIT to a point where they should be treated
don\'t think they have a problem. So we use that as a base to think
about what we\'re doing and what we\'re doing with SBIRT.

We know that substance abuse has significant social and financial
consequences. We\'re all aware of that. We know that effective
treatments exist, but few people get to those treatments. You saw on the
prior slides how very few people actually get there. We know from other
chronic problems and our work with chronic substance abuse issues that
the earliest we can get involved and the earliest an intervention takes
place, the less the chronicity has in terms of long-term impact on
society and, of course, on the individual, and we know that many times
illicit drug use and alcohol abuse problems are not even addressed by
medical professionals in primary care.

We do know that when we bring research ‑‑ and there\'s a tremendous body
of research about screening and brief interventions ‑‑ when we bring it
to medical settings, we know that the best places to do this are in
primary care. So we are involved with this project in emergency
services, in trauma care, primary care, dental offices, breast exam
clinics, adolescent clinics, schools, and we are using a chronic
treatment model, but we are involving the primary care, not waiting for
specialty treatment to pick up issues, but we are involving primary care
as early as possible, and including primary care all the way through the
treatment process.

There are some goals that we have. But let me say that our primary goal
is to bring screening and brief intervention into primary care. The
primary goal is to change how primary care is looking at substance abuse
issues. We want to increase access for non-dependent users as early as
we can. Again, we want to bring the generalist in, not wait for
specialty treatment only but bring the generalist in as soon as we can,
get rid of as many barriers as we can, increase the numbers of brief
interventions, reduce the prevalence of alcohol and drug and
medication-related disorders, and we want to build coalitions across
providers in all areas.

We have some core components, and just take a minute to define what they
are. We see screening as a very brief identification, a very brief
screen that occurs in a primary care practice or a primary care entry
point to a system. What we have in our grants currently is the use of an
AUDIT or a DAST. We have a numerical system, and when scoring gets to a
certain level, then we proceed with an intervention or a brief
treatment.

An intervention for us is an encounter that raises the awareness of the
patient that they have a problem. We use motivational skills to do that,
and brief treatment is the first step in the treatment process. Those
are typically two to six treatment sessions. When we go beyond six
sessions, we typically talk about that as a longer-term treatment.

So the focus, very much up front, is let\'s talk to patients when they
come into primary care, let\'s score, let\'s intervene as early as we
can, let\'s begin the treatment process, and for everyone that process
is going to be a little bit different. The grants that you all have been
involved with awarding are listed here, as well as the values. We have
grants in six states and one tribal organization, and we\'re going to
talk a little about those as we move ahead.

But the first thing I want to tell you about is really exciting to me.
This stuff works, guys. Look at this. Here are 2,900 patients. This is
very early data. We\'ve just been doing this for a year. These are
patients that entered our system, had an intervention or a brief
treatment, and then six months later we followed up with those patients
and asked them how they\'re doing. We have a 39 percent change rate on
people who are drinking to intoxication. That definition is people who
have five or more drinks in one session. And for illicit drug use, we
have nearly a 20 percent improvement. These are people who have
abstained for more than 30 days.

These are big numbers. We don\'t see this kind of effectiveness in many
places at all. So we\'re really excited about this.

Let me tell you a little about how we get those numbers and what\'s
going on in each one of our grants. Again, these are the areas that we
have grants, and I\'m just going to walk through them very quickly.
We\'ll start in Pennsylvania. In Pennsylvania we have activity going on
in Philadelphia, in Lewistown, and in Pittsburgh. In Philadelphia we\'re
in a public hospital. Excuse me, we\'re in a public health clinic
operated by the Philadelphia County Health Department, and it\'s in
District 3, which is the most economically challenged part of
Philadelphia. So they\'re doing a heck of a job with a really tough
population.

Lewistown is in the Lewistown Hospital. It\'s a community 501(c)(3)
not-for-profit hospital. They are doing brief intervention screening
with their emergency room population.

In Pittsburgh we\'re working with the residency programs at the
university to help teach the residents how to use screening and brief
intervention early so it becomes integrated with their training and they
carry it forward into practice.

In Illinois, we\'re in Steger County Hospital. We all know Steger County
Hospital is Cook County Hospital. We\'re in the main hospital in the
trauma center, we\'re in the emergency room, and we\'re in the community
health clinic center there. We are also seeing patients on the floors
after admissions. In Cook County we are seeing more illicit drug use
than we are in any other of our facilities, and we\'re picking up more
heroin dependence than we ever thought we would see. But the public
population that\'s using that facility is a highly at-risk group, and
that\'s why we\'re seeing those.

In Texas we\'re in the Harris County Hospital District. The Harris
County Hospital District operates Ben Taub Hospital. It\'s the Level 1
trauma center for that area. They have an emergency room, a medical
clinic, three community clinics, Strawberry Park, and they\'re in the
schools in the Houston area. They\'re in the Galina Park school system,
where 4,000 students have a health clinic, and in that clinic we\'re
using screening and brief intervention with all of the providers. Texas
is giving us a real win example.

But as a contrast, we\'re seeing many more Hispanics, as you would
imagine, in the Houston area than we are anywhere else. So that\'s a
particular kind of intervention or a particular experience that we\'re
getting, and we\'re also interacting with the Texas Medical College and
with Baylor Medical School. So wonderful residency interaction, and
we\'re making a lot of progress.

New Mexico. We\'re in 25 rural health clinics. We could almost describe
those as frontier clinics. Most of those clinics are in very underserved
areas. We have Indian population with the Hopi Indians, we have the
Navajo Indians, and we have a little interaction beginning in Farmington
with the tribes over in Arizona. We also experienced some interesting
things in those frontier areas. We have places, for example, in
Espanola, New Mexico, where we\'re seeing more black tar heroin use than
we are anywhere else. Espanola is the black tar heroin capital of the
world, I think.

It\'s interesting when talking with people there, they don\'t have a
hepatitis problem, and they don\'t have a hepatitis problem because the
things that people have to do to their needles to get them to take the
black tar heroin will kill the hepatitis. So it\'s interesting but
really challenging to have third-generation black tar heroin users
coming into primary care settings and getting challenged about what
they\'re doing simply by some simple questions by the provider they\'re
used to seeing for their flu, for their school physicals, who are
starting to ask them about what are you doing with illegal substances
and how often are you using them.

California has a tremendous experience. In California, they were doing
screening and brief intervention much before our grant through a company
called Altim in San Diego County, soon to expand, and we think that may
be into Los Angeles. Because of their vast experience, we\'re getting
about 40 percent of all of our use coming through San Diego, but they
use a different type of intervention than anywhere else. In San Diego,
they hire interventionists right off the street, and we call them health
educators. Health educators have to have a high school diploma, and
that\'s it. They prefer them not to have any more education because they
want to teach them a rote way to interact with the patients, and
specifically they want it done their way, not somebody else\'s way.
It\'s very effective. It\'s working quite well.

They are getting 14 percent of the patients that come into the emergency
room at Scripp Mercy and in the community health centers to tell them
about illegal drug use and heavy drinking. So that\'s a wonderfully high
percentage and very close to what we expect to have from the literature
that we\'re bringing into practice.

In Washington State, we\'re in hospital trauma centers only. We\'re in
the Level 1 trauma center at Harbor View, and we\'re in trauma centers
in Yakima, in Takoma, in Vancouver, and in Everett, Washington. That\'s
an interesting experience because in Yakima we deal with a very
agricultural community, high Hispanic, high migrant population. In
Everett, Washington, we\'re dealing with the Boeing workers. They\'re
putting together airplanes, and at Harbor View it\'s a Level 1 trauma
center and they\'re getting any comer. They\'re the safety net facility
for the entire region.

So in one facility we have quite a microcosm of what\'s going on, and
we\'re getting to understand a little about how payment sources affect
drinking patterns and affect how we are able to interact with ESPRES and
how we can make that much more effective.

In Alaska, we\'re working with tribal organizations. We\'re working with
the Cook Inlet Tribal Council, and we\'re working with the South Central
Foundation, and they are working entirely in the Native Alaskan
community. Here\'s a little bit of what our numbers look like through
the 5th of this month. We had screened more patients than we had
targeted. In fact, we\'re up at this point almost 15 percent. Our
screenings are up much higher than we had anticipated, but you see where
we\'re struggling.

We\'re struggling with this brief treatment concept, because it\'s a new
concept to bring in. Providers are more used to let\'s see a person,
let\'s screen him, and let\'s refer him to long treatment, and we\'re
trying to introduce the concept of two, three, four, five treatment
sessions may be effective. So that\'s tough in every grantee spot that
we have, and we\'re focusing a lot there.

But you\'ll also see that we\'re getting about the number of referrals
to long-term treatment that we expected. What that means simply is that
the dollars that we put into this grant are not being moved into the
specialty treatment area. They\'re being invested in screening, brief
intervention, and brief treatment. So that\'s a good measure for us.

So our goals again. Expand the states\' continuum of care; include
screening, brief intervention, brief treatment into primary care
settings; support clinically appropriate treatment for non-dependent ‑‑
underline non-dependent ‑‑ substance users; develop collaborative
linkages between specialty care and primary care; and identify
opportunities to change policy. We are identifying lots of
opportunities.

Let me tell you, sustainability is a huge issue that everyone\'s been
working on. Everyone in every state has a plan to help address their
local Medicare systems, address their local insurance companies, et
cetera, to try to get some movement. An example. Rochester, New York.
Blue Cross has listed a code for screening, brief intervention and
referral to treatment. Yay!

Okay, here\'s some other stuff going on. UPPL, we\'ve done a lot of work
with UPPL. We\'re working with CMS to develop code. CMS introduced a
code this year to screen all new enrollees in the Medicare system, and
we\'re using it for screening, brief intervention, referral for
treatment. All of our grantees are involved with doing that.

NHTSA is doing lots of work with hospital emergency rooms, as you can
imagine. ONDCP loves this program. This program is the number 2
initiative for ONDCP to promote nationwide and help us get some extra
dollars. You see the American Society of Addiction Medicine is also
involved.

A couple of things around the corner. You\'re going to look at grants to
universities and colleges through a Targeted Capacity Expansion
opportunity. You\'re going to see that tomorrow. We\'re going to talk
about that. We have some possible opportunities in the \'06 budget
that\'s gone to the President to have two more grants to two more
states. So we\'re doing some work there. And we have activity going on
worldwide. There is screening and brief intervention work going on in
Amsterdam, in Brazil, in Athens, in Spain, and we\'re working with the
World Health Organization.

So I\'m going to stop at that point because I probably talked enough,
and Dr. Clark wants to get on schedule. But do you all have any
questions that I could respond to?

DR. VOTH: Yes. This is Dr. Voth over here. Is drug screening being used
in any part of that? I mean, I know the administration is very
supportive of the idea particularly of student drug screening, and it
seems that would be a hand-in-glove kind of a fit for at least some of
these projects.

MR. STEGBAUER: Our grantees are doing a couple of things, but the
screening tool that\'s most commonly used is the DAST. The DAST is being
used to do screening in almost all of the grantee locations. Related to
a clinical screen, some places are using clinical screens. By the time
we have a clinical screen ordered for a person, we\'re already into our
treatment and our intervention process. So we don\'t advocate a chemical
screen, but we certainly do advocate the DAST and good interviewing
techniques, you bet.

DR. FLETCHER: Are you seeing any variability in the utilization of the
screening in terms of gender, ethnicity, those kinds of demographic
characteristics?

MR. STEGBAUER: Ann Mahoney is here, and Ann did a report in one of her
states about the distribution across gender, and we are seeing a
slightly higher, not significant, but we see a higher percentage of
females in the screen than we do males. In some of our grant locations,
it\'s simply because we have a higher percentage of females going to
primary care, and that accounts for a lot of it. Related to gender,
because of the way we screen, the screening is done in many locations
for 100 percent of the people that walk in the door. So we can\'t follow
that through. We will have some information about screening positives or
negatives or the referral patterns that might be interesting, however.

DR. SUCHINSKY: Do you have any data which shows an impact, if any, on
individuals who have true dependence rather than just abuse? Because one
of the things we hear is shouldn\'t primary care take care of the
dependent population, too?

MR. STEGBAUER: In our follow-up work, we contact patients six months
after our intervention with them and we ask what\'s going on with you,
and we make some record of that. So we are going to have some
information that will be very interesting to you. What we have seen, we
have seen people move downward in our scoring categories from a high
user to a moderate user to a light user. We\'ve seen that type of
movement on our scoring screens. So I\'m not sure that\'s directly what
you\'re asking for, but that\'s how I can respond.

DR. SUCHINSKY: It would be interesting to see whether there\'s a
difference between various drugs. I mean, with alcohol, I can see this
is happening. I\'m not sure I can see it with opiate addiction.

MR. STEGBAUER: Yes, but with a 20 percent change in pattern, we\'re
pretty excited about that.

DR. McCORRY: I love this initiative. I think it\'s great. I think the
substance abuse field is so much further ahead than the mental health
field in terms of screening brief intervention, and it\'s great to hear
the kinds of results you\'re having.

A quick question. Any thought to introducing a mental health screen as
part of the SBIRT setting? Secondly, any thought around introducing
medications?

(Laughter.)

DR. McCORRY: Is this the wrong advisory council?

MR. STEGBAUER: I think we\'re going to have Dr. Clark respond to that.

DR. McCORRY: Also, you mentioned black tar heroin and buprenorphine in
primary care settings. Any thoughts on that topic?

MR. STEGBAUER: You know, we were in Lewistown on Monday of this week,
and we talked with the physicians who are on the buprenorphine panel in
Lewistown, and they\'ve really seen a response that\'s been heartening
for them. So I can just talk from the vignette of one example. They had
an experience with screening people in their clinic and then a higher
entry into the buprenorphine clinic. So that\'s a bit of a response.

But I\'m not going to tackle the first part of that question. That\'s a
Dr. Clark question.

MR. DeCERCHIO: A question and comment. The comment is that we\'re using
this in Florida with older adults. We have three sites. We\'ve partnered
with the Florida Mental Health Institute, and we\'re using the SBIRT
model to do older adults in senior settings, not in traditional
treatment settings, and that\'s being evaluated. I think it has a lot of
promise for that population in alcohol, and even prescription misuse,
not abuse but misuse as an educational model. So if you do another
round, I would encourage not just limiting it to either the emergency or
primary care settings but looking at other populations.

The 63 percent you were concerned about in terms of engaging in SBIRT in
the treatment part, but considering you\'re screening people kind of
cold in other settings, what do we know about why it is they\'re not
participating? You kind of alluded to the deliverer of the services not
being comfortable with the model, but you\'ve got folks who may be
dependent who are not ready to engage in four to six sessions, and
knowing more about that number and what\'s driving it, it may be a
delivery issue, but it may very well be an issue of folks\' willingness
to participate, denial, et cetera.

MR. STEGBAUER: So let\'s just look at our numbers for a minute and
we\'ll kind of answer this question. The research says that we should
have somewhere around 20 percent of everyone that we simply screen that
will screen positive. By screening positive, we simply mean that there
should be about 20 percent of everyone that would fall into screens that
we should talk to about their substance use problems because it\'s
problematic, and that we should have most of those people just go
through an intervention when they say, you know, I appreciate you
talking to me about it, I didn\'t realize I had that much of a problem,
et cetera.

About 5 percent should go on to some type of further treatment, and
that\'s the distribution we\'re getting. We\'re getting about 80 percent
of people we talk to who are screening through just fine and don\'t have
a problem. But the other 20 percent are people that are in that initial
category that are saying I don\'t have a problem, and gosh, their
screens are picking them up, and somebody is starting to talk to them
about their problems.

DR. CLARK: Ann, did you want to say something?

DR. MAHONEY: Yes. I just wanted to speak. I was the project officer for
New Mexico and Illinois SBIRT projects. Illinois has started to do some
work with buprenorphine referrals connected to SBIRT, and I\'m actually
leaving this minute to go talk to New Mexico about their potential and
their interest in doing that. The big issue with buprenorphine, of
course ‑‑ well, it\'s two-fold. One is the infrastructure, and secondly
is the cost. It is more costly, and we do have cost bands for treatment.

DR. McCORRY: We were talking, though, at lunch around this whole idea of
primary care as the continuity of care, and that specialty care might be
episodes within this continuous health relationship between a primary
care doc and his or her patient. So even after treatment, even after
extended treatment, when we talk about recovery support, where do we
locate recovery support? Maybe back with the primary care doc who will
have a continuous health relationship, and there might be another piece
on the back end of this model post-discharge in terms of recovery that
has the relationship between the physician or the health practitioner
and the person in recovery on a continuous basis.

DR. MAHONEY: Stay tuned for Illinois. (Inaudible.)

DR. CLARK: Stay tuned for Illinois. We\'ll wrap this discussion down and
move to the next item on the agenda, which is an Access to Recovery
update.

Dr. Andrea Kopstein will give us an update on Access to Recovery. She\'s
currently branch chief of the Practice Improvement Branch within CSAT\'s
Division of Services Improvement. Andrea is also CSAT\'s lead on the
Access to Recovery initiative. She has spent 12 years working on
substance abuse-related issues with the federal government prior to
joining CSAT in 2001. She was a survey statistician working on the
National Household Survey on Drug Use and Health, first at the National
Institute of Drug Abuse and subsequently at SAMHSA.

DR. KOPSTEIN: Thank you.

I know that you all heard some about Access to Recovery already today,
and hopefully some of what I\'ll present will be new or informative.

One thing I will say is, in terms of data and things like that, Access
to Recovery, many of the sites have just implemented recently, and some
have yet to implement. So right now we\'re just starting to get our
first tricklings of GPRA data, and just this last week the Office of
Management and Budget has approved the Access to Recovery data
collection instrument. So that\'s in the future at this point in time.

I just thought I\'d go through some of the requirements. These grants
were awarded ‑‑ oh, I guess it was in August of 2004, and I just want to
go through some of the requirements that are being asked. I know some of
you come from states where there are Access to Recovery grants. First of
all, they have to assure that there\'s client choice of service
providers. They have to implement a voucher system that supports both
clinical treatment and, importantly, recovery support services. They
have to do significant outreach to a range of service providers
previously not receiving federal funds, and that includes faith-based
organizations.

All these grantees had to develop eligibility systems for both the
clinical treatment they would be providing and for the recovery support
services. They have to, in the course of these three-year grants,
maintain updated lists of these eligible providers.

They have to make sure that all the clients that enter their systems are
assessed and given appropriate levels of service for what was determined
during the assessment. Again, they have to collect the data that we\'re
requiring, GPRA and the seven domains outcome data, which will be
forthcoming. Of course, they have to prevent fraud and abuse.

At this point in time, 12 of the 15 Access to Recovery grants are
implemented, and that would be Connecticut ‑‑ I should have had a map
like Tom had, that looked good ‑‑ Connecticut, Florida, Illinois,
Louisiana, Missouri, New Jersey, New Mexico, Tennessee, Washington,
Wisconsin and Wyoming. The three ‑‑ Texas, California, and the
California Rural Indian Health Board, our only tribal organization ‑‑
will all be implementing in the next couple of weeks. So by the end of
May, everybody.

This number is almost a half month old now, but the numbers of actual
services and vouchers and clients are escalating rapidly as they all
come on board. But at the end of April, we had about 3,700 vouchers that
had been issued by the implemented grantees. These grantees have agreed
over the three-year period to serve a total of 125,000 clients, which is
actually in their notice of grant award. That was the intent.

Again, all of the 15 Access to Recovery grants are doing a range of
targeted populations, a range of different service combinations, a lot
of variety but some commonalities also. Again, this number is from the
end of April, so it\'s certainly larger than that, but they had seen
1,700 clients that had been screened and assessed, and a high percentage
of these clients do get vouchered services. Many of them seem to be
getting clinical treatment and recovery support services. Some get only
one or the other.

As I said, grantees have to do outreach, and there are a variety of
mechanisms being used. They\'re using waiting lists, self-referral,
family, friends, self-help organizations, social support systems,
faith-based organizations, et cetera. There are lots of places where
they\'re doing outreach. A lot of these grantees have some sort of 800
number or hotline for potential clients to call in.

We have multiple grantees in Access to Recovery that are doing criminal
justice populations, and therefore their outreach is to jails, drug
courts and prisons, where they\'re getting their clients.

Again, large eligibility lists. Most of these grantees have websites for
doing outreach, both to clients and to new providers. This is just the
same, that they\'re preventing fraud and abuse.

With this particular initiative, we told the grantees that we expect
them to manage these programs based on the performance of these
providers. With the reporting systems, the eligibility lists need to be
updated. They need to be looking to see are they doing what they were
expected to do, and many of them have client satisfaction surveys in
place. So they\'ll be looking to see are the clients who get referred to
these particular providers happy with what they got.

Grantees, of course, because this is such a high profile initiative, we
have a lot of reporting requirements, endless reporting requirements. We
have their weekly reports, monthly reports, quarterly reports, we\'re
doing quarterly Congressional reports. It\'s really interesting.

The next slides are just going to go through the grantees and give you
some basic information. Like I said, there\'s not much data on any of
these right now, so what I thought I\'d provide on all of them for you
is just when they implemented, if they did, which target populations
they\'re doing, and where in the geographic area are they actually
implementing the Access to Recovery program, because that does vary site
by site.

California is planning to implement by May 31st in just two counties.
It\'s such a huge state that they decided to just focus on Los Angeles
and Sacramento Counties, and they\'re focusing on youth 12 to 20 years
of age in those two areas.

The California Rural Indian Health Board is also obviously in
California, and they\'re actually doing statewide, and their
implementation date is next week, May 24th, and they\'re going to be
serving rural and urban dwelling American Indians and Alaskan Natives in
the State of California. This includes 51 tribal councils and Indian
health provider organizations that they\'re trying to have on their
eligibility lists.

Connecticut implemented on January 31st, and they\'re targeted
non-dependent adults who abuse drugs and people in need of recovery
support services. So the general population, basically, which most of
them have targeted more specifically than that. They are going
statewide.

Florida implemented February 9th of 2005, and their target populations
include adults 18 and older who are involved with the criminal justice
system and drug courts, 18 and older adults involved with the child
welfare system and putting children at risk, and adults who have
co-occurring disorders or abuse prescription drugs. They\'re
implementing in five districts in the State of Florida, and they do have
a hotline, as do many others.

Idaho just implemented on April 18th of 2005, and they\'re serving both
youth and adults, and they\'re emphasizing delivery of services to
Native American and Hispanic-Latino populations. They\'re focusing on
rural and frontier sections of Idaho.

Illinois implemented on April 20th. Like I said, a lot of them just
implemented, so that affects those numbers you saw. They\'re focusing on
a population of probationers with substance use disorders referred to
clinical treatment by the Circuit Court of Cook County and the Illinois
5th and 6th District Courts. The counties they\'re targeting in Illinois
include Cook, Champaign, Christian, Clark, Coles, Crawford, Cumberland,
DeWitt, Douglas, Edgar, Effingham, Ford, Iroquois, Jasper, Logan, Macon,
McLean, Moultrie, Piatt, Sangamon, Shelby, and Vermillion. So a lot of
counties.

Louisiana implemented on March 1st, and this particular program is
targeted residents with special emphasis on women and adolescents with
addictions to alcohol, cocaine, heroin, and OxyContin. They will be
going statewide, but they\'re implementing over time by region.

Missouri implemented on April 1st, and they\'re expanding clinical
treatment and recovery support services for adults ages 17 and older, so
again the general population, and another one that is going statewide.

New Jersey also implemented March 1st, and their initiative is providing
both clinical treatment and recovery support services, with priority to
clients ages 16 to 34 who abuse heroin. This is another statewide Access
to Recovery grant.

New Mexico implemented March 14th, and they will be serving adults over
18 in four counties, and also adults 18 and over who are members of the
five Sandoval Indian pueblos, with particular outreach to women, Native
American and Hispanic women, and people exiting from jails or prisons
after in-prison clinical treatment.

Tennessee implemented on April 5th, and they are providing services to
adults 18 and older with a current or past history of substance use or
addiction, and they are particularly focusing on methamphetamine in
Tennessee.

Texas will be implementing next week, and they\'re focusing, like
others, on individuals from the criminal and juvenile justice systems.
They\'re proposing in the first year to do Bexar County, Dallas and
Tarrant County, El Paso County, and Travis County. Some of the courts
that are going to be participating include felony, family, adult,
juvenile, reentry, diversion, and pre-trial drug courts.

Washington State implemented their Access to Recovery initiative on
February 1st, and they\'re focusing on low-income individuals, although
many of these Access to Recovery client eligibility standards did
include some kind of measure of socioeconomic status. But they
particularly emphasized that they will be dealing with Child Protective
Services, shelters and supported housing, free and low-income medical
clinics, and community detoxification programs.

Wisconsin was actually our first Access to Recovery site to start up.
They started in December of 2004. They started mainly with clinical
treatment services but recently have expanded and starting issuing
recovery support services. They implemented just in Milwaukee County,
where they say it\'s the area of highest need in the state.

Then Wyoming, the last one, just implemented on May 2nd, and they are
targeting adolescents who have been adjudicated through the Wyoming
Circuit Court system and their families. Wyoming is focusing on Natrona
County. They said that\'s the highest need for clinical treatment in
their state.

Then just in summary, basically all these grantees have made a lot of
progress recently, and so we do expect the numbers to start swelling in
terms of clients served, vouchers issues. We\'re providing technical
assistance as we go along.

In summary, these are the main goals of Access to Recovery, which is
where we\'re all going to with these grants. It\'s supposed to expand
capacity by increasing the number and types of providers, including
faith-based, who deliver both clinical treatment and/or recovery support
services, and some of these grantees, many of them, have training
programs in place to help some of these non-traditional type of
providers get to the eligibility standards that they\'ve established for
these services.

They are also supposed to be allowing recovery to be pursued through
many different and personal pathways, and another main goal is requiring
grantees to manage performance based on the outcomes that demonstrate
client successes.

That was the end of my slide show. Do you have any questions?

DR. McCORRY: It seems the implementation of this grant has been
particularly difficult. Looking overall at the implementation process,
what were the real difficulties, the things that have just been real
tough to work through to get this up and running?

DR. KOPSTEIN: I\'d say one of the most common issues that grantees had
to surmount to actually implement had to do with the recovery support
services component of this, because I think many of the traditional
grant programs have emphasized clinical treatment, and there\'s not a
lot of national information available to these grantees on recovery
support services such as rate-setting and definitions. The other thing
is they\'re dealing with different levels of sophistication of what some
of these recovery support services providers actually have. We have a
lot of reporting requirements. Not all of these providers ‑‑ many of
these providers I think do not have the sophistication, do not have
computers on board or the staff to do the data reporting that we
require. That\'s a big one.

Some of the other really significant barriers that these grantees have
been dealing with is just the infrastructure it takes to track. We\'re
requiring a lot of tracking. So they have to have the infrastructure in
place to track these vouchers that they\'re issuing, and be monitoring
for fraud and abuse what they\'re tracking, and figuring out what
outcomes are coming. So it\'s a fascinating opportunity, but it has a
lot of components of it that had to be addressed and were different from
what they dealt with before.

MS. BERTRAND: I had a question about recovery support services that
weren\'t historically allowed to be billable under many states. How are
they working with those that are not professional services to allow them
in terms of the data?

DR. KOPSTEIN: In terms of the data?

MS. BERTRAND: In terms of being able to bill community-based
organizations that are not a professional service. How are they working
that out?

DR. KOPSTEIN: Well, I\'d say that\'s one of the barriers that I was
talking about, that they had to figure out how to ‑‑ well, first of all,
what standards do they have to establish. For instance, if they\'re
going to cover transportation, do you need the transportation people to
be a licensed driver, to have a good safety record, to be insured?
Whatever. They had to establish those standards for every service they
said they\'re going to cover, and then they had to figure a way how to
bill them, and it\'s also on the grantee to figure out how they\'re
going to get the outcomes data reporting that we need.

What we had said in the pre-application period was sometimes clients are
in multiple services simultaneously, in which case you could have some
of that outcomes data being collected in a more traditional setting. If
they\'re not, you need to figure out how to get some version of it.
They\'re obviously figuring out ways to do that because, as I said,
we\'re seeing each week bigger and bigger numbers of recovery support
services being provided, even in the last couple of weeks. So obviously
they\'re figuring it out.

MR. DeCERCHIO: I just wanted to reinforce what Andrea is saying. I mean,
it\'s a whole different delivery method. So we\'re outreaching to
organizations that we\'ve never had contracts with. If you introduce
state financing and accountability and just the purchasing mechanism,
the method of payment, we\'re using a managing entity, a non-profit
that\'s going to have much more flexibility in those types of fiduciary
relationships with those organizations rather than running a
reimbursement voucher all the way up to the comptroller\'s office and
getting approval in the required documentation. That\'s been very real,
as opposed to just going through the traditional contractors and
providers.

So this is slow to start, but this is a whole new delivery. Vouchers,
issuing the vouchers, tracking the actual expenditure against the
voucher. At the same time, you\'re issuing it against the front end and
you\'re putting a dollar amount on the front end and then tracking
what\'s coming in and what\'s being expended so you don\'t get in
trouble and overobligate. That\'s a whole new delivery mechanism for
most of us in the states. We don\'t usually have that issue. You pay as
you go. You\'re not authorizing. So you need online data. You need to
know every day how much is being redeemed, at the same time how much
you\'re authorizing and issuing at the front end.

We\'ve gone out to a third-party managed care organization to do that
rather than say we don\'t have with our data system the ability to do
that. So there are real challenges. The clinical challenges in my mind
were less than these operational issues. It\'s a fair amount of
infrastructure. In one certain place, I think you\'ll see geometrically
implementation. I know you\'re under a lot of pressure. We all are. But
developing and having that infrastructure and putting that in place to
hit the core tenets has been a major, major challenge, and a very real
one.

DR. KOPSTEIN: And I will add to that. Two of our grantees had existing
voucher programs. Milwaukee and Wisconsin did, and Albuquerque, but both
of those systems were just doing clinical treatment. So adding that
recovery support service component of it has even challenged them.

DR. CLARK: Nevertheless, the recovery support services are a cornerstone
of the endeavor, and I really appreciate Andrea and Mady and the team
working on this, because indeed it is clear that the President expects
that we will use the voucher mechanism and that we will expand our list
of providers to include community-based and faith-based providers, and
the best mechanism for those providers to participate in this initiative
is in the arena of recovery support services.

We\'ll be working with Dave Donaldson and our faith team, Jocelyn
Whitfield. As I mentioned in my presentation, I\'ll be visiting a number
of these jurisdictions, essentially carrying the message that we are
welcoming non-traditional providers into the fold of delivery and
recovery management services. So I think with the ingenuity of my team
and the cooperation of the state authorities like Ken, we\'ll be able to
make this work to the satisfaction of all parties involved.

Anita, you had another question?

MS. BERTRAND: I wanted to just thank you and encourage the staff here to
continue to work with those states because I believe that the
non-traditional services are where people really recover, and they\'re
so important. Although they\'re not sophisticated enough to be able to
deal with the professional services, they\'re very valuable.

DR. KOPSTEIN: Oh, yes. Thank you. As we talk, we\'re planning a new
round of site visits to try to get out there and see what barriers and
issues these grantees are experiencing so that we can help them. We
provide ongoing technical assistance, and as they go along they\'re
figuring out also what kind of technical assistance they need. I don\'t
think it was obvious to everyone in the beginning what it would take. So
we are working with them, and thank you very much. Yes.

DR. CLARK: I want to also acknowledge the contribution of DSCA under
Anne Herron. Given this activity and given its complexity and given the
closeness with which we have to work with state authorities, our
Division of State and Community Assistance is playing a major role
working in partnership with our DSI under Mady Chalk. So the issue here
is this is an all CSAT kind of activity, and the partnership requires
not only what we do internal to SAMHSA but what we do external.

MR. DeCERCHIO: One of the beauties of ATR is when the grant ends, the
partnerships that are formed between faith-based organizations and
licensed providers and community organizations providing recovery
support services will sustain, and oftentimes the sustainability is not
always accomplished with these types of grants. But those partnerships
are very real and are forming in order to deliver this, and those are
going to remain. That\'s a core part of what we\'re doing, and I think
that is a significant promise. That is sustainable and it\'s expandable
within how we currently do business.

DR. CLARK: Any other discussion on Access to Recovery?

(No response.)

DR. CLARK: Well, we\'ll keep you apprised. We probably won\'t be
discussing it at our next Council meeting unless there\'s something that
develops. We\'ll allow this to mature a little bit and we\'ll keep you
apprised of what\'s developing. The key issue is that, again, this is a
Presidential initiative. The White House talks about it. The Secretary
of HHS talks about it. Obviously, Mr. Curie talks about it. So from our
point of view, we get inquiries from the White House, the Department,
and the Administrator\'s Office ‑‑ not that we\'re operating under any
pressure.

(Laughter.)

DR. CLARK: We can\'t talk about it. We\'ve got to do it. This is a key
issue.

At our last meeting, we asked you for topics you would like to include
for future agenda topics. One of those was the issue of treatment as it
relates to women, families and children. Sharon Amatetti has worked with
Stella Jones and Linda White-Young to pull together a report. Sharon is
a public health analyst in CSAT\'s Office of Program Analysis and
Coordination. She\'s also the coordinator of the Center for Women and
Families\' coordinating committee. In this capacity, she is responsible
for ensuring that women, youth and family issues are coordinated with
the Office of the Administrator and other SAMHSA centers and federal
agencies, and that adequate attention to women, youth and families is
incorporated through all CSAT programs.

Sharon also manages the Center\'s activities pertaining to child
welfare, the impact of parental alcohol and drug abuse on children.

Linda White-Young is a project officer for CSAT\'s PPW grants in the
Division of Services Improvement, and Stella Jones is a project officer
for CSAT\'s HIV/AIDS, also in DSI.

Sharon?

MS. AMATETTI: Good afternoon, and I thank you, Dr. Clark.

I thought it was funny that Anne Herron thought that she was short and
had trouble being seen.

(Laughter.)

MS. AMATETTI: If you can\'t see me, I\'ll try to at least speak loudly
so that you can hear me.

As Dr. Clark mentioned, Council member Betty Ward Fletcher did ask at
the last meeting that we look at the issue of women\'s treatment, and
particularly not so much about our specific programs but sort of overall
what is CSAT doing regarding women\'s treatment and what are some of the
particular treatment barriers for women, and that\'s what I wanted to
spend time talking about today.

I wanted to begin by talking first about what our national survey on
drug use and health tells us about the treatment need. You\'ll see here
on this slide that approximately 14 million men and almost 8 million
women reported in the year 2003 that they had behaviors related to
alcohol and other drug use that reflected a need for treatment. They
didn\'t say that they needed treatment, but the questions that we asked
them in that survey indicated that they needed treatment.

Of those people, you\'ll see that a very small percentage, the middle
two bars, indicate those people who actually received treatment at a
specialty facility. When we do the math, we see that only about 9
percent of men and 8 percent of women who this survey indicated needed
treatment actually got treatment.

Now, I want to talk a little bit about those people who did not receive
treatment. That\'s the group on the right there, the men and women on
the right there, those bars there. If you look at that, you\'ll see that
the vast majority of people who this survey indicated needed treatment
did not receive treatment. So we have to ask ourselves why not. So here
are the same two bars from the last slide that showed that these people
who are data indicated needed treatment did not receive treatment. What
we learned, and Tom talked about this very briefly in a slide, is that
the vast majority of people who we thought needed treatment didn\'t feel
that they needed treatment. This is sort of the denial bars is what I
would call them.

In the middle bars there, you\'ll see that those people who didn\'t
receive treatment but some of them did feel that they needed treatment
but they still didn\'t get it, that that is a very small percentage of
the whole. Here\'s another way of looking at it. You\'ll see that,
really, 95 percent of both men and women who needed treatment didn\'t
feel that they needed treatment, and only 5 percent of those who did
identify that they needed treatment didn\'t get treatment.

That\'s a pretty big issue for us. I think that we have to look at the
whole picture, but one of the things we want to ask ourselves is why
not? Why aren\'t people getting treatment, even those people who felt
that they needed treatment and didn\'t get treatment? Why? Why did that
5 percent who said that they felt that they needed treatment didn\'t
receive treatment?

These are the things that they tell us. Forty-one percent were not ready
to stop using. Thirty-three percent said something about cost or that
there were insurance barriers. Twenty percent talked about something
having to do with stigma as being a barrier to getting treatment.
Seventeen percent felt that they could handle the problem without
treatment, and 12 percent talked about other access barriers such as
there were no programs that would suit them in their area, they
couldn\'t get to treatment, they didn\'t have any type of
transportation.

So in terms of treatment barriers, we have some challenges in terms of
helping individuals in need of treatment to recognize the need for
treatment, and once recognized, to do something about it. I think our
programs like our Screening and Brief Interventions really talk to those
types of issues. But what would we do if denial and lack of readiness
did not exist? I mean, that\'s something that we need to think about.
Imagine if what we wish for came true. Would our treatment system be
anywhere near ready to address the desire for treatment if there was no
such thing as denial?

But let\'s go back to the 5 percent of folks who knew they needed
treatment but did not end up getting treatment. We might think of these
people sort of as the people in our showroom. If we use the analogy of
buying a car, these are not the folks out there driving a clunker that
keeps breaking down but who think their car is fine even though they
can\'t reliably get to work or get to where they\'re going. They\'re
also not the ones who know that they need a new car but they hate the
car-buying process, so they\'re just going to put that off.

These are the people in our showroom ready to take action. But then they
find out that the cost of the car is way beyond their means, so they\'re
not going to be buying a car today. Or perhaps they think that other
people in their neighborhood will think that they\'re sort of snobby if
they come home in a brand new car, so they\'re not going to deal with
getting a new car, and they turn away and go home. Or perhaps they like
the car and they have the money and they don\'t care about the
neighbors, but then they find out when they go to test the car that they
can\'t actually reach the gas pedal, and I can assure you that does
happen.

(Laughter.)

MS. AMATETTI: So these are the types of barriers that come up for
treatment clients, too, those having to do with costs, those having to
do with stigma and other program characteristics. Now, all the people in
this showroom are women, because we know that men and women have
different buying practices. So we\'re just going to talk about all these
barriers as they pertain to women.

These are the types of barriers that most commonly come to mind when we
talk about treatment barriers. We think about things having to do with
cost and with stigma and the program characteristics. There are some
things that are different about these issues ‑‑ cost, stigma, program
issues ‑‑ for men and for women, and I just want to talk a little bit
about some of the gender issues having to do with cost, because there
are some. There\'s sort of a good news and a bad news about this when it
comes to women.

We know that more women receive Medicaid due to their parenting status,
which is helpful, you would think, for women. But we also know that
there are coverage limitations that limit the usefulness of that, and
that the residential family model and the very comprehensive programs
tend to cost more than other programs. So the benefits of being a woman
can be both positive and negative in terms of expenses of program costs.

We also know that more women receive welfare or temporary assistance for
needy families. But then again, there are some downsides to that, which
is that clients with felony convictions often cannot get hold of those
TANF benefits, and that work requirements and child care can be
problematic as well.

I know that many of you are very familiar with these issues, but I just
want to sort of go over some of the gender issues briefly. In terms of
stigma, I think women certainly share the shame applied to all
alcoholics and addicts, male and female, but women tend to be held at a
higher standard due to their status as being women who have children.
This is particularly true for pregnant women who are using. Women with
HIV are doubly stigmatized and may be reluctant to talk to treatment
programs about their HIV status, or even to talk to family members.

There are program-specific barriers that impact women differently than
men. Certainly accounting for children, we know how difficult it is for
women to enter residential programs if there\'s no opportunity for them
to have their children participate, and even to participate in
outpatient programs when they don\'t have childcare for their children.
We know that it\'s also much more limited in terms of getting treatment
opportunities for pregnant women.

In terms of family and partner resistance, that becomes much more of an
issue for women than it does for men. Many of their partners are
resistant to them participating in treatment because then they need to
deal with the children in the household or other responsibilities that
the woman generally takes on. We know that women have a higher
prevalence of co-occurring mental health needs and medication, and many
of the programs are reluctant ‑‑ and I think a Council member talked
about this this morning ‑‑ are reluctant to work with clients who are
taking psychotropic medications, and also some of the mental health
providers are reluctant to work with clients with those medications who
are also taking methadone.

In terms of the greater prevalence of victimization trauma, we know that
anywhere from 50 to 90 percent of women participating in substance abuse
treatment programs have reported this history, depending on how it\'s
measured and determined, but programs often are not prepared to deal
with those histories, and that can be very off-putting to a woman who
comes into treatment with trauma histories.

There\'s a great need for drug-free housing for women, particularly
women with children or who are trying to be reunited with their
children, and then also limited AA and NA meetings that are women-only
meetings often in rural areas can be a problem.

So I\'ve described a lot of the barriers, and we\'ll come back to those
in a little bit to describe what some of the grantees have told us
they\'re doing to address those barriers. But I did want to just
familiarize you a bit with what CSAT is doing and what services and
programs we have supported for women. This is a table that shows the
discretionary portfolio that CSAT supports and the many different grant
programs that we have that have women only or women predominantly in
their programs.

Only one of these seven programs is designed just for women, and that\'s
the last program, the pregnant and postpartum women in residential
treatment for women and children programs, and we have 20 of those
programs, and Linda White-Young is the project officer for all of those.
But we also have many other grant programs that have grantees who are
just serving women in those grants, or predominantly serving them. Of
the 423 programs that we support in these categories, a quarter of them
are serving predominantly women.

We also serve women through the block grant, of course. We have the
block grant set-aside, which gives priority access to pregnant and
parenting women, and then, as you heard, Andrea talked about some of the
ATR programs are focusing their services for women. Louisiana,
Wisconsin, and Florida, with their emphasis on child welfare, are
providing services for women, and I\'m sure there are many others, but
they\'ve not been identified as such.

These are just some slides about the discretionary portfolio and the
services that they describe themselves as offering. I just wanted you to
see that 33 percent of those programs are offering HIV/AIDS services
because we have a very large portfolio of TCE HIV grantees, and 25
percent of them do have programs that care for women with their children
with them.

This is just some more of the different types of specialty services that
the providers have reported that they\'re serving.

This slide really is just to show you that in that group of grantees,
it\'s about a 50-50 mix in that half of them are outpatient programs and
half of them are residential programs, approximately.

I wanted to talk about, getting back to the barriers, some of the
strategies that our grantees have employed to address the barriers
having to do with cost, having to do with stigma, and having to do with
the program-specific concerns. Some of them are helping their clients to
apply for Medicaid and TANF. We hear that often clients need help just
getting the proper documentation that they need in order to be able to
make an application.

They\'re providing such things as family support activities, couples
counseling, family days, education, communications, all the types of
program services that you would find in good comprehensive programs such
as you would find at The Village. Val is here from The Village on our
Council, and her program is an example of a very comprehensive program
that\'s done a lot of these types of things to address those barrier
needs; providing women-only groups, of course; allowing children to
attend with mothers and providing child care, and identifying additional
caretakers for children.

In terms of some other things that they\'re doing, there is, as we said,
a reluctance to work with clients using medications for mental health
disorders among substance abuse treatment providers, and some have
sought a better relationship with psychiatrists in their communities to
be able to provide more thorough and comprehensive services for clients
with co-occurring disorders. Also, the issue of getting appropriate
medication through Medicaid-supported clients has been a problem that
some of the grantees have had to address.

Also, being able to provide more state of the art trauma services for
clients. We have just really wrapped up our five-year study of women,
co-occurring disorders and violence, which looked at different
interventions for women with histories of trauma and co-occurring mental
health disorders, and a lot of the work that came out of that study is
now being translated so that the programs can use what we\'ve learned.

In terms of housing, there are efforts to collaborate with supportive
housing agencies, assist clients to budget for housing, to seek out
women-only AA and NA meetings, and when that\'s not possible, to develop
alternative meetings through the help of the program, to develop
meetings that they call Double Trouble for people who have more than one
issue they\'re confronting, such as an HIV-positive woman who is in
recovery, to provide facilities at the agencies for clients to hold
those meetings, and of course provide transportation to meetings when
they are available.

So I went through that very quickly. There are many people at CSAT
besides myself who work very closely with our grantees. As I mentioned,
Linda White-Young manages all of the pregnant, postpartum, residential
women and children\'s programs, as well as many of the other Targeted
Capacity programs that serve women. Stella Jones has been working with
the TCE HIV programs, and Rita Vandirvort has been working with us
around treatment financing because of the issues around cost and
portability insurance. So there are other people at the Center who are
working in these issues along with me, and we\'re here to talk about any
issues that you want to discuss.

Thank you.

DR. FLETCHER: Sharon, please let me thank you for a very informative
report on issues related to women.

Does the research tell us anything about the entry into treatment in
terms of women given that there\'s this perception that the mono
phenomenon exists? When they enter treatment, the level of addiction, is
there variability in terms of that?

MS. AMATETTI: Well, what we know is that women generally need to use for
a shorter period of time and at lower amounts to develop serious and
multiple problems when they present for treatment, as compared to men.
So we\'re getting women presenting at treatment with quite an array of
issues, already in a very short period of time compared to men often
having serious problems, and that\'s why it\'s so important, I think, to
have very comprehensive approaches to working with these clients, and
that\'s really what we\'re trying to model through our grant programs.

MS. JACKSON: Thank you very much, Sharon. That was a wonderful
presentation to something that\'s very near and dear to my heart. We\'ve
been working with women and children since CSAT/CSAP started in 1992,
and I\'m happy to say that we had a five-year grant which you were the
project officer for, which started are women and children\'s program,
and since then have been able, through the State of Florida, to continue
that program, and it\'s flourishing. We have actually 50 beds for women
with children in our program at The Village.

The point, I guess, is that through all these years, we continue to have
waiting lists for women and their children. I think that the barriers
that you mentioned are really appropriate. I mean, you really hit the
nail on the head with a hammer, and I think that\'s something that we
need to look at.

A couple of things that I don\'t know for sure if this is nationwide,
but just through talking with my colleagues and so on, the denial or
perhaps lack of emphasis on treating this particular population. One of
the things that I know is happening, and I think it\'s still happening
in Miami/Dade ‑‑ it was still happening a few months ago, so I\'m sure
it hasn\'t changed ‑‑ several years ago, there was a lot of testing when
babies were being born of the mothers. Almost all mothers, in fact, were
being tested at Jackson, for instance, in Miami/Dade County. One hundred
percent of the moms who were giving birth were being tested for drugs
because there happened to be a grant there, a research grant, and they
were able and willing to do it at the time.

Once most hospitals decided that they didn\'t want to pay for that drug
testing, the rule now is that you only test if a mother is obviously
high or shows those kinds of signs. So the detection system for, for
instance, mothers who are giving birth, is really very poor.

Another area that I would like to see us explore a little bit more is
the work of another agency, Healthy Start, where they do a lot of
screening for substance abuse, but we happen to have a Healthy Start
program, and we find that in our area at least, very few women show up
with the screening device showing that they have any need at all for
substance abuse. I really have to question what kind of screening ‑‑ I
know what kind of screening they\'re doing. I have to question the
effectiveness of the screening or the training of the screeners. I
don\'t know exactly what\'s going on. These are things we\'ve looked at
in our community.

Finally, I really am appreciative of CSAT and SAMHSA. I mean, to see
that a quarter of our discretionary programs are going for programs for
women is heartening, because I have been very worried that this was kind
of going to go by the wayside eventually, unless we do something to
really figure out how we can treat women with their families. The
comprehensive treatment that we do is an extremely expensive way to
treat women, yet it\'s a very effective way to treat a whole family, and
cost effective when you look at the whole family.

I don\'t know how many research projects ‑‑ I know that this is not
SAMHSA\'s area to do research on this. I don\'t know how many research
projects are going on at NIDA, for instance, or if you\'re even informed
of that, and how much national emphasis there is on that.

So those were just a couple of thoughts that I had, the research, the
issues about not testing, drug testing pregnant moms, and the costs, of
course, are just tremendous. Do you see that as being a national
problem? Those are certainly problems that are in our area.

MS. AMATETTI: Well, in regards to the substance-exposed infants at
birth, we have a national center on substance abuse and child welfare
that is supported with Administration of Children and Families, and
really looks at the involvement of families in the child welfare system
as the result of parental substance use. We\'re in the middle, actually,
of an analysis right now looking at state policies around screening for
children in the hospitals. This really came at the impetus of a new
amendment to the Child Abuse Prevention Treatment Act, which now says in
the Act that all states do screen. It\'s not so much that they screen,
but if they screen, if they are screening and they get a positive
result, they need to make a mandatory referral to child welfare for
coordination.

So it doesn\'t require screening per se, but it says if you are
screening, you have to make a referral, with the language in the rule
saying that it\'s to provide early intervention services, not to be a
punitive response. But we were looking at this rule and said, well,
what\'s going to happen and how are states going to respond? What we\'re
finding is a very chaotic picture out there in terms of very diverse
responses of the states to this issue, really not a lot of resources to
address it on a very broad scale. When things are being done that seem
like they\'re effective and cutting edge, they tend to be local
interventions and not statewide interventions.

So I think in the future, and I\'d be happy to come back after we\'re
done with this work to talk about what we found from that analysis. But
the early analysis is that it\'s all over the place.

In terms of working with NIDA, I\'m excited because we\'re now working
with both NIDA and NIAAA planning a big national women\'s conference for
next summer. In fact, we\'re having a meeting tomorrow. They\'re coming
down. We\'re looking at what the evidence base is, and we want to term
this conference \"News You Can Use.\" That\'s what our slogan is. So
it\'s really about what\'s coming out of the women\'s treatment research
that we can share with audiences in that venue.

Ken?

MR. DeCERCHIO: Sharon, a quick recommendation. I think I would put the
cumulative block grant set-asides or targets for a woman as part of ‑‑ I
know it\'s a discretionary slide, but I think it\'s fairly substantial.
I mean, at a minimum, we\'re spending \$13 million, and I think it\'s a
low figure, in Florida. I think it\'s a strength of the substance abuse
system that SAMHSA can take a lot of credit for.

Prior to the set-aside, we didn\'t have many women\'s programs. Mental
health doesn\'t have gender-specific programs, and I think it\'s a
tremendous strength. We see a growth. We see women\'s and kids\'
programs sprouting up that we\'re not even funding, that they\'re
seeking funding in other areas. I\'ve seen this expand beyond what
we\'re funding, and I think it\'s a tremendous strength to the system.
Yes, the glass is always half empty, but I think it\'s a significant
strength. It\'s major.

When we\'ve spoken with child welfare, the ability to do this, we\'ve
got 13 women\'s and children\'s programs that have residential capacity,
probably 50 specialized gender-specific programs. So I think we can ‑‑ I
hate to use the word \"marketing,\" but I think we can take more credit
as a system, and this administration can take more credit as a system.
It\'s a tremendous asset.

The other thing is I think we need to look at other models, too. We need
to try to figure out how to do better in-home services. We\'re not going
to build enough residential capacity to bring enough moms and kids in
concurrently who need treatment, and we need to figure out ways to get
smarter about it and look at some in-home models and some intensive case
management and wrap-around, some harm reduction, maybe even applying
SBIRT to a group of women who aren\'t going to part with their children
in order to get treatment. We\'re going to have to figure that one out.

MS. AMATETTI: That\'s a good recommendation, and thank you for that. We
will do that.

I do want to tell you one of the things I think we\'re doing well right
now is when that set-aside, the block grant set-aside was put in place,
many of the states reassigned assignments to something they called the
women\'s treatment coordinator. For the past several years CSAT has been
organizing that group of coordinators, and we meet with them regularly
every year. This year we\'re going to be down in Florida with the
NASADAD meeting. We\'re going to visit Val Jackson\'s program, and
we\'re also going to be sharing with them our collection of women\'s
treatment standards.

We asked all of the women\'s treatment coordinators to send us the
standards that their states are using for women\'s treatment. They
don\'t all have them, of course, but we\'ve now compiled them, looked at
what are the best parts of different ones, and we\'re going to be
sharing that back with them. So I\'m encouraged that we have that
opportunity to meet with them.

DR. CLARK: Chilo?

DR. MADRID: One of the biggest barriers that we face where I come from
regarding women and children\'s treatment is Child Protective Services.
A lot of our women are very scared to lose their kids. So my question
is, is there any work being done at the federal level to make these
agencies a bit more sensitive?

The other question that goes along with that is this whole issue of
Medicaid concerning funding. Women with children, women that are single,
women that have children but their children have been taken away from
them, what are some of the funding issues concerning those three types
of populations, and what are some of the things that are being done to
sensitize Medicaid to help us as well as Child Protective Services, as
well as adult protective services, so that the responsibility doesn\'t
fall just on, let\'s say, the drug treatment office?

MS. AMATETTI: First your question about Child Protective Services,
families involved with that. Well, as I mentioned, we have now a
National Center for Substance Abuse and Child Welfare, and the Center
predominantly works with state organizations and agencies around doing
better work together. We have a program of in-depth technical assistance
where we go out to states. It\'s an application program where states
have to come together with a team from child welfare, from substance
abuse, from the criminal justice sector, to commit to working together
and to develop a program and do systems change. In fact, Florida
participated in that program last year, and we now have a new cohort of
states that we\'re working with.

We\'ve conducted a great amount of technical assistance across states
and really are trying to deal with some of the issues around stigma,
very many of them having to do with other agency responses to our
clients, but also the practical implications of working together across
systems and making that work more effectively, looking at things like
the family drug treatment courts, which we also support, but there are
many of them that are supported with other funds that have been a very
effective model as well.

So we are looking to be better coordinated with child welfare certainly,
and we\'ve gotten a great response at the federal level as well.

Around the Medicaid issues, I don\'t know, Rita, if you want to respond
to that question at all.

Rita really works with our financing issues.

MS. VANDIRVORT: Well, I wish I had some good news to share about
Medicaid. Clearly, Medicaid is really a state-driven program, especially
when you\'re talking about substance abuse, because substance abuse is
essentially an optional program under Medicaid. Things like Resources
for Recovery that Robert Wood Johnson has initiated to try to expand the
understanding about how to use Medicaid options, I know I\'ve spoken to
most of our grantees at CSAT around ways to utilize Medicaid to expand
its coverage.

I guess the bottom line is if states want to utilize Medicaid and expand
their substance abuse coverage, it\'s certainly possible. The mechanisms
are there. But as you all know probably better than I do, the pressures
that states have been under, Medicaid budgets have been cut, as have a
great deal of other budgets.

The women and children are probably the most core group, and even some
of the proposals changing Medicaid talk about the mandatory group
retaining much of the service array they have. The mandatory group is
the women and children on TANF. So some of the other groups are probably
most in jeopardy.

We\'ve had some discussions with Mady, with Joan, with Dr. Clark, and
with Anne\'s help, and I think we think it\'s probably really working
with the states at this level rather than looking to CMS to move in a
different direction, which is where we\'ll probably get some action
working with states, because the big policies probably aren\'t going to
go in that direction.

DR. CLARK: Eric?

DR. VOTH: Great compliments about these programs. I think they\'re
spectacular, and I always find myself trying to look at some of these
things from a 10,000 foot view. To a little bit of an extent, we\'re
trying to put the genie back in the bottle, which is great. But just
imagine for a moment if we had a way to intervene at earlier stages, and
I\'m talking here about student drug testing. I mean, if you had SBIRT
programs geared toward student drug testing, or drug testing on demand
that had support systems, you\'d take all these gals who are in their
20s with kids and there you started with an average of 12 to 13 years
old, some were being dominated by boyfriends, early sexual activities,
et cetera, and I\'ll tell you that the reasons the schools don\'t do it
is because they\'re afraid of sticking their toe in the water and
finding out that it\'s a huge iceberg phenomenon out there.

If they had the support of things like SBIRT, which is great, and if it
can be broadened ‑‑ and I\'m kind of on a soap box here ‑‑ I think we\'d
be looking at a reduction in the need for these kind of phenomena. But
again, it\'s getting people to accept that, and I think that\'s going to
be very difficult. But that may be something that could be done in a
kind of sticking our toe in the water, starting funding processes down
some of those roads, et cetera.

DR. CLARK: Frank, and then Val.

DR. McCORRY: Thank you, Sharon, for a great presentation, and the
discussion I think has really been very interesting. I really enjoyed
the Council members comments.

I want to make a comment, ask a question, and I was picking up on what
Rita was talking about, because I was thinking maybe it would be great
to get CMS to present to the Council. My idea was, and it was from
Sharon\'s presentation around barriers, helping clients who apply for
Medicaid. But, in fact, this whole idea of financing the system of care,
I know we have block grants. New York is a very big Medicaid state, and
we have local appropriations, as well as county appropriations, and we
have self-pay, all supporting a very large treatment system in New York,
and yet it\'s very difficult for me to understand it from my
perspective, even within the system.

I don\'t know whether issues related to financing the system of care and
the role of Medicaid in both supporting it or inhibiting it is something
that might be ‑‑ I\'d certainly be interested in it. I don\'t know if
the Council would be interested in it, certainly to understand it and to
see if, in dialogue with CMS or in dialogue with other federal agencies,
as well as state structures like NASADAD, that there might be some
ability to ‑‑ for example, SBIRT is so well established as an
evidence-based practice that CMS would not be endorsing that within the
state Medicaid plan.

Is it substance abuse treatment? No. But it\'s really kind of primary
care, medical care, and whether it would cost more or less is always a
discussion.

So my first issue is whether financing the system of care, and
particularly the role of Medicaid in supporting or not supporting it,
might be of interest to kind of take on here for a little discussion.
Then I have a second one.

MS. VANDIRVORT: I just want to comment. I do think that the whole notion
of SBIRT and moving a lot of this screening into primary care is very
much in line with some of the initiatives that this administration has
pushed to be sure that there is a primary care benefit. So there may be
some ties there that we can build on.

We also have in the past worked with them around the work of the New
Freedom Initiative, the New Freedom Commission and some of their work. I
certainly think there might be some bridges we could make around some of
our initiatives and their initiatives that might give more boost to
them.

DR. McCORRY: It\'s amazing what other systems don\'t know about the care
that we deliver. Even knowing this might be of benefit.

The second, Sharon, is you mentioned meeting with NIDA tomorrow, and I
thought out of the NIDA treatment principles, I think there is in that
oval but I\'m trying to remember whether child care services is one of
the ovals in terms of principles of treatment effectiveness that NIDA
espouses. When Ken was talking about new models, I was wondering whether
we could pursue that a little bit more. How do we help women who still
have their kids, as well as they don\'t lose them? But also, how do we
support women to be able to access treatment who have family
responsibilities?

I thought of ATR. I don\'t know whether, as a recovery support service,
child care services for women in treatment who have children would be an
interesting thing to add to the ATR portfolio. But also I thought with
NIDA, as you speak to them about these kinds of issues, as they define
principles of treatment effectiveness, the real role of women who are
responsible for children and how that can play out both in terms of the
research, and then how we can infuse that into these kinds of grant
structures.

MS. AMATETTI: I just want to say quickly, I don\'t remember either, but
I think they speak to ancillary services more broadly, with child care
being one of them. But CSAT has revised its comprehensive model of
services for women that will be in the new women\'s TIP when it is
published that talks very much about the services for children, child
care and beyond, not just child care but all of the services that
children would benefit from when they\'re living in a household and
participating in treatment with their mother. So look for that.

DR. CLARK: Val, and then Ken.

MS. JACKSON: Thank you. I think in-home onsite, as Ken mentioned, is a
very viable thing for women with children. But what I wanted to address
was to carry on what Sharon is saying. You mentioned student testing and
the SBIRT model. I think that the way that we have to view this is
beyond child care. If you have a mother who has her children or who is
possibly going to get her children back, or a father who may have
custody ‑‑ by the way, we treat fathers, and we also treat couples.

The issue is that you cannot stop with child care. So what\'s happened
‑‑ and I can only speak for my agency. I don\'t want to keep referring
back to my agency, but I think it applies to a lot of other
organizations across the U.S. ‑‑ is that as we\'ve grown and gone
through the evolution of first having just child care, we found that
what we have to do is we have to assess every child. We are now to a
point where we\'ve gone to a foundation. The Chris Everett Foundation
supports us in actually providing psychiatric or psychological services
for the kids, developmental services for the kids. The therapists go to
school with the kids to meet with the teachers, along with the parents.

I mean, there\'s just a whole host of things that I could go on and on
and on about that must begin, and when you talk to the parents and to
the kids once the whole family is receiving services, you see this
amazing transformation. I think it\'s definitely something we have to
look at. That\'s preventing, perhaps preventing ‑‑ I don\'t know that
there\'s research on it ‑‑ but preventing, or at least bringing to light
the next generation of addiction much earlier, or preventing it totally,
and many other problems.

Secondly, I wanted to mention that one of the things that we do ‑‑ and I
do think that Florida is somewhat of a model with the family and with
women with children\'s services, because there is great support
statewide for it. One of the things that we\'ve negotiated is to have
joint custody. We literally have joint custody with the state for the
children who are with us. So an incentive for the mom not to leave
treatment is that she can\'t take her kids with her. She can\'t walk out
the door with those kids. She\'ll have to leave them behind. That\'s a
big carrot that you have, and I think that that also satisfies the
child\'s safety considerations that is in child welfare.

Of course, they\'re also doing a lot in Florida, in northern Florida,
working with the child welfare folks to actually use the substance abuse
money and child welfare services to make sure that the kids and the
families are getting services. But that joint custody we found has been
a really good benefit to getting and keeping moms and families.

DR. CLARK: Ken?

MR. DeCERCHIO: I think part of the exploration, too, was the financing.
That would be a good discussion. Part of that discussion would be good
to have RWJ here to talk about what they\'ve observed as not a
point-counterpoint but as another perspective on the Medicaid issue.

On financing, a couple of our providers, Gateway in Jacksonville, have
created supportive housing. They\'re now accepting more children, more
families into supportive housing, and they\'ve deemphasized residential
supportive housing and wraparound. So they\'re getting higher numbers of
children who are involved in child welfare.

Well, guess what? Those children are with their moms. They\'re not
eligible for 4(e) home care dollars. So they\'ve come to us and said
we\'re having a hard time for the financial support for larger numbers
of kids, whereas before they would only take an infant in or an under
five-year-old to residential treatment. Now they\'ve got three and four
children, and they\'ve got 15, 20, 25 families in supportive housing
that are not really eligible for any of the child welfare funding, not
substance abuse treatment or even wraparound, but the kinds of support.
Because the children haven\'t been removed, they\'re not eligible for
4(e), and in some cases they\'re being diverted from child welfare, in
other cases under protective supervision.

I think part of the financing exploration is this nexus with 4(e)
funding, the categorical funding in child welfare. It would be nice,
through the national center, to come back and talk about that and have a
similar discussion with the Administration for Children and Families
about how we can jointly finance some of those support services that
create incentives to keep families together, rather than create
incentives for higher levels of reimbursement for kids that have been
removed from their homes.

DR. CLARK: Rita?

MS. VANDIRVORT: I absolutely agree with everything you said. That\'s
right.

I just wanted to mention that I am working with Sybil Goldman, who is a
special assistant for children and families here, on a project where
we\'re developing information for providers, kind of a catalog for
funding, because underneath what you were saying is Medicaid is
important, and I think there are opportunities there, but I think we
have to look across all of the funding streams to really put together a
system today. Nobody has a lot, so it\'s kind of understanding where
your opportunities are across child welfare, across juvenile justice.

So it\'s a multi-year project. In fact, I think we tried to get Chilo to
come to that meeting. I hope he does.

DR. CLARK: Hint, hint.

MS. VANDIRVORT: We\'re looking at the different funding streams. The
first year is going to be kind of a comprehensive catalog. The next year
we\'ll talk about blending and braiding funds and how you really put it
together.

DR. CLARK: Dave?

MR. DONALDSON: I think we have to insert into that the preventive side,
such as the President\'s other big initiative, the healthy marriage
initiative, which is going to the states as part of TANF. I was
wondering, are you having any collaboration with ACF on that?

MS. AMATETTI: Yes. The Office of Family Assistance, which manages the
TANF program, we\'ve been working very closely with them over the years,
actually from when TANF was first implemented. We\'re looking closely at
the reauthorization and we keep waiting for that, when that\'s going to
happen, because it has the stipulation in there that you can now more
broadly count participation in substance abuse treatment as an allowable
work activity, which would be very helpful. Some states have done that
already on their own, but it\'s not across the nation. So we\'re looking
to see when that will be put into law.

MR. DONALDSON: Yes, like Ohio, which they have now a whole division
called Strengthening Marriage and Family. That would be good if you
haven\'t tapped into that.

MS. AMATETTI: Right, and the marriage initiatives there.

DR. CLARK: Okay. Thank you, Sharon. I really appreciate your
presentation.

(Applause.)

DR. CLARK: I think we sat through a number of presentations, all
wonderful. You probably need to stretch your legs. So why don\'t we take
a 15-minute break and reconvene at 3?

(Recess.)

DR. CLARK: Two more presentations. We would like to get moving. It\'s
been a long day. It will be longer the longer we delay.

One of the topics that was requested by CSAT Council is an update on
Partners for Recovery, or PRF, and their treatment and workforce
development efforts at CSAT. Presenting on this topic is Dr. Karl White,
workforce development team leader at CSAT\'s Division of Services
Improvement, and project officer for the Addiction Technology Transfer
Centers.

He will be joined by Ms. Donna Cotter, CSAT\'s Partners for Recovery
coordinator. Donna is currently responsible for coordinating the
development of SAMHSA\'s Partners for Recovery initiative, a
collaboration of communities and organizations mobilized to help
individuals and families achieve and maintain recovery and lead
fulfilling lives.

Karl? Donna?

DR. WHITE: The first thing you\'re to notice today is how Donna and I
coordinated our outfits for this presentation.

(Laughter.)

DR. WHITE: We wanted to make sure you noticed.

The next thing we want to recognize right up front is that we have
squeezed at least two hours worth of material into 20 minutes. So we\'re
going to run through it fairly quickly, and we\'ll be happy to take as
many questions as you have when we finish.

Partners for Recovery has launched two workforce initiatives in
conjunction with the Division of Services Improvement. The first was to
produce a report on workforce development, and that was commissioned by
Dr. Mady Chalk, our division director. The second was to work in the
area of leadership development, which Donna is going to talk about after
I talk about the new report.

This will be the cover of the report. We would give you a copy today
except it\'s in content clearance and we don\'t have clearance to pass
it out. But the material we\'ll be discussing with you is directly from
the report.

Tom McClellan has always been one of the wise sages in our field, and
this quote by Tom talks to the fact that if we don\'t take care of our
workforce issues, and we do have a workforce crisis, we\'re not going to
end up meeting the needs of the clients that we serve.

CSAT started really looking at workforce development issues back in
1999, and the program that it was a part of has morphed now into
Partners for Recovery. To start the work on our current report, we
commissioned an environmental scan. This was a new word to me, and as
we\'ve used it it\'s taken on a whole lot of new meaning. Our
environmental scan meant taking everything we had at CSAT, all of our
workforce surveys produced by our ATTCs, all of the research that we
could find in the area ‑‑ McClellan\'s research, Rick Harwood\'s
research, and anyone else\'s name that you can mention who has done
research in this area ‑‑ and boiling it down into what were the
commonalities, what were the differences, and what were the trends that
emerged.

After we did that, we saw that we needed to try it out on the
stakeholders, is this still relevant in your situation. So we convened
stakeholder groups. The groups are listed. I don\'t need to read them to
you. But the last one on the list stands a little explanation. We had
two sections of the country that had not completed any workforce data,
the upper midwest and the middle southern states, Texas, Oklahoma,
Arkansas, Missouri. We convened providers, state directors and ATTC
directors from those areas after we did the workforce report and said
does this fit? Are these the issues being faced by your states and in
your regions?

In both ‑‑ we couldn\'t call them focus groups. In both of our
stakeholders information gathering groups, they concurred that what we
had discovered through our environmental scans still fit in their
region.

What the report revealed and what our scan revealed was the composition
of our workforce looks like this, and as you read the bullets under
gender, age, ethnicity and race, you\'ll see that we have problems and
inconsistencies in each area. Seventy percent of the counselors in
training today in academic institutions are Caucasian women. That in no
way matches the client base that we serve across the country. I was
thinking about the statistics this morning from our Hispanic work group.
It\'s a problem. We need to change the way this looks.

Education level. We have a lot of people with degrees. Very few people
receive their addiction training as part of their formal education. I
didn\'t. All the training I have in addiction came ‑‑ besides what I
learned in the fraternity house ‑‑

(Laughter.)

DR. WHITE: ‑‑ came after graduation and through formal training. We need
to work on that. We should be graduating people with what we know about
evidence-based practices and addiction treatment, not waiting until they
graduate to train them.

Medical staff. I think these statistics are telling. Dr. Clark and I met
recently with the Addiction Nurses Association. They want to work with
us in attracting more nurses into the addiction specialty so we can have
more nurses in our treatment programs.

Kind of an historical context for the key issues that are facing the
field. We don\'t have a workforce to meet the demand currently. We have
a changing profile of those needing services across the country. Not
only do we have some people coming in from Central America and South
America that can\'t read or speak English, their literacy level is such
that they can\'t read Spanish. So many of the educational techniques
that we use in our treatment programs are no longer effective, and this
is a big problem.

We have increased public financing challenges, and I would add another
word to this slide, challenges and barriers to adopting evidence-based
treatment in many settings, and increased utilization of medications and
treatment. I mean, there are programs now that are willing to adopt
medication-assisted treatment that for years prided themselves on being
\"drug-free\" treatment centers. Betty Ford has recently entered into,
as part of the Clinical Trials Network with NIDA, has been using
buprenorphine as part of their detoxification. I was in a meeting with
their clinical director in Los Angeles recently, and the rapid results
they get in readying patients to fully participate in treatment with
buprenorphine detox is just amazing, and those results will be released
in some training materials through our ATTC network in the next six
months.

Movement to a recovery management model of care, where we\'re no longer
looking at just treatment but we\'re looking at a full continuum of
recovery services, we\'re looking at providing treatment in
non-traditional settings, our outreach to faith-based organizations and
other types of community-based organizations to provide services in the
recovery process. Stephenie talked this morning and Dr. Clark has talked
about the performance and patient outcome measures and how that\'s
currently impacting the work that we do, and we still have
discrimination associated with addiction both for our clients and, to
some extent, for those of us who choose to work in this field.

The report examines in detail this list of areas, and the next few
slides will just barely illuminate it.

Before I go any further, I neglected to do the people that have really
done the work on illuminating these issues for us. We have with us in
the audience today Melanie Witter and Peter Gomand from Abt Associates,
who have been primary authors on helping put together this report. They
could tell you page and number from where these slides came. But I
wanted to recognize that they\'re here, and they\'re also a resource for
you to talk to.

Peter and Melanie, raise your hands. Good. Thanks.

Infrastructure issues facing the addiction workforce. We have a
workforce shortage. Staff turnover, the second bullet, from Jeff
Knudsen\'s study. Workforce turnover doesn\'t necessarily mean people
are leaving. We\'re beginning to see workforce churning, where people
are leaving one job and going to another for as little as \$500 more a
year. So it\'s not people departing the field so much as the turnover
can be attributed to the low salary level, and another slide speaks to
that.

We talked this morning about the money we\'re putting into our TCE
programs. It\'s a double-edged sword. We increase treatment capacity. We
don\'t have the number of treatment providers to treat the clients. So
we need to continue to work on increasing our workforce.

Again, accountability, performance measures, complex leadership and
management issues. Leadership is reaching retirement age. We\'ve talked
about the graying of the field, the aging of the field. Last Saturday
night I was at a concert and heard one of my favorite female vocalists,
and she said, \"You know, 30 years ago when I started, I had blue eyes
and black hair. I still have blue eyes.\" I look around at my colleagues
and, yes, a lot of us are in that same situation now. We still have the
same color eyes, and some of us have managed to hide the gray. But we do
have an aging workforce, and we really do need to look at sustainability
and replacement of those leaders, and Donna will talk to that in a few
minutes.

Recruitment. We know we\'re going to have a workforce shortage. Rich
Landis\' research talks about the unfilled positions.

Low salaries. When Melanie and Donna and I met with our stakeholders
group of counselors, and again with our group of clinical supervisors,
and we flashed up \$28,000 as an average salary, half of the people in
the room were making less than half that amount in the counselor group,
and the clinical supervisors said they would love to be making \$28,000.
So when you average salaries across the nation, it\'s not really
reflective of the low salary level in many areas of our country.

When you look at the health care disciplines, and then you look at the
low number of people that are addiction certified or certified as
addiction specialists across the different health care specialties, it
gives us cause for concern. We need to recruit people as addiction
specialists in all of the different disciplines.

Academic education. It\'s one of the recommendations that, through our
ATTC network, we\'ve already started to work on. We have 442 colleges
and universities offering some kind of degree or certificate in
addiction science, addiction counseling, addiction education. What we
don\'t know is what those programs consist of. There are no accrediting
standards or standardization of addiction science programs. We\'re
working with INCASE. Some of you may be familiar with INCASE. It\'s the
International Consortium of Addiction Science Educators. About 125 of
these colleges and universities are members of that organization.

We would like to work with them to know what\'s actually being taught,
that a B.A. in addiction counseling from South Carolina and a B.A. in
addiction counseling from UCLA prepares the person to provide the same
services when they enter the treatment field. So it\'s a challenge.
It\'s an uphill climb, but we are beginning to look at that area.

Retention issues. Rick Harwood\'s slide I think speaks again to what
Jeff Knudsen said about the churning of the field. We didn\'t find that
much evidence of people leaving but changing jobs, and sometimes going
into a mental health position that paid more than their addiction
treatment position, which is not leaving if they\'re working on
co-occurring, but still they\'re changing jobs. Then we don\'t have any
safety net. When we met with human resource directors in our
constituency group and this small woman from TASC finally spoke up and
she said, you know, the elephant is in the room. We don\'t take care of
our own. We are so short-staffed that we ignore the signs and symptoms
in our own staff members until sometimes it\'s too late. So we need a
safety net for the workforce in our own profession.

Study issues. At SAMHSA, we don\'t do research, but we have lots of
recommendations for the institutes on what they could be doing to look
at the preparation of the workforce for our field.

Recommendations. We need career paths. We need loan forgiveness. Through
the federal government you can get loan forgiveness for lots of
professions. Addiction counselors are not currently listed.

We need to train better clinical supervisors. We have no hope of
adequately implementing evidence-based practices with any fidelity if we
don\'t have clinical supervisors who are trained in that implementation.

We need to sustain leadership and management training. Donna is going to
talk about leadership training. The other side of the coin is teaching
CEOs how to balance a checkbook, teach them how not to go out of
business.

We need to expand the recruitment of health care professionals. I\'ve
talked about that. We need to improve student recruitment. The lack of
diversity in the pre-service academic courses that are being taught is
scary. We really need to increase our efforts to recruit diversity into
the workforce, and I think part of that needs to start in recruiting
students from diverse backgrounds into our academic programs.

Support the adoption of accreditation standards. I\'ve mentioned that.
We need to encourage boards for all health professions to start
including test questions on addiction. We need to address substance
abuse misuse and relapse in the workforce and encourage our institutes
to do studies.

Those are the recommendations that you\'ll see when you get the full
report. There is a lot more in the report than could be covered in these
few slides, but we feel like we\'re beginning to get a handle on some of
the initiatives that need to be funded, some of the action steps that we
need to be doing at CSAT.

So in terms of next steps, we want to complete this document. We want to
get it through content clearance so that we can start working with our
various stakeholder groups to develop an action plan. We want to roll it
out. This report will probably end up being incorporated into a bigger
strategic plan for SAMHSA that\'s being prepared by the Annapolis
Coalition. The SAMHSA leadership contracted with the Annapolis Coalition
to provide a strategic plan for workforce development. Two of our ATTC
directors, Steve Gallin from the Northwest Frontier and Mike Flaherty
from our Northeast ATTC, are chairing the Substance Use Subcommittee to
develop this strategic plan. They are joined by several other people who
have worked with us for a long time, and we will have one-third of that
plan, the mental health, prevention and substance abuse treatment. We
see a lot of their work already prepared in this document that can be
rolled into the strategic plan.

We want to encourage stakeholders at all levels to take a close look at
their workforce issues and come to us and let us know what is needed to
improve the quality of the workforce at all levels.

I\'ll turn it over to Donna, who will talk about one ‑‑ I\'m going to go
ahead and call it a successful initiative that was started in the area
of leadership development, and then we\'ll both be available for
questions.

MS. COTTER: Thank you, Karl.

First of all, I\'ve had these cubes delivered for each of you. We also
are offering to ship them for you if you don\'t want to put them in your
suitcases. I hope you\'ll use them and I hope you\'ll remember the
Partners for Recovery, because as programs go in the federal government,
Partners for Recovery has outlasted most. It started, as you know, as
the National Treatment Plan, and with your support, and with the
guidance of Chilo and Melody Heaps, who is not here today I see, has
continued into Partners for Recovery. As you saw, the workforce report
is a Partners-supported effort, and the Leadership Institute is also
Partners supported.

There\'s a lot to say about these leadership institutes. I agree with
Karl; they are a success. They are not a one-week course that you attend
or a two-day course that you attend and then you walk away a leader.
These are intensive. That\'s a key word here. They\'re six months in
time, length. They have a variety of methods for training, including a
one-week intensive seminar. We have asked the U.S. Department of
Agriculture graduate school to assist us in providing the leadership
training in that one week, and they have just had the most marvelous
trainer. Everyone wants to clone this woman across the country. They do
have other trainers who we will use.

Why do we need this training? Karl says I dye my hair, and he\'s right.

DR. WHITE: I didn\'t say that.

(Laughter.)

MS. COTTER: There\'s a lot of workforce turnover. He\'s told you that.
Frankly, there aren\'t very many educational opportunities for addiction
training professionals. You know that.

This began, actually, with an Addiction Technology Transfer Center in
Florida, and they took it on and designed it. It became so successful
that, frankly, we stole it. We put some more money behind it. We
polished it up on the edges, and they too are improving it, as they\'ve
done now two sessions in Florida, and we asked the ATTCs to take it on
and conduct it. There are 15 leadership institutes scheduled from
October of 2003 to 2005. Eleven institutes were conducted through May,
and 145 emerging leaders have been trained.

This is a quick look at the ATTC network just so that you can
familiarize yourself with the fact that most of the country at least has
some coverage with regard to offering this institute.

This is a list of where the institutes have taken place in the past. Ne
is northeast, and I\'ve learned that NE is New England. So we have them
going through the end of this year, and then we\'re going to support
another complete round. Some of these institutes, I think it\'s
important to mention that two of them have been focused on Hispanic
clinicians. I have heard raves about the one that was performed in
Puerto Rico. It was bilingual, and I heard you put on a show, Rafaela.
It was quite popular and very highly acclaimed. The one in New England,
while not done in Spanish, was done for an Hispanic group of clinicians.
So we\'re attempting to be culturally sensitive in everything that we,
the Partners, do.

Of course, the intended outcomes are to develop and retain the potential
leaders of the future for this field and build capacity to meet both
organizational and system demands. This is a little bit of an in-depth
about what the six-month institute is about. First of all, the protege
gets a 365-degree assessment. So by the time they arrive at the
training, their bosses, their peers and their directors have already
talked to them ‑‑ not actually talked to them but filled out
questionnaires about them. So whether or not they want to know it, this
is an in-depth look at each individual ‑‑ what am I about, what are my
strengths, what are my weaknesses.

Then they go through a five-day immersion training, and I cannot tell
you the rave reviews that have come back from people who have taken this
course. Then they develop their own individual leadership development
plan, and they also have mentors matched to them. As we\'ve said before,
Val has been a mentor, and we\'re grateful for that. Many, many of you
who do color your hair, or who don\'t, could be excellent mentors in
this program. We\'re hoping that it becomes institutionalized. We\'re
hoping that we can keep it sustained because it\'s very positive, and
it\'s working.

There is a three-month booster session. The people use e-learning
through Blackboard, and of course they get their continuing education
credits, and then they present a project at the end, and they go through
an official graduation. We\'re hoping to have finances to be able to, on
an annual basis, bring together across the nation the emerging leaders
who have taken this training.

Approximately 200 will participate in this first cycle. The participants
evaluate it after they\'ve taken it, and we\'re also setting up
evaluation criteria for the full institute. The second cycle will begin
in October 2005, and as you see, we\'re creating a new generation of
leaders. So we\'d all better watch ourselves.

Here\'s what one participant stated. We didn\'t put these words in their
mouths. \"This training is comprehensive, fast-paced, personal,
experiential, and all together important. A year after participating,
I\'m still using what I learned. This hasn\'t benefitted only me but my
agency and colleagues as well.\" Another individual said to me this was
a life-changing experience. So we\'re really, really, really pleased to
have the PFR engaged with the ATTCs in this effort.

My boss has told me that if I make it brief, I could just tell you a
little bit more about what the Partners for Recovery have been doing.
We\'ve been so busy, we haven\'t had the opportunity to brief you. I
want to just run down a list.

I believe the \"Know Your Rights\" brochure was in your packet. This
brochure is available in Spanish. We will be releasing it in Spanish.
This has been very popular. We\'ve given pilot trainings in Pennsylvania
and New York, and they want more. We\'re going to try to do some
regional-based trainings across the country. This is very helpful for
people in recovery, people in treatment, family, friends, loved ones.

There\'s a national public education campaign to reduce stigma
spearheaded by NCADD, and Partners for Recovery has provided some seed
money, along with Ivette Torres\' shop, to get the basics of this
campaign defined.

In the area of recovery, I was glad to see Kathy Nugent here. Partners
is providing the logistics support for a recovery summit that she is
doing in September, and we\'re going to hopefully be able, for the
substance use disorder field, to define principles of recovery and talk
about systems of care that would support recovery.

In the area of collaboration, some of you know we did a 2004 forum. We
sponsored it, Partners did, to begin dialogue among substance use
disorder treatment, prevention, and mental health services disciplines.
As a matter of fact, the Partners for Recovery steering committee is now
reconfigured, and it has representation from the mental health side, the
prevention side, and the substance use disorder treatment side. We will
be reconvening that committee in late July. So the direction for the
future will be coming and defined by that group.

Some other areas, very quickly. SAS, NCSL and Tom McClellan have put
together a training package for state legislatures on performance
measures, PFR money. NASADAD establishing their national treatment
network, PFR money. Data strategy experts that Stephenie talked about,
several of them were funded by the Partners for Recovery. The Hispanic
stakeholders meeting was paid for, the logistics were paid for by the
Partners for Recovery.

We are also supporting state conferences, and I want you to know that a
website is developed for Partners for Recovery. We are in the midst of
getting it cleared, and hopefully we will release it in July. It will be
www.pfr.samhsa.gov, pretty simple. You can also get it directly through
the SAMHSA site because it is a government-supported website. You\'re
going to see a lot of good information on that. We\'re also going to get
some states to contribute to it for us.

I just want you to know, and probably Dr. Clark is going to give me the
hook, but Partners, under the 2006 budget, is targeted for a 50 percent
cut. We\'re going to do the very best that we can to keep this
initiative alive because even though you don\'t hear about it, you hear
about all these programs. A lot of times, our fingers are in the pot
providing the basic structure and support for this.

So I guess I\'m done.

DR. CLARK: Any questions?

MR. DeCERCHIO: I just want to recognize ‑‑ we get lots of good feedback
from other state directors, from the ATTC, our ATTC, and I compliment
you all on this initiative. With a small cadre of folks, you\'ve got
your fingers in a lot of things. For many of us, this is a hard
initiative to get our arms around, the state directors, and we really
appreciate the fact that you\'ve taken it and run with it and really
impacted many different areas. So thanks for all your work on this.

DR. MADRID: I also would like to compliment the Partners for Recovery.
The leadership institutes, I think, is a fabulous idea, the fact that
you included two Hispanic groups. You just fulfilled one of the tasks
that we kind of gave ourselves, and I think that even though finances
are restricted at this time, I will probably encourage you and talk with
you all about maybe partnering on some other things that the Hispanic
work group has talked about.

So again, thank you for all the fine work that you all are doing.

DR. CLARK: All right. Thank you, Karl and Donna.

(Applause.)

DR. CLARK: We should move into our next topic. Another topic of interest
expressed at the last Council meeting was to examine CSAT\'s efforts
with regard to co-occurring disorders. As you know, this is one of the
redwoods, one of the four major issues of concern for Mr. Curie and
SAMHSA. Joining us today to discuss this issue is Dr. Charlene LeFauve,
branch chief for the Co-Occurring and Homeless Activities Branch in
CSAT\'s Division of State and Community Assistance. Charlene is a
clinical psychologist who specializes in treating addictions and
co-occurring disorders for 12 years before joining the federal workforce
in 1998.

Her federal career includes policy, legislative and research experiences
at the National Institute on Drug Abuse, the White House Office of
National Drug Control Policy, and the National Institute on Alcohol
Abuse and Alcoholism. She came to SAMHSA last summer from the National
Institute on Alcohol Abuse and Alcoholism Division of Treatment and
Recovery Research, where she served as a program official for
pharmacotherapy and behavioral clinical trials research for treatment of
alcohol use disorders with co-occurring psychiatric disorders.

Charlene?

DR. LeFAUVE: Thank you, Dr. Clark.

I\'ve been sitting in the middle of the back area and I\'ve had a little
bit of trouble hearing today. So I told my colleagues I was going to
speak very loudly when I got up here. Not only that, I\'m the last
speaker, so I hope everyone is still excited and alert.

The phenomenon of co-occurring psychiatric alcohol and/or substance use
disorders is one that continues to challenge our nations, individuals,
spouses, children, families, communities, providers, payers, the
military, policymakers, legislators, the workforce, the research
community, and every aspect of our society is significantly impacted.

In my former role at NIH and in academia, I spent 100 percent of my
focus on the clinical management and etiological aspects of co-occurring
disorders. I have treated every variation and permutation of
co-occurring disorders across the spectrum of severity that one can
imagine: VA populations, inpatient locked units, detox units, outpatient
walk-in clinics, residential care, chronic pain management
narcotic-addicted populations, HIV/HCV, alcohol-dependent liver
transplant candidates, gay and lesbian populations with co-occurring
cocaine dependency and alcohol abuse and borderline personality
disorder, and I can go on and on. The list is not finished here.

But the point is I list this intentionally to illustrate a very
significant piece, and that is despite my experiences to date, I have
never been as challenged as I have been in my current position where the
pieces of the puzzle, all of varying sizes and shapes, are not fitting
together very well in terms of our understanding of how to address
service delivery issues and treatment challenges in real-world settings
across our nation.

I am excited to have this opportunity to address you all today, and I
want to thank Dr. Clark and Ms. Herron for their support and leadership.

During this presentation, you will hear a bit about the epidemiology of
co-occurring disorders and treatment, some data on homelessness among
substance abuse treatment populations, areas in which the field is
seeking guidance, and a description of some key initiatives in our
branch. I will also discuss SAMHSA\'s vision and CHAB\'s mission, and
close with some SAMHSA-relevant co-occurring programs that relate to our
collective vision and mission. The last section of my talk will not
include all SAMHSA activities that relate to co-occurring disorders,
only a few that are pertinent to our discussion.

This slide is an illustration to us all that the faces of co-occurring
psychiatric and alcohol use or substance use disorders are literally
everywhere. Unlike the homeless population, where more often than not
the presence of a person on a step or under an overpass or in a doorway,
on a park bench, or at an entryway to the transit system is evident, a
person who has had a lifetime struggle with, say, generalized anxiety
disorder and panic attacks and severe alcohol abuse or dependence could
be an associate sitting next to you in this room.

An undiagnosed dysthymic person with bulimia, chronic pain, and opioid
dependence could be anyone you see in an elevator during the day or at a
professional meeting, or working in a toll booth, or standing next to
you in a tailored suit at the airport. On the other hand, you can also
imagine that co-occurring disorders have the same faces as you and I.
They are the face of our nation, more than we may be able to truly
quantify if we look across the lifespan and across special populations.

Let\'s take a look at some of the data that has been recently published
to provide a snapshot of one piece of this puzzle. Twenty percent of
those persons surveyed in a National Epidemiological Survey on Alcohol
and Related Conditions, also known as NESARC, funded by the National
Institute on Alcohol Abuse and Alcoholism, 20 percent of those in this
general population study with any substance use disorder, also have at
least one mood disorder, and 18 percent have at least one anxiety
disorder. Twenty-nine percent of individuals with a current alcohol use
disorder, and 48 percent of those with a drug use disorder, have at
least one personality disorder.

Another data source tells us, in terms of our youth, those who are
incarcerated, one-half to three-quarters of those suffer from a mental
health disorder. More than half have substance use problems as well.
Four million adults sampled from our National Survey on Drug Use and
Health have a serious mental illness and a substance use disorder as
well. These are people 18 years and older. Illicit drug use is more than
twice as high among persons with SMI than it is for those who do not
have SMI.

Now, I have this one slide here on suicide just as a point of
information. This is a significant and serious public health problem
that devastates individuals, families and communities. In our nation in
2001, the latest Center for Disease Control study data show that 30,000
people committed suicide, and it is the eighth leading cause of death in
the United States in particular for men. Women report attempting suicide
during their lifetime about three times more than men. The point here is
to say that those people who use alcohol, who have a history of mental
illness, substance abuse disorders, or alcohol use disorders are most
consistently impacted by 90 percent of all the people who die by
suicide.

So those are the people who we see. Those folks with co-occurring
disorders are at greatest risk of committing suicide, and the protective
factors are to clinically treat mental illnesses and substance abuse
ahead of time to prevent suicide and to have successful encounters with
care.

In terms of treatment, 49 percent of persons with co-occurring severe
mental illness and substance use disorder received no past-year
treatment for either disorder. This is from our National Household
Survey data. Only 7.5 percent received treatment for both disorders.
That\'s a very small percentage. 40.7 percent of individuals who sought
treatment for alcohol had at least one mood disorder, and 33 percent had
at least one anxiety disorder.

Now, one dilemma we face as an agency ‑‑ I\'ve discussed this with Dr.
Clark and others ‑‑ is that 80 percent or more of people with
co-occurring disorders do not perceive a need for treatment. So we have
a lot of people walking around who don\'t perceive a need for treatment
even though they have a disorder, and there are others who don\'t know
they have a disorder. All their lives they\'ve been very, very nervous
in situations or having hyperarousal when they\'re just sitting in
situations in an unpredictable fashion, and they don\'t know that they
have an undiagnosed panic disorder. They\'ve been drinking or binge
drinking since high school, and they\'re now 50 years old and finally
may realize they\'re undiagnosed.

Forty-three percent of youth in mental health treatment have
co-occurring substance use disorders. I know Sharon Amatetti gave a nice
overview of women\'s issues, but women in substance abuse treatment
report sexual abuse as children or adults, so that complicates treatment
of women as well.

Our branch also focuses on homelessness. Up to 50 percent of homeless
adults have co-occurring mental illnesses and substance use disorders,
depending on the study and the methodology associated with it. Nearly a
quarter of homeless substance abuse treatment admissions from our
Treatment Episode Data Set had co-occurring disorders in the year 2000.
That was of about 120,000 treatment episodes. Among homeless veterans,
one-third to a half have co-occurring mental illnesses and substance use
disorders, and among detainees with mental illnesses, 72 percent also
have co-occurring substance use disorders. So our criminal justice
system is overly represented with folks who have co-occurring disorders.

So we tried to think about what the field wants to know and the kinds of
questions we\'re getting from our grantees and when we attend various
and sundry grantee meetings and other meetings. One is what are the best
screening and assessment approaches. Again, if you don\'t know that
someone has a co-occurring disorder, you can\'t even begin to tackle the
problem.

What are the evidence-based practices for co-occurring disorders? How do
we pay for services given the complexities of the funding mechanisms in
our states and the problems with substance abuse and mental health
parity in the private insurance sector? How do we develop the workforce?
I was nodding vigorously listening to Karl White\'s commentary and his
presentation. Frankly, when I was in graduate school and was making a
selection for my postdoctoral training, I had mentors who really thought
I had a lot of promise, and they said don\'t go specialize in substance
abuse, whatever you do. You don\'t want to treat those people. Trust me.
Do neuropsychology. Do something else like forensics, but don\'t do
substance abuse.

This is real for a lot of people. That goes from counselors coming out
of high school all the way up through the professions into the medical
arena. It is not a popular area of expertise, and people who treat
co-occurring disorders or even attempt to do so suffer from burnout,
frustration, high recidivism of the clients, and a lack of pay that\'s
consistent with their skills, among other things. So I\'m excited to
comment that we are collaborating with Karl and Mady Chalk\'s shop on an
initiative to look at how we can improve the workforce in relationship
to co-occurring disorders with a small budget.

SAMHSA\'s vision for co-occurring disorders is to provide leadership and
direction in defining and transferring the latest evidence-based
practices, services and infrastructure to all levels of co-occurring
disorders in the service system. Our mission is to support that vision
by improving the quantity and quality of treatment services for persons
with co-occurring disorders and those at risk for homelessness and who
are homeless, serving as a resource within SAMHSA for state of the art
treatment interventions, approaches, science-based evidence for
co-occurring and homeless issues, and collaborating with our sister
centers ‑‑ Anne used that term earlier; I like that ‑‑ collaborating
with our sister centers, CMHS and CSAP, to forge a SAMHSA-wide effort to
address co-occurring disorders.

This happens through our co-occurring work group, through the matrix
model, and just through our linkages and out of necessity. We have to
work together.

We also provide policy and planning. We fund contracts. We conduct
information dissemination and work to develop tools, like through the
Treatment Improvement Exchange, some TIE communiques or something that
we\'ve been discussing as a possibility, and other relevant review
articles that would be helpful to the states and to the field.

Our initiatives that I\'m going to briefly describe include the COSIG
grants, which are Co-Occurring Sate Incentive Grants, Co-Occurring
Targeted Capacity Expansion Grants, quadrant validation and screening
instrument, quadrant operationalization, and homeless initiatives. I\'ll
start with how we are trying to operationalize SAMHSA\'s vision.

This is through our Co-Occurring Center of Excellence. In the
Co-Occurring Center of Excellence, there are a number of functions and
activities, one of which is to provide technical assistance to the COSIG
states, and the funding for the COSIGs is in collaboration with CMHS. We
support grantees and systems change and infrastructure development. We
support grantees in overcoming service delivery barriers, such as
standardizing screening and assessment tools and developing issues in
terms of workforce development and credentialing. This is a function of
the COSIG itself, and the COCE assists in that process.

We enhance service coordination, improve financial incentives, and share
information among stakeholders. Right now there are 11 grantees, and
four new grantees are being managed by CMHS, and they are being awarded
this year, in \'05.

The quadrant model. I have it here because it\'s a key aspect of our
mission in terms of identifying ways to improve systems of care for
folks with co-occurring disorders who fall into different parts of this
quadrant, and it was developed as a framework conceptually by some
researchers in collaboration with NASADAD and NASMHPD to provide a
mechanism to address symptom severity and level of service coordination
on a continuum from less severe to more severe disorders, and from a
consultation and collaboration to integration model, respectively. It\'s
not intended as a way to classify individual clients or diagnose them.
Rather it displays sort of the universe of individuals with co-occurring
disorders and just is supposed to be a tool for the field and service
providers to figure out what would be the best approach to care.

Although the quadrant model is a valuable conceptual tool, the
population systems and services are presented only in general terms. So
we do have a project that we\'re working on now to develop more precise
and clinically useful descriptions of each quadrant, and look at the
clinical and diagnostic characteristics of each quadrant, and identify
appropriate clinical interventions, and consider how services are funded
in each quadrant, and identify funding opportunities and barriers
associated with those quadrants.

Also, we have a contract managed by Rick Ries at the University of
Washington to use large existing data sets of persons receiving a
systematic assessment of substance use and mental disorders. The goal
primarily is to assess or test the assumptions of the quadrant model and
to develop a clinical screening instrument.

A second mechanism that we are using through the COCE and as a branch to
improve care of co-occurring disorders is the Co-Occurring Policy
Academy Model. The objective for these academies are to develop state
action plans to enhance the provision of services to persons with
co-occurring disorders. To date, we have conducted two, one in Baltimore
last year, one in D.C. this January, and we have another one coming up
in Philadelphia. We\'re also exploring the possibility of a national
summit on co-occurring disorders for American Indian and Alaska Native
populations.

Dr. Clark has already praised and talked about the TIP. I will say
nothing more other than the fact that we are working very closely with
the co-occurring matrix work group and Kathryn Power and Elizabeth Lopez
and Mark Weber\'s shop to identify user-friendly digestible bites of TIP
42 that would not be functional as weight-lifting equipment that might
be targeted to primary care. I\'ve heard primary care mentioned quite a
bit today. We hear you. We are exploring that, and we intend to target
them and other medical ER frontline personnel.

The COCE mission is to receive and transmit advances in science and
advances in evidence-based treatment for co-occurring disorders, and to
guide enhancements in infrastructure and clinical capacities, and to
foster the adoption of evidence-based practices. There are core products
and services associated with the COCE that you will see on our website,
which I\'m going to show in the next slide. There are overview papers
and technical reports we\'ve produced that are on the web. There\'s TA
and training that some of you may have experienced through your linkages
through the states. There\'s the COCE website I just mentioned. We do
meetings and conferences. I mentioned the policy academies, and we\'re
involved in a pilot evaluation of measures for the COSIGs to look at
performance management issues.

Here\'s a snapshot of the website. It is a reservoir of information on
co-occurring disorders and provides linkages to other very valuable
sources and to our other federal partners.

This is a list of our COCE overview papers. They\'re covering pretty
much the gamut, as you can see, and providing sort of an overview of all
the experts in the field of co-occurring disorders and services as it
relates to these areas: definitions, workforce, systems, prevention,
evaluation and monitoring, screening and assessment.

We have a COCE steering council that has membership from all of these
organizations, and we work very closely with the Division of State and
Community Assistance in collaboration to achieve the missions I\'ve
described here. How do we do that? Well, through the substance abuse
prevention and treatment block grant. We collaborate in terms of the
policy academies, providing targeted technical assistance. We work with
the state systems development program, and I mentioned the Treatment
Improvement Exchange earlier, and we also have some alliances being
built in terms of rural and frontier, special populations such as
trauma, women and families, HIV, Native American and Alaska Native.

I\'m going to just comment very quickly on NREPP. This is not housed in
our branch, but it is a National Registry of Effective Programs and
Practices that is very relevant to what we\'re doing as we try to
identify the best approaches for co-occurring disorders. This is a
resource that has been around since 1998, and CSAT has initiated its
involvement in 2003.

It\'s an integrated part of our science to service piece, and potential
promising programs or programs that people feel would be a model program
for service delivery and treatment effectiveness are reviewed through a
rigorous scientific review process. In the end, there\'s a determination
of whether the program is promising, whether the program is in a
particular stage of development and that others can benefit from it.

Another piece of what we want to make sure is important for co-occurring
is to look at systems-level approaches. Systems of care for people with
co-occurring disorders have to be comprehensive and involve multiple
systems. You all know that. Also, key precepts of systems integration
include successful systems, and it can occur only when a comparable
emphasis is placed on integrated services. It doesn\'t need or require
necessarily the creation of new services but rather existing agencies
coming together to form a seamless program, and it can be measured both
at the systems level and in terms of client-level outcomes. This is
about improving people\'s lives.

How do we sustain the momentum of our programs in CHAB and SAMHSA?
Continued collaboration within SAMHSA and across our centers, working
with those of you in the room who represent state authorities, county
authorities, tribal authorities, NASADAD, NASMHPD, NACBHD, which we
heard from earlier, and our other federal partners. Working with
provider organizations, client-consumer advocacy groups, and so on are
key to our success.

I\'d like to acknowledge everyone in my branch and thank Bryant Goodine,
George Kanuck, Jim Herrell, Joanne Gampel, Edie Jungblut, Ali Manwar and
Kirk James for their input into this presentation, and I\'d like to open
the floor for discussion. Thank you.

(Applause.)

MR. KOPANDA: Thanks, Charlene.

Are there any questions?

DR. MADRID: I want to thank you for the excellent presentation. I do
have a question.

The chemotherapy involved in dealing with the multiple diagnoses of
individuals coming into treatment, what type of work are we doing
concerning medication, the administration of the different types of
medication, the funding of the different types of medication? It\'s real
tough for me as a service provider ‑‑ for example, a criminal justice
contract, \$58 a day residential treatment, an individual coming in that
has three or four diagnoses requiring a lot of medication to just
stabilize so that we can begin the work. What direction are we taking to
address that particular grassroots issue?

DR. LeFAUVE: Thank you for that very penetrating question. Actually,
I\'m aware of some activities in Bob Lubran\'s shop, collaborating with
NIAAA in terms of medications for the treatment of alcohol dependence
and the buprenorphine. But specific pharmacotherapies targeting
co-occurring disorders is a conversation that we will continue to have.
We don\'t have, to my knowledge, an active program in CSAT that targets
pharmacotherapies to treat co-occurring disorders specifically. We are
presenting at the American Psychiatric Association, and Kenneth Hoffman
is in the room. He is our new medical officer under Bob Lubran\'s shop,
and I am happy to have him offer any insights into your question given
that this is his primary area of expertise.

Dr. Hoffman?

DR. HOFFMAN: Thank you. I\'m new into this. Certainly I\'ve jumped right
in to look at, first, the ones that are geared specifically toward the
treatment of addiction, medically assisted treatments. And you\'re
right, we\'re moving into looking at the alcohol issues. CMHS has also
come up with an evidence-based co-occurring disorder. So I suspect with
Mady, we\'ll be looking to work more with them. Certainly in the field
at this point there\'s a lot of use of the various antidepressants,
antipsychotics, anticonvulsants, mood stabilizers with people that have
these disorders, and I think this is probably a good time to start to
judiciously sort out where these different things might fit given that
you inherit a lot of people coming in for addiction treatment who might
not have been diagnosed, been overwhelmed with this other substance and,
by the way, they\'ve gotten all these other psychotropics.

So I think there\'s two avenues to approach at this point, and this has
to be, I think, integrated into the work that you\'re doing.

DR. LeFAUVE: Thank you.

Dr. McCorry?

DR. McCORRY: Thanks, Charlene. Thanks for the presentation. You\'ve
given me some homework here in terms of looking at the COCE overview
papers, which I haven\'t done. So I have a lot of reading to do once I
leave the meeting.

Also, I was really happy to hear and pleased to hear about Rick Ries\'
work in populating the quadrant, because my questions are somewhat
related to that. I do this work back in New York, and my issue as I see
it, and I\'m just hoping you can comment on it for me, that the term
\"integrated,\" which is on the dual diagnosis lists that SAMHSA puts
out, and those are wonderful lists ‑‑ you can from clinical through
systems stuff. But whenever you talk co-occurring disorders, when they
talk about integrated care, it very quickly becomes a discussion about
the seriously mentally ill. But there\'s integrated care needs within
the substance abuse treatment system.

So sometimes it\'s difficult or it\'s not quite clear what the model is
for integrated care within the substance abuse service system, which is
actually treating the majority of people with mental health issues, not
the seriously mentally ill but the wider population of people who have
mental health issues, depression, anxiety, personality disorders, but
don\'t rise to the threshold of seriously mentally ill.

Second to the integrated is the issue of coordinated care, which is
talked about in the SAMHSA report but you almost never hear about it in
terms of models, in terms of actual functional models of what
coordinated care looks like between two systems. So I want to add one
thing and then ask you to comment on it.

My thought around an integrated service delivery model for AOD involves
clinical supervision, probably a little bit more psychiatric nursing
care, some case management off-site capacity, and probably some more
individual counseling capacity. Those are the four or five that I\'ve
been able to pull out of my work back in New York. I\'ve never checked
the evidence, if there is evidence, to say, gee, that makes sense or
not. But my concern is really more at a systems level.

One is the model. I\'d like to know if people have figured out what a
really effective substance abuse integrated program looks like. I\'d
like to know that, because then I could take it and try to implement it
in New York.

Secondly, I\'d like to know if there\'s models that have shown
coordinated care to work.

Third is this kind of more political systemic issue in which integrated
care almost invariably ends up being a discussion of the seriously
mentally ill, which leads our field to a one-down position, not that
their needs aren\'t great, but integration is typically defined as for
the seriously mentally ill despite the fact that most of the folks in
need of integrated care are on our side of the ledger.

So again, a long speech again, but I was wondering, either through COSIG
or COCE, are we kind of pushing through to that issue of what does it
have to look like in a New York program dealing with co-occurring
disorders, or Florida, or whatever program, that we could say this is
what you should be aiming for, this is what you\'re going to need, even
though you might be a long way from it but we know you\'re going to need
these kinds of things to treat the typical population of individuals
with both disorders who really belong on our side of the service system
because they\'re not seriously mentally ill but they are seriously
addicted?

DR. LeFAUVE: Thank you. Thank you very much for that question. I know it
probably sounded a little silly when I said thank you for that
penetrating question earlier, but I thought that was kind of funny.

But anyway, I\'m going to defer to TIP 42, and without identifying
particular scientists and particular models, I\'m going to say that TIP
42 does offer general guidelines and has chapters targeting particular
disorders that are very useful models for someone such as yourself, or
anyone in the nation, to at least attempt to approximate. Our NREPP, as
far as I know, has not right now identified a specific co-occurring
disorders program.

I do have Dr. Jim Herrell here, who sits on the NREPP committee, who
might be able to comment a little bit more about that piece. But to my
understanding, that\'s where we are.

Jim?

DR. HERRELL: Thanks. The NREPP program solicits persons to submit
treatment and related interventions that they have reason to believe are
good, and then they have to demonstrate that they have an evidence base
to back it up. As of now, the really small number of co-occurring
focused programs are all specific interventions. They\'re not systems,
they\'re not integrating a variety of levels of services. They\'re
pretty focused interventions. The actual research on integrating
services is much harder to do than kind of individual focused things. As
you probably know, even to the extent there\'s an evidence base, it\'s a
little bit fuzzy on whether integration really improves the quality of
service, depending on how integration is funded. You\'ve got a long,
long way to go on that.

DR. McCORRY: One follow-up. Have the COSIG grants yielded anything
around what it should look like on the AOD side?

DR. LeFAUVE: The COSIG grants ‑‑ actually, my whole branch is here. So
if they want to jump in, please do. But the COSIG grants at this stage
are not at that point where we have an answer to that kind of question.
I think we\'re in year ‑‑ let me defer to Jim. Yes, year 2.

Jim, please, step up to the microphone.

In short, the answer is not yet.

DR. HERRELL: The COSIG grants are also ‑‑ the acronym is co-occurring
state infrastructure grants. They are not even required with our money
to provide treatment, although many of them choose to do so. They\'re
specifically to reorganize the way they provide services. Some of them
are doing pretty good studies of what they\'re doing. So we hope to get
some evidence from it. We\'re doing at two or three different levels a
multisite evaluation of the COSIG program to try to learn generalizable
lessons, but nothing yet. Just anecdotes so far.

DR. CLARK: Val, and then Ken.

MS. JACKSON: Thank you. Thank you for the presentation.

Maybe I\'m just not very knowledgeable. I mean, I\'m knowledgeable about
co-occurring, but maybe I\'m not knowledgeable enough about the field.
All day today I have heard references to the resistance and just coming
on of treatment centers being okay with utilizing pharmaceuticals and so
on to treat co-occurring disorders, as well as such things as
buprenorphine, and other uses too. But co-occurring certainly has been
here all day.

Do we know the percent of agencies across this country that utilize
pharmaceuticals that have an assessment system for co-occurring? I mean,
have we done a baseline here from where to go someplace? Because it
seems like I really like the work that I\'m hearing, but my mind always
goes how does it get to the field and how do we grow it? That\'s where
I\'m coming from. So what do we know, and how do we get that
information, and is it important to get that information?

DR. LeFAUVE: CSAT does not, or SAMHSA, as far as I know, does not have a
systematic data strategy or collection on aspects of pharmacotherapy in
co-occurring disorders. Bob Lubran is in the room and, Bob, I\'m going
to ask if you have any other knowledge to the contrary. It is an
important issue. I don\'t have a plan for you in terms of what next
steps would be in that area. I do know we are in dialogue with Ken
Hoffman and Bob Lubran. We are collaborating across divisions and
branches, and it is a very important issue. This is what I did before I
came here, was pharmacotherapies and behavioral therapies combined to
treat co-occurring disorders.

DR. CLARK: We actually do have something from our TEDS data about the
use of pharmacotherapy specifically for addiction, but not necessarily
for co-occurring disorders. It gets to be a complex thing. You saw Karl
White\'s data about the number of physicians that our system has. So
implicitly for the substance abuse program itself, that becomes a
problem because they don\'t have access. So they\'re either working in
coordination with the mental health center, where the prescriber is, or
they\'re trying to, like Gateway, attempting to prescribe its own
medication, and they encounter problems because, again, the cost of
medications is an issue.

That\'s something that we also have to acknowledge in dealing with these
co-occurring. But the substance abuse treatment program, to truly be in
the arena of co-occurring, as part of a no-wrong-door paradigm, you have
to have Medicaid eligibility in order to prescribe the medication.
Otherwise, what you\'re doing is getting compassionate dispensation from
the hardship prescription practices from the drug companies, which is
not a good way to build a strategic approach to dealing with the
medication needs of your patients.

So that is one of the limiting steps. Those programs that have access to
both state funds and to Medicaid for psychiatric care, then it\'s less
of an issue. Under many jurisdictions, as Frank pointed out, in order to
be eligible for mental health funds, you have to prioritize the severe
and persistently mentally ill. That goes beyond SMI. Oddly enough, under
the mental health block grant, all you need is SMI. But states, through
their statutes, have often refined down the population served to severe
and persistently mentally ill, which means if you have a depression of
some six-month duration, you might not make criteria. Nevertheless, the
substance abuse treatment program is coping with somebody who is
suicidal or depressed enough so that they\'re disabled. Some
jurisdictions go so far as to say you need to be psychiatrically
disabled for a year in order to meet criteria.

So there\'s wide variation. What we\'ll be doing with the COCE and the
COSIG and the other centers within SAMHSA is getting a handle on these
matters. The NESARC data also show that some 40 percent of the
individuals who present to substance abuse treatment have a co-occurring
anxiety disorder. The conundrum is how do you treat that anxiety
disorder, or does it merit treatment? We know from a recent RAND study
that both depression and anxiety disorders subside with the provision,
oddly enough, of substance abuse treatment.

The beauty of being abstinent, guess what? A lot of the symptoms, they
may not completely go away, but they\'re manageable, especially with
cognitive-behavioral strategies. So medication should be part of the
armamentarium but should not be the objective of the intervention. What
should be the objective is a return to functional care, and we use
whatever strategies will assist us in achieving that, and sometimes
medications are not warranted.

MR. DeCERCHIO: The feedback that I hear from our providers is that the
financing of psychiatric medications is a very significant issue. Many
of our providers have psychiatrists and have doctors, but it\'s
increasingly becoming an issue of how to finance, and it\'s increasingly
coming to us. We did a small budget issue, \$150,000 for a drug program
to give small grants to programs for medications. One of our large
co-occurring centers I think came and needed another \$30,000 alone
because of the increased medication costs. Folks coming out of county
jails have three days of medication in their transition from a drug
court into our treatment centers, and if they\'re on medication, we\'ve
got to pick up that tab right away.

I hear more about that than I do, gee, Ken, how come you\'re not funding
buprenorphine, or we need more access to naltrexone. I hear this is the
issue more and more in terms of financing medications. You mentioned the
drug companies, and I know it\'s not ideal, but perhaps we\'ve got to do
a better job of connecting our providers to even some of that to help
with their situations.

DR. CLARK: I think what this Council can do for our co-occurring and
homeless branch is to reiterate these themes and examine what it is that
we do in light of your experience in the community so that our message
to the larger SAMHSA discussion is to address some of these components,
particularly when you\'re dealing with the severe and persistently
mentally ill. The key issue is adherence to medication, and as some of
my patients in the past have said, well, you know, why did you stop
taking your medications? Well, I\'m not stupid, you can\'t take this and
drink at the same time. So they drink and don\'t take the psychiatric
medication, and then, of course, decompensate.

So what we need are cognitive-behavioral strategies to facilitate
adherence. Nevertheless, those issues need to be addressed, and they
need to be addressed in concert with the mental health delivery system
because we need to know what the limits of the mental health delivery
systems are in the context of how do we pay for care and what are we
going to use.

We know from the disability point of view that a lot of our clients are
not recognizably disabled. Because of active substance use, they don\'t
meet criteria for SSI determination of disability, which means again no
Medicaid eligibility, which means no medication. So you\'ve got a person
who, because of active substance use, does not meet criteria for SSI
disability determination and yet who has a psychiatric condition that
lends itself to medication intervention. So these are ongoing issues.

Eric?

DR. VOTH: Well, and I think it\'s reasonable even further upstream, to
HHS, to say that we are pointing out again and emphasizing a need for
affordable psychiatric medications at all levels, whether that means
governmental support, whether it means negotiating with drug companies,
whether it means new R&D. If you track the cost of new psychiatric
medicines, it\'s staggering. SSRIs came on the market and they were
considered expensive then. Look at the new mood stabilizing agents.
It\'s just phenomenal.

So we can highlight our concern in that regard. If the cost of some of
the new antipsychotics was a third, we\'d have three times as much
availability for people that need it.

DR. CLARK: It\'s an issue when you think you can pay \$10 a day for the
pill alone. So in practical terms, as we do systems development, when
you\'ve got a shortage of funds, the system is confronted with, gee, do
I pay \$10 a day for the medication or do I pay \$10 a day for the
behavioral intervention, including the ACT team? The ACT team is useless
without medication compliance, without the medication. So the ACT team
winds up getting chopped because I\'m forced to make a Hobson\'s choice,
and I choose to interpret ‑‑ my Hobson\'s choice is I prefer medication
over behavioral intervention because the medication acts as at least
some form of control.

So, yes, we need to develop strategies that address that issue, and we
need to make sure that we\'re working. There are 340(b) issues in
community health centers. There are formularies. There are a whole host
of strategies that can be mobilized. But the first thing we have to do
is use our existing resources to adequately highlight these issues.

Anxiety disorders and mild depressions may fall into sort of a gray
zone. How much medication do you need for mild depression and mild
anxiety disorders may not be that clear, but we do need a system that
will allow people who are managing the person, working with the person
to manage their condition to address this without risk of suicide and
risk of decompensation.

MS. BERTRAND: I want to thank you for your presentation. I\'m just
thinking, trying to wrap up all that we\'ve heard today. A lot of what
I\'m hearing ties back into integrating components into substance abuse
programs, whether it be this co-occurring disorder, and earlier you
talked about women\'s issues and the sexual abuse that people experience
and all of those things. I\'m on a committee with Kathy Nugent ‑‑ she\'s
not here now ‑‑ and we\'re putting together a technical assistance group
for July, and what I\'m really trying to encourage us to look at is a
lot of it ties back to workforce development in terms of designing
programs and finding ways to leverage other systems outside of the
substance abuse system, because many of them, we all know, tie back to
what we\'re all doing, whether it be children\'s issues and parenting
and all these things.

But a lot of directors and CEOs and professionals don\'t realize that
they have so much at their disposal if they would look outside of this
system. Healthy Start, Families and Children First in Ohio, \$50,000
here to support this treatment program in this area, and all of those
things tie right back into some of the things that we struggle with in
our programs. My other colleagues and those that work with me, I try to
encourage them to look outside of this system. What is impacting the
work that we do? If it\'s criminal justice, let\'s look at our criminal
justice department and try to leverage funding to support the work that
we\'re doing here and tie it all together, make a comprehensive program.

It takes a lot of work, but there\'s ways to do it. So I encourage us
just to keep looking at training professionals into thinking outside of
just this particular profession, because we have so many other systems
that are impacted by the work that we do.

MS. JACKSON: Can I say one last thing?

DR. CLARK: Yes, Val?

MS. JACKSON: You know, I think that that\'s exactly right. I like that
you\'ve mentioned the workforce development and the slide that was up
there that looked at the percentage of physicians, PAs and so on that
are in our centers. I still have to say that our agency has physicians
and we have a full-time PA, and we do prescribe and go chase down
medications however we can ‑‑ that\'s definitely a problem ‑‑ when
they\'re needed.

But we have a lot of people. If you look at the agencies that are like
ours, we have a lot of people that have much more serious mental
illnesses than mild depression or anxiety. We have bipolar, we have
borderline, we have schizophrenic, we have any number of those, and they
are coming to our door because evidently they\'re not getting what they
need at a mental health door or some other door. Probably some of that
has to do with the entire behavioral health medical system that we have
now.

So we are faced with treating that, and I think that we have to find
ways to get not only the medications but the proper people there that
can do that. Some of it comes from outside. I don\'t have any problem
with that. But when they\'re sitting in our front lobby, we need to do
something with them outside of expelling them and saying go down the
street and see if you can find something there. I really think it\'s
important.

DR. CLARK: Indeed, that\'s what the Co-Occurring Policy Academy and the
COSIG strategy and the COCE are trying to do, to make sure that we have
a no-wrong-door paradigm and to identify barriers to care. So if indeed
you\'re the first door that the person suffering with schizophrenia
presents and you treat that person, that\'s fine. But if that person is
being bounced to you because their substance abuse problem is deemed
\"out of control\" and they\'re not being treated at the mental health
center where otherwise they might be treated, that\'s not fine.

So our approach is to stress the need for integrated care, which
includes no wrong door. Wherever you present, the care model starts.
That might militate against the kinds of experiences that you\'re
having. Now, of course, we\'ve got to deal with consumer choice. Some
people may prefer to have a substance abuse problem, as opposed to being
deemed out of control from a psychiatric problem, and vice versa. So
again, we\'ve got these devices in place. It is a priority for the
Administrator. We\'ll continue to press for strategies that we can use
so that we can address these matters, and we need your input, whether
it\'s a matter of psychopharmacology, whether it\'s a matter of systems,
whether it\'s a matter that our policy academies are good or bad or
ugly.

These are the kinds of things that we have to sort through because, in a
sense, we are blazing new trails, and sometimes you don\'t get what you
want, but at least you\'re trying to get something for the people who
need care.

PARTICIPANT: Sometimes you get what you need.

DR. CLARK: Sometimes you don\'t get what you need either.

DR. LeFAUVE: Thank you.

DR. CLARK: Thank you, Charlene, and thank your branch for being here to
give you support and answer questions.

(Applause.)

DR. CLARK: Well, we are actually well into the Council roundtable, so
are there issues that you\'d like to address now or would you prefer to
address them tomorrow during Council roundtable? Are you roundtabled
out? Do you have another half-hour or not?

MR. DeCERCHIO: A quick comment. In your presentation this morning, I
noticed in the proposed budget some of the scaling back of the best
practices initiatives and potentially for \'06. A lot of good work has
been done with NIDA in bridging the gap and blending work, and NIAAA,
and just the counter to that potential budget issue is to continue that
work. I think it\'s having an impact and it\'s reaching down into the
providers of the Clinical Trials Network. The only way we\'re going to
counter that is to continue that type of work. I don\'t know if we\'ll
counter it per se, but there\'s research money, there are initiatives,
and then being able to link back to us through you and through states
and directly to providers is going to become increasingly important as
we all have increased expectations for the use of evidence-based
practices.

It\'s just an observation on my part. A lot of good work has been done
by SAMHSA and you in connecting with the branches, but it\'s obvious
it\'s going to have to continue as the distinction between research on
the one hand and services on the other seems to be kind of being made
again.

DR. CLARK: Val?

MS. JACKSON: To kind of follow up on that, and I think very relevant to
it is that two or three weeks ago, I think at the recommendation of CSAT
SAMHSA, I was asked to attend a NIDA meeting ‑‑ Melody Heaps was also
there ‑‑ that discussed really that very thing, Ken, in terms of how,
looking from NIDA\'s perspective, do they get sustainability of their
evidence-based practices and be able to actually get them into the
centers and get them into standard practices.

The Clinical Trials Network is obviously one approach, but they were
looking at other ways and from other divisions of NIDA. One of the
things is there was a SAMHSA representative there sent by Dr. Clark who
I talked to. Science to service came up, and I requested Dr. Stein to ‑‑
that I think probably SAMHSA has a lot to contribute in terms of ‑‑ they
were saying what do you want researched, and the answer in my mind was,
hey, you ought to go over and talk to CSAT and CSAP and CMHS because all
of us who are out here doing services could tell you a lot of questions
we\'d really like to get answered. We mentioned lots of them today, and
we just got done talking about the co-occurring issue.

I don\'t know how that connection works really so much, but they were
very responsive and said, yes, that\'s a good idea, we should be talking
more, but I don\'t know what that really means.

DR. CLARK: Well, in all fairness to the NIH, we are talking. We have a
designated person at SAMHSA, Kevin Hennessey. We are actively involved
in partnership with NIDA and NIAAA and NIMH. Mr. Curie is in dialogue
with Dr. Zerhouni. But I think the institutes correctly want to talk to
service providers directly, not mediated through another entity.
Nevertheless, we talk to service providers because we\'re funding them,
and it\'s good that you have some exposure to the research enterprise,
because then when we have these kinds of meetings, you can confront us
with the activity of the research enterprise and the potential.

So I think that works well. It\'s a good mix. We try to sponsor to our
CPDB meeting, to NIDA\'s CPDB meeting, providers from the field so that
they can go see what\'s happening in the research arena, not for the
purpose of doing research but for the purpose of understanding what\'s
happening in the arena of science that might affect what it is they do
and how it is that they do business. In order to translate science to
services, people on both sides of the equation have to have some sense
of what\'s going on. It\'s an incremental and long-term proposition.

Mr. Curie is really chagrined that it takes so long to bring new
developments in the field to practice. NIDA just released a study on the
use of motivational incentives for methamphetamine and cocaine, and
it\'s taken them a long time to get around to finding paradigms that are
morally acceptable to the field. The real question will be will they be
adopted? So the research says this works, people stay in treatment
longer, they produce fewer urines that are positive for proscribed
substances. But the real question is, okay, now that we\'ve done that,
will it work? Because if it won\'t work, if it\'s not adopted ‑‑ it
worked in the laboratory, it worked in the controlled clinical setting,
but if it\'s never adopted by treatment providers, it doesn\'t work.

MS. JACKSON: Yes, and that\'s kind of exactly the point. A very good
example, actually, that we were talking about in that meeting is that a
lot of times what NIDA is researching ‑‑ and I\'m on one of the nodes of
the Clinical Trials Network, which I love and I value in great terms, so
I\'m not trying to be disparaging or critical. I\'m only saying that in
many cases, some of the studies that are being done, some of the studies
that get approved at the national level are practices that definitely
are evidence-based practices, but they are either too costly, they\'re
one-on-one individual versus group approaches, some things like that,
that really will probably preclude them from being used on a daily basis
down the line after the research is over.

Somehow, what I think we need to do is to take some of the practices
that we know work, we know either from our own experiences or from some
other evidence, and begin to get those into the best practices manuals,
and we need to look at some group approaches. I know it\'s very hard to
research groups, but NIDA needs to research group processes.

DR. CLARK: Well, they just figured out how to research acupuncture. So
if you can come up with a double-blind dummy study with acupuncture, you
can figure out how to research groups. They\'ve got some positive
results on acupuncture. That was one of the problems. How do you come up
with a blind for an acupuncture needle? If they figured that out, they
can figure out how to do groups.

But it is the dialogue that\'s important in my mind. I know Nora Volkow
is very much interested in making sure that health services research at
NIDA is done. The only question, of course, is how do you refine that?
We\'ll all continue to work together. She\'s sent her staff here; we\'ve
met with them. We\'ve had an ongoing relationship. It is not going to be
perfect, but the objective is to produce more in the way of things that
can be used. She, too, is concerned about the long lag time between the
evolution of an idea and the institutionalization of that idea.

From our point of view, for instance, let\'s take motivational
incentives again as an example. If it works, then how do we get the
field to adopt it? The issue is also getting the field to adopt it. We
can\'t say we have some practices that work but we don\'t want to use
your practices that work. We can\'t have it both ways. We want you to
research our practices and come back in 10 years and tell us that they
work. So you say, well, we\'ve been doing this for 10 years, it works,
would you mind adopting it? No, we\'re not interested. That gets to be a
conundrum.

I know you\'re not saying that, but these are some of the dynamics that
we have to compromise with at the interface.

MS. JACKSON: Doesn\'t SAMHSA limit the incentives to be something like
\$20 or something like that?

DR. CLARK: Well, that\'s the beauty of the most recent study. The
incentives actually turned out to be very minor, and the people
apparently did well just with the prospect of a chance of getting an
incentive. They didn\'t even need the actual incentive. There was
something about being valued apart from regular motivational
enhancement. These are people who are not guaranteed an outcome, and
then what they got as a reward was nominal. Maybe it has to do with
dopamine. Maybe it has to do with gambling. We don\'t want to ask those
kinds of questions. You\'ve got to be in it to win it.

But they were able to produce better results, they had fewer positive
urines, and they had greater adherence to the treatment strategy and
better retention. They got better results. So what do we say to that?
Exactly. We, in an applied sense, could probably do something similar to
that without being that disruptive. Is it that ethically or morally
repugnant that somebody uses a nominal incentive to get up that morning,
to go to group or to go to treatment and produce the kinds of results
that we want? We need a field that\'s going to be flexible enough
that\'s going to say, okay, we can do that, that\'s not such a bad
thing.

Frank?

DR. McCORRY: Just to go back because I had mentioned it earlier, and in
Rita\'s presentation earlier, whether the Council might in the future
want to look at the financing of the system. Ken and I were speaking
briefly about it. I had kind of raised it in terms of Medicaid. But
really, so many systems have stakes in our system of care in terms of
our outcomes. Public welfare, public safety, health care, social
welfare, they all have stakes in what happens to our clients, and Anita
said it. Well, I get \$50,000 from here, and then something over there,
and providers kind of cobble together these systems that are bigger than
what you get from the single funding source of CSAT or SAMHSA.

I just think understanding that better and appreciating that better, and
then perhaps being able to advocate a little differently with these
other systems of care, having them recognize their stake in our system
of care, I thought it might be interesting over a few meetings to kind
of explore that a little bit, knowing that it\'s got to be very
individualistic by state, even below state level, but I thought it might
be an interesting thing to do.

DR. CLARK: We\'ll put that down and see what we can come up with and
consult with you.

Any other issues, dialogue?

(No response.)

DR. CLARK: If there are no other issues for today, we can bring this
meeting to a close. We will adjourn. We will return tomorrow. The public
meeting opens, although there doesn\'t seem to be any public left ‑‑ the
public meeting opens at 10:00 in the morning. The closed session is from
9:00 to 10:00, so we\'ll expect Council members here at 9 o\'clock.
We\'ll do some grant reviews, and then the public meeting is at 10
o\'clock.

So I\'ll see you in the morning.

(Whereupon, at 4:50 p.m., the meeting was recessed, to reconvene at
10:00 a.m. on Friday, May 20, 2005.)