SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Wednesday,

September 20, 2006

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

3746 Prospect Avenue

Cleveland, Ohio 44115

David P. Donaldson, M.A.

CEO

We Care America

44180 Riverside Parkway, Suite 201

Lansdowne, Virginia 20176

Bettye Ward Fletcher, Ph.D.

President and CEO

Professional Associates, Inc.

P.O. Box 5711

Brandon, Mississippi 39047

Melody M. Heaps, M.A.

President

Treatment Alternatives for Safe Communities (TASC)

1500 North Halsted Street

Chicago, Illinois 60622

IN ATTENDANCE:

Valera Jackson, M.S.

CEO

Village South/WestCare Foundation, Inc.

3180 Biscayne Boulevard

Miami, Florida 33137

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

Gregory E. Skipper, M.D., FASAM

Medical Director

Alabama Physician Health Program and

Alabama Veterinary Professionals Wellness Program

19 South Jackson Street

Montgomery, Alabama 36104

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

PAGE

Call to Order

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

Director, CSAT 7

Member Introductions and Activity Updates 9, 22

SAMHSA Update

Eric B. Broderick, D.D.S., M.P.H.

Acting Deputy Administrator

Assistant Surgeon General

Substance Abuse and Mental Health

Services Administration 15

Discussion 24

Recognition Ceremony for Retiring Members

David P. Donaldson, M.A., Valera Jackson, M.S.,

Chilo L. Madrid, Ph.D., Gregory E. Skipper, M.D.,

FASAM, and Eric A. Voth, M.D., F.A.C.P. 27

Director\'s Report

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 29

Discussion 45

Consideration of June 23, 2006

Council Minutes 52

CSAT\'s Alcohol Initiatives

H. Westley Clark, M.D., J.D., M.P.H., CAS,, FASAM 53

Gregory E. Skipper, M.D., FASAM

NAC Member 68

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

PAGE

Public Comment 75

CSAT\'s Alcohol Initiatives

Discussion 88

Proposition 36 Cost Study

Larry Carr, Ph.D.

Deputy Director

Office of Applied Research and Analysis

California Department of Alcohol

and Drug Programs 99

Angela Hawken, Ph.D.

Policy Analyst

Integrated Substance Abuse Programs

University of California, Los Angeles 101

Discussion 129

E-Therapy Update

Valera Jackson, M.S.

NAC Member 135

Discussion 142

Public Comment 149

Substance Abuse Treatment Services for

Individuals with Disabilities

Ruby B. Neville, M.S.W., L.G.S.W.

Public Health Advisor

Division of State and Community Assistance

CSAT/SAMHSA 153

Discussion 164

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

PAGE

Update on Screening, Brief Intervention, Referral,

and Treatment (SBIRT) and Access to Recovery (ATR)

Jack B. Stein, L.C.S.W., Ph.D.

Director

Division of Services Improvement

CSAT/SAMHSA 167

Discussion 177

Fentanyl Update

Melody M. Heaps, M.A.

NAC Member 179

Discussion 184

Council Roundtable 190

[P R O C E E D I N G S]{.underline} (9:12 a.m.)

DR. CLARK: All right. Although we don\'t have a quorum, I think we
should move forward. We\'re expecting Admiral Broderick here at
approximately 9:15. So I\'d like to get some preliminary comments out of
the way.

Good morning and I\'m delighted to welcome each of you to the 48th
meeting of the CSAT National Advisory Council. I hope you will find the
discussions today fruitful since I think the topics will be of interest.

This is a one-day meeting. So we\'re going to have a full agenda.

We also have public guests and we will address that issue later.

The first thing I\'d like to do is point out to the members of the
council that we really value your membership on the council and we
appreciate your input. Some of you will be rotating off the council as
of this meeting, and we hope you will remain encouraged and continue to
be a strong voice for the field because the problem we face with
substance use disorders is obviously very much real and ongoing and we
need your support. It is not only a domestic problem; it\'s a worldwide
problem for those of you who are embarking on worldwide endeavors.
That\'s you. Dave Donaldson is going off to visit the world.

So we will be hearing from Dr. Broderick shortly.

As you know, since we last met, SAMHSA has undergone a major transition.
Our former director, Mr. Charles Curie, tendered his resignation to the
Secretary effective August 5th. Dr. Eric Broderick has been serving as
Acting Deputy Administrator and will continue to serve in that capacity
until Mr. Curie\'s successor is named. He\'s essentially the steward of
the agency and he will elaborate on that when he comes down. He has been
in the federal service for over 20 years and is an adept administrator,
and we welcome his contribution.

But as I said before, I really can\'t overemphasize your role as members
on our National Advisory Council. I thank you for adjusting your
schedules to attend this meeting and for the advice that you provide. We
are here because we\'re all familiar with the problem of substance use
disorders and its major complications. The expertise you bring with you
enriches our discussion, facilitates the way CSAT reaches its goals.
Some of you have got particular areas of expertise and we have attempted
to exploit that for the benefit of the field in general.

So why don\'t we take a couple of minutes to allow members to introduce
themselves so that not only all of us will know each other again and
familiarize us with any new projects that you\'ve pursued since we last
met and also so that those in the audience can know you better. So why
don\'t we start off with Anita.

MS. BERTRAND: Good morning. My name is Anita Bertrand from the Cleveland
area.

No really new projects other than just real busy with Recovery Month
activities. We had a banquet on September 7th and Dr. Clark was able to
come up. We are getting really good feedback regarding that event.

I participated in a race/walk this past Saturday with, I think it was,
40 across the country and walked 3.5 miles. This Saturday we\'re going
to have a motorcycle ride for recovery, and we\'re expecting over 100
riders and our mayor of Cleveland and one of the commissioners.

So just keeping busy with Recovery Month and typical treatment and peer
recovery support services activities.

DR. CLARK: Dr. Skipper.

DR. SKIPPER: I\'m Greg Skipper and I am a physician. I run the Physician
Health Program in Alabama for troubled doctors. Recently I\'ve been
involved in a national study of physician health programs to ferret out
ultimately, hopefully, are they as successful as reported and what makes
them successful. We\'re hoping to see some activities of those programs
that might be translated into the general treatment world. So that\'s
been exciting. It\'s a study funded by the Robert Wood Johnson
Foundation.

I\'ve also been heavily involved in more or less serving as a consultant
for the ethyl glucuronide issue that\'s developed nationally, and I\'m
happy that there\'s an advisory coming out from SAMHSA. I\'m being
contacted probably 10 to 15 times a day now by people around the country
that have been affected by this.

So glad to be here.

DR. CLARK: Dave?

MR. DONALDSON: Thank you, Dr. Clark. I just want to say that this will
be my last day. I want to thank you for your leadership and your
effective team, Cynthia and George, Jocelyn, Clif. It\'s just been a
great pleasure and wonderful experience to serve with you.

As you mentioned, my world has changed. I\'ve been spending most of my
time overseas working in Africa, relief and development, and then also
helping the victims of the war in the Middle East.

But, again, I just want to say thank you. You and your team have been an
incredible catalyst for engaging the faith community that has certainly
spilled over into other agencies. I\'m looking forward to seeing that
built upon in the days ahead. Thank you.

DR. CLARK: Thank you for your contributions.

Val?

MS. JACKSON: Good morning and thank you. I appreciate being here.

I think outside of my regular duties, I might mention that I have been
very busy being involved with the privatization of services in Florida,
that is, the Department of Children and Families putting out money to,
for instance, Miami-Dade County, which is the largest district in
Florida, and allowing the South Florida Provider Coalition, which is a
not-for-profit organization, to be able to distribute the money. The
hope with that is that there will be more time for state agencies to
look at policy kinds of issues and also more participation in the
community in terms of being able to look at the issues, implementation
of evidence-based practices and consortium training, those kinds of
things that are really beneficial to a community in providing treatment
and prevention. So as chair of that organization, I really have been
excited about the prospect of that.

Thank you very much. I appreciate being here.

DR. CLARK: Thank you.

Frank?

DR. McCORRY: Good morning. My name is Frank McCorry. I want to tell you
about a couple of things that are going on both in New York, as well as
some other stuff that I\'ve been involved in.

One is I was able to attend, I think it was last week, the Medicaid
invitational conference, and I thought that was really a terrific thing.
This conference was put on by SAMHSA, as well as CMS. We bring together
mental health providers with substance abuse providers and leadership in
both fields, along with Medicaid directors. It gives us an opportunity
really to bring together the financing and the provider arms or the
advocacy arms, as well as the state bureaucratic arms and federal arms
of the substance abuse service system.

What struck me and something that I\'ve raised here ‑‑ but, in fact,
Cynthia asked me to do something this time, but I hope to do it in the
future ‑‑ is the need for just this ongoing, sustained dialogue with the
Medicaid community and the lack of a real financing model for substance
abuse services. It\'s interesting. We have a treatment model, and if you
go to NIDA and you look at what NIDA has put out around the principles
of treatment, we understand how to treat much better than we understand
how to pay for treatment. This forum, this Medicaid invitational
conference, I thought was an opportunity to start to advance that
dialogue. So I thought it was a terrific venue for a very important
discussion that I think really has to be sustained over the next few
years if substance abuse services are really going to move in and become
part of mainstream health care.

A couple of other things going on in New York. Our commissioner, Shari
Noonan, resigned. Fortunately, she\'s going to stay in the field,
running a provider agency in the Albany community, but in New York the
single-state agency is in its own transition period, as are the Feds.

A couple of other things. Washington Circle, which I\'ve been involved
in, is working on two new performance measures and we hope to specify
and pilot test them this year. One is around adult screening for alcohol
abuse in both primary, as well as other kinds of settings.
Interestingly, I just saw something come over the wire yesterday maybe
that Medicaid is going to pay for adult screening for alcohol abuse. We
hope to develop a performance measure that might fit that bill.

We\'re also looking at a performance measure to drive
medication-assisted treatment. To me, when you look at the lack of the
use of medication in substance abuse treatment settings, even though
they have been shown to be quite efficacious, it\'s really a tremendous
need. So we\'re hoping to develop a measure that will also conform to
some of the standards that are being developed through groups like the
National Quality Forum around medication-assisted treatment, and
hopefully, the ability to measure it will drive somewhat the interest
and capacity to deliver that service.

So thank you. It\'s great to be here. It\'s always great to see my
colleagues on the council. Maybe Dave will get a chance to tell us a
little bit about the work that he plans to do in Africa, which is
tremendously exciting.

DR. CLARK: Well, we will hold up with Bettye and Melody. We have Dr.
Broderick here. If you don\'t mind, Melody. Given his schedule, I\'d
like for us all to get a SAMHSA update.

Dr. Broderick is serving as the Acting Deputy Administrator of SAMHSA.
He is committed to advancing SAMHSA\'s vision of a life in the community
for everyone, as well as its mission of building resilience and
facilitating recovery. He has over 33 years of experience in the
Department of Health and Human Services and extensive experience in
health policy development, program assessment, and budget formulation.
Between 2002 and 2005, he served as Senior Advisor for Tribal Health
Policy in the Immediate Office of the Secretary, Office of Governmental
Affairs.

Dr. Broderick also has extensive experience managing public health
programs, focusing on mental health, substance abuse, and oral health
with the Indian Health Service.

His bio, along with each presenter\'s bio and the council members\'
bios, are in the bio document on the handout table, and I invite you to
pick, up a copy of the document.

Dr. Broderick.

DR. BRODERICK: Thank you, Westley. Hi. How are you all this morning?

As Westley said, my name is Ric Broderick. I\'m very comfortable if you
would call me by my first name. I don\'t stand on much pretense.

I\'ve been at SAMHSA a fairly short time, and I just take this
opportunity to come down and greet you and introduce you to me, not that
I want to talk all that much about myself, but I\'ve found people most
curious as to where I come from and how I came to be here. So I will
spend just a few minutes telling you a little bit about myself and add
to what Westley said.

I\'m a dentist by training. As you can tell, I\'m a member of the
Commissioned Corps of the United States Public Health Service. I get a
lot of questions about what does Assistant Surgeon General mean. It\'s a
rank. This is what it means. It\'s equivalent to a rear admiral in the
Navy. As Westley said, I\'ve been with the Department for some time.

I practiced in the Indian Health Service in clinical practice for about
12 years and then got advanced training in public health and since that
time have managed public health programs principally in the Indian
Health Service and, of late, the last four years in the Immediate Office
of the Secretary in a health policy role with regard to tribal affairs.
Indian communities is where I\'ve worked and what my principal focus has
been up to six months ago when I joined SAMHSA. Through an unusual turn
of events, I guess, I come to sit before you today as SAMHSA\'s Acting
Deputy Administrator.

As you commented, the organization is in transition. The SAMHSA
Administrator is a politically appointed, Senate-confirmed position.
That process is one that is underway, identification of a successor to
Mr. Curie. In that interim time, I see myself as the steward of SAMHSA
with the very capable help of Dr. Clark and our colleagues in the other
centers and offices.

So the process is one that you all are probably familiar with. The White
House Personnel Office, along with the Secretary of the Department of
Health and Human Services, undergoes a process of search and
identification of an individual who will ultimately be nominated by the
President, and that will start a process that will lead to Senate
confirmation. I can\'t tell you who that individual will be. If I knew,
I would tell you. And I can\'t tell you when that will be. If I knew
that, I would tell you that as well. But I understand that the
interviews are underway, and at the point in time that the President
identifies an individual, an announcement will be made and Senate
confirmation, as I said, will follow. There aren\'t that many
legislative days until the election, and it\'s unlikely that there will
be a lame duck session of Congress. It\'s difficult to say when the end
game will be over and we will have an administrator.

But suffice it to say that until that time we\'re very interested and
will continue with some enthusiasm pursuing the goals that you all have
helped us set. The SAMHSA matrix is a wonderful tool that allows us to
focus our energies and efforts collectively on the things that are
important. I\'ve had the good opportunity to talk about and learn much
about those goals from Dr. Clark and our colleagues. I\'ve very quickly
come to believe that it\'s the right stuff. So I try to assure people
that in this period of transition, the agency will continue along that
path. I have a strong belief that there\'s little to be gained,
especially during times of transition, doing things that cause an agency
to shift direction. I have no intentions of turning SAMHSA on its ear or
making dramatic personnel changes or anything like that. We will stay
the course and we will pursue it with energy.

The one thing that I\'ve observed over time is occasionally
organizations are prone to slow down a bit in times of transition
because who knows who the new Administrator is going to be and what his
or her priorities are going to be. We are, I think, collectively
committed to not allowing that to happen to SAMHSA in this time of
transition, to continue to stay the course, to focus on the priorities
that we have identified with the field and to continue our efforts to
serve the people who need our services so much. So we are, as I said,
committed to work with you in that way.

Thank you all for what you do. SAMHSA\'s councils are very important to
us. They provide an opportunity in a systematic way to obtain advice and
guidance from experts in the field and people who have a perspective
that\'s very valuable that we may not have. So I know it\'s something
that\'s not within the daily scope of the things you do and it may be an
inconvenience to come here from time to time, but it is very, very
helpful and I want to thank you personally for taking the time to do
that.

I\'ve had a number of people say, well, okay, you said the matrix is
important and the Redwoods are going to continue, but what is it that
really focuses your attention? Where is your passion? What is it that
you want to work on? I guess we\'re all sort of formed by our
experiences.

I have a lot of interest, because of the places that I\'ve worked and
the interactions I\'ve had with communities, in identifying where
SAMHSA\'s resources are applied and compared that with where the burden
of disease is. We know that both the application of resources and the
burden of disease are not homogeneous across the country. If you were to
take a map of the United States and lay out where those two things
occur, you see pockets. You see some places receive more resources than
others. Some places have a higher disease burden than others. To the
extent that there is neatness of fit there, that\'s a good thing. If
it\'s not, we need to figure out why and see what can be done. It sort
of leads us to issues of discussions of access to care. Is where the
disease burden occurs where access to care problems also occur? And what
can we do to improve access to care in general to substance abuse
treatment services, and in those areas where the need is highest, can we
figure out ways to improve access in those areas?

That sort of leads to a discussion of health disparities with regard to
substance abuse treatment. We all know that there are health disparities
with regard to substance abuse in general, and it\'s something that is
of great interest to me. As I\'ve said, I\'ve worked in Indian
communities for a long, long time. You all know the epidemiology of
substance abuse. The disease burden in those communities is great as in
other communities where there\'s a disparate amount of substance abuse.
So that is of great interest to me.

I worked in several small communities in very rural locations over the
past number of decades and saw firsthand the devastation that a
community goes through when there\'s an epidemic of suicide among very
young people. I worked in a community in Wyoming in the mid-1980s that
had a suicide epidemic, and 15 or so kids from age 8 to 15 or 18 killed
themselves over a year-and-a-half period. That community is still
devastated by that 20 years later. Virtually all of those involved
substance abuse. So issues of co-occurring disorders is of interest to
me and substance abuse prevention.

The intersect between public health and the substance abuse treatment
world is also an interest to me, how we involve public health providers
and primary care providers as sort of points of actually first contact
with folks or actually more contact with people who may need substance
abuse treatment than substance abuse providers and how we engage that
community in screening and referral. Very important. That stuff works. I
mean, I know as a provider myself that if someone came to me for
treatment, they weren\'t coming to me to have their blood pressure
screened, but I could very easily screen it and, if there was an issue,
refer them. That works with lots of different disorders, substance abuse
as well. So that is an interest of mine, all formed by my own
experience, quite frankly, as a clinical provider.

That\'s probably enough about me. I\'d most like to hear what the areas
of interest are for you. I know I interrupted two of you who were making
your opening statements and introductions, and I apologize for that. If
we could continue with that, that would be great. If you have any
questions for me, I\'d be more than willing to answer them and just tell
you that I\'m always interested and very accessible in things that you
all might have to say. Please feel free to call on me with any concerns
or advice that you might have.

DR. CLARK: Thanks, Dr. Broderick.

Does anyone have any questions of Dr. Broderick?

(No response.)

DR. CLARK: Then why don\'t we have Dr. Fletcher and Melody Heaps
introduce themselves and maybe you\'ll have some questions after those
introductions. Bettye.

DR. FLETCHER: Thank you very much, Dr. Clark. I\'m Betty Ward Fletcher.
I\'m from Jackson, Mississippi, and I\'m with Professional Associates,
Inc., which is a research and evaluation firm that does quite a bit of
evaluative work in the area of outcomes evaluation.

Two areas that are relevant here that I\'m involved with currently. One
is our firm, along with a local hospital, is sponsoring a training event
for pastoral leaders and the clergy on substance abuse treatment and
knowledge regarding available treatment resources. That is in
collaboration with the National Association of Children of Alcoholics.

The second area that I\'ll share with you that\'s very dear to me is I
was invited to teach a course in substance abuse intervention this
semester at the graduate level at the local university, and I am doing
that. We are using the treatment improvement protocols, which is a
tremendous resource. Students are elated simply because it\'s a document
that they can relate to very easily. Of course, it\'s cost effective for
them because they can get it off the Internet. But it has really proven
to be a real resource. So I commend those who have taken leadership in
developing those protocols because they are useful, they are being used,
and it\'s a tremendous resource at the local level.

MS. HEAPS: Good morning. My name is Melody Heaps and I\'m President of
TASC, which is an agency in Illinois that connects individuals in need
of treatment into treatment from the criminal justice system or the
child welfare system or other public systems.

Since the last advisory council ‑‑ David tells me that\'s our report for
today ‑‑ we\'ve been involved in a number of very exciting public
forums. The DEA opened its museum in Illinois. We were responsible for
helping bring it to Chicago and also to develop the local prevention and
treatment story as a part of that, and it\'s been a very exciting
endeavor.

In addition, the National Institute on Drug Abuse has hired us to
develop their training of judges, and we had a press conference in
Chicago to announce their principles for effective treatment in the
criminal justice system. I was able to get the mayor and a number of
officials there. It was at a police station. It was really kind of fun
with some recovering individuals, also related to the upcoming Recovery
Month.

We are involved in network building both as a result of what we do
naturally, which is to develop networks of treatment and partnership,
but also in response to ATR and SBIRT and ATR particularly in reaching
out to the new service systems, faith-based systems and other systems.
That\'s been exciting.

We are anticipating a major initiative. The focus as of late, because of
the numbers of individuals returning from prisons to our communities, on
reentry, I\'m very interested in shifting the focus back to no entry. So
we will, in Illinois, be really pushing for a major, major initiative to
look at both how one prevents, as well as what I call deter and deflect
individuals from either entering the system or further penetrating the
justice system so that we can look at no entry as actually one of the
reasons TASC was initially set up as a sentencing alternative mechanism.

We\'re also very involved in looking at research projects, developing
research projects with regard to buprenorphine and the criminal justice
system and community systems and medication support. So we\'re looking
forward to a very energetic year. Thank you.

DR. CLARK: Thank you. Are there any council members with any questions
of Eric?

MS. JACKSON: I just have a comment and perhaps a question of
clarification. You mentioned working in Wyoming and also identifying
areas that you see where the burden of the disease is.

I remember back. It must be in the \'80s, and maybe some of this is
still going on. I was working mostly with NIAAA, and there was a lot of
topographical sort of geographical work identifying hot spots of need. I
found that study that was going on at that time very interesting, and I
happened to live in South Dakota. I suspect you\'re familiar with Pine
Ridge, South Dakota where the average life span is 53 years old, even
today, a very sad situation. I grew up in that area. Now I live in
Miami, Florida where there is a whole different set of circumstances,
which I find also to be extremely serious.

I\'m very interested in your ideas of how do we really identify those
needs, those hot spots, which I think is extremely important. We need to
still serve, of course, the mainstream of America because it doesn\'t
limit itself to one spot or the other. Perhaps a little more
clarification on that I would really appreciate.

DR. BRODERICK: Sure. There\'s much information available from many, many
different sources about virtually anything one would want to know I
guess. But with regard to this field, sort of basic epidemiology tools
are available.

What I would like to explore ‑‑ I\'ve got this map in my head that I\'ve
not seen on paper anywhere ‑‑ is the ability to use a GIS approach. I
don\'t know how familiar you are with it. I don\'t claim to be an expert
by any means.

MS. JACKSON: I\'m not an expert.

DR. BRODERICK: Yes, me neither. But I know that they take data, and
they\'re not too concerned about data purity. Anything that can be found
goes into a GIS system and then you can map based upon multiple
variables. So if you want to know cancer deaths and interstate highway
systems, the software is such that it can map those two things out
relative to one another.

So what I would like to do is explore with folks who are expert in GIS
the ability for us to be able to map the epidemiology of substance
abuse. I suspect work has already been done on it, quite frankly. I
can\'t imagine that it hasn\'t. But to look at, quite frankly, also
mental health and look at then the overlay of resources that we know are
available to communities to combat those conditions, whether they\'re
SAMHSA resources or not ‑‑ there are many, many parts of the safety net
in play ‑‑ to try to figure out whether or not there\'s close
approximation or not close approximation with regard to where the
conditions occur. So it\'s not terribly profound, I don\'t think. It\'s
something that is a pretty fundamental public health approach to looking
at resource application as it relates to epidemiology and to find out if
the resources are being applied in a way that the most people will get
the most good.

MS. JACKSON: If I could just add one more thing. When we were dealing
with this back in the \'80s and working with the project that was an
NIAAA, it sounds very similar, a public health approach to that. I think
there were several factors on crashes. This was mostly on alcohol
crashes and, of course, cirrhosis, different factors that indicated high
density areas where alcoholism was rampant.

One of the issues was whether or not, like many things, if you have an
area of high density, is that epidemic spreading and do we need to look
at it from that factor. Also, of course, that lends itself into
prevention. So I would be very interested in your carrying on your work
that way. I think it\'s a great way to go.

DR. CLARK: Well, thank you. Dr. Broderick has agreed to linger for a
while while we attend to another item of business.

As you know, we have five members of the council whose terms end in
November. They are Dave Donaldson, Val Jackson, Chilo Madrid, Greg
Skipper, and Eric Voth. Dr. Madrid and Dr. Voth were unable to be with
us today. However, I think it\'s noteworthy this is the first meeting
that Chilo has missed since he became a member of the council, which is
a good thing.

I\'d also like to emphasize to retiring members that, although your term
officially ends in November, you may be asked to continue to serve as a
member of the council until your successor has been named by the
Secretary. To give you fair warning, this can take up to six months.

I especially thank you for your continued service on the council and the
times you\'ve adjusted your schedule to participate in these meetings.
It shows that you\'re committed to the field.

To all council members and members of the audience, including staff, we
also appreciate your support of CSAT and its efforts.

Now I invite Val Jackson, Dr. Skipper, and Dave Donaldson to come
forward.

As they come, Dave has informed us that he and his family are relocating
to Nairobi after the first of the year, part of his company.

Val claims to be semi-retired, but we don\'t know that to be a fact
based on her eternal comments.

And then Dr. Skipper, I think you\'re going to Portugal after this
meeting. Right? Yes.

So all these people who are making these life changes, we really
appreciate their contribution.

A plaque in each person\'s name signed by Dr. Broderick and me is dated
September 2006 reads as follows: \"With appreciation for your
outstanding tenure on the Substance Abuse and Mental Health
Administration\'s Center for Substance Abuse Treatment National Advisory
Council and gratitude for your tireless effort, support, advice, and
insights to the benefit of SAMHSA, Department of Health and Human
Services, and the people we serve.\"

(Applause.)

DR. CLARK: I want to thank Eric for taking this time out to give a
report for SAMHSA and for participating in our recognition ceremony.

DR. BRODERICK: Thank you and thank you all again for your willingness to
contribute your time and your expertise and wisdom to SAMHSA. We\'re
much the better for it. Thank you.

DR. CLARK: Now I will give the CSAT Director\'s report. This is going to
be an overview of some of the changes in CSAT and also a report on our
National Survey on Drug Use and Health. Not only have there been changes
in the upper echelons of SAMHSA, there have been internal changes within
CSAT. I\'d like to bring you up to date on what\'s occurred since our
last regular council meeting.

The Division of State and Community Assistance has lost three employees
to retirement: Terry Schomburg, Nita Fleagle, and Lonn Aussicker. Two
have moved on within the SAMHSA organization: Rick Dulin to the Division
of Pharmacologic Therapies within CSAT and Rasheda Stevenson to the
Center for Mental Health Services.

But it\'s not all losses. They\'ve also gained Alejandro Arias from the
Center for Substance Abuse Prevention, Juli Harkins from the Division of
Services Improvement, and Bryant Goodine from SAMHSA\'s MEO. Then we
have Ting Mei Chau, our newest emerging leader intern. The Division of
Services Improvement\'s new employees include its new Director, Jack
Stein. Dr. Stein is from NIDA and has joined us. He\'s currently without
a secretary, as Paulette Waiters has left SAMHSA, and he\'s recruiting
for someone to assist him in answering his email. Other DSI gains
include Natalie Lu and Dawn Levinson.

The Office of Program Analysis and Coordination has gained Danielle
Johnson, a transfer from the Division of Pharmacologic Therapies, and
also Shavonne Reed.

Lastly, my office has had its comings and goings. Stephen LeBlanc has
been detailed from Consumer Affairs to NIH. He was replaced by Hardy
Stone who has been detailed from CMHS. Rich Kopanda\'s new staff
assistant is Millie Nevels, and my new staff assistant is Dolkie, or
Dee, Encarnacion, who transferred from CSAP, replacing Elsie Fisher, who
left us for NIH.

So you can see there\'s a lot of intragovernmental movement. It\'s like
some kind of current stream. Sometimes it\'s like el nino, though.

(Laughter.)

DR. CLARK: So please joins me in welcoming all the new folks to CSAT and
to SAMHSA as a whole.

(Applause.)

DR. CLARK: During the time that CSAT was absent a Director of DSI, I
asked Anne Herron to be the Acting Division Director and, at the same
time, John Campbell was asked to serve in Anne\'s place as Acting
Director of the Division of State and Community Assistance. I just want
to say again how proud I am of these two individuals for their stellar
contributions in these \"acting\" positions. Their support and job
performance has been truly outstanding. Thank you, Anne, and thank you,
John.

Now on to other matters. We have a presentation to give. As you know,
SAMHSA recently released the 2005 National Survey on Drug Use and
Health. So I\'ll go up to the podium and present that slide show.

As you know, the National Survey on Drug Use and Health is an annual
survey conducted by our Office of Applied Studies. It surveys roughly
68,000 people nationwide.

You were provided a hard copy of this report, so you don\'t need to
write any of this down, and you can also get the full NSDUH report from
our website. So those in the audience also can have access to the full
reach of the data.

We know that slightly more than half of all Americans aged 12 and older
reported being current drinkers of alcohol. This translates to 126
million individuals. This is up from the 2004 estimate of 121 million.

More than one-fifth of persons aged 12 and older participated in binge
drinking, and this is five or more drinks on a single occasion at least
one day in the past 30 days prior to the survey. That translates to 55
million people. This is about the same as in 2004.

In 2005, heavy drinking was reported by 6.6 percent of the population
aged 12 and older or 16 million people. This is similar to the 2004
rate. Heavy drinking, of course, is defined as five or more drinks on a
single occasion for at least five days in the past 30 days.

Among young adults aged 18 to 25, the rate of binge drinking was quite
high, up to 42 percent. The rate of heavy drinking was 15.3 percent.
These rates are similar to 2002 and 2003.

When we look at the rate of current use among youth aged 12 to 17, the
current alcohol use declined from 17.6 percent in 2004 to 16.5 percent
in 2005, and this is a statistically significant drop. So youth drinking
has declined, but you\'ll notice overall current use in the age 12 to
20, which is an age range where drinking is illegal, it\'s basically the
same, and then 18 to 20 has remained basically the same. So we\'re
reaching our 12- to 17-year-olds, but the overall current use in that 12
to 20 range is basically the same.

Youth binge drinking for 12- to 17-year-olds has declined from 11.1
percent to 9.9 percent, but heavy drinking did not change significantly.
It\'s 2.7 percent in 2004 and 2.4 percent in 2005. Although these
declines in past month and binge alcohol use among youth 12 to 17
between 2004 and 2005, overall underage drinking remained essentially
unchanged in the 12 to 20 range.

In 2005, about 10.8 million persons aged 12 to 20 reported drinking
alcohol in the past month.

Among persons 12 to 20, past month alcohol use was 12 percent among
Native Hawaiians or other Pacific Islanders, 15.5 percent among Asians,
19 percent among African Americans, 21.7 percent among American
Indians/Alaska Natives, 24 percent among those reporting two or more
races, 25.9 percent among Hispanics, and 32.3 percent among whites.

In 2005, an estimated 13 percent of persons aged 12 or older drove under
the influence of alcohol at least once in the past year. The percentage
has dropped since 2002. There\'s a statistically significant drop
between 2002 and 2005. This 2005 estimate corresponds, though, to 31.7
million people.

This slide shows the distribution of DUI across age groups, and you
still see the peak at the 21 to 25. But you\'ll notice 18 to 20 is
actually quite high. It\'s one-fifth. 26 to 29 is 22.6. But it persists.
It doesn\'t really decline below 10 percent until you reach 55.

Illicit drug use. An estimated 19.7 million Americans aged 12 and older
were current illicit drug users, meaning they had used an illicit drug
during the month prior to the survey interview. This estimate represents
8.1 percent of the population aged 12 and older. This rate is similar to
that in 2004, and you can see the numbers there for 2003.

You\'ll notice, though, for illicit drug use, that there was a
statistically significant drop between 2002 and 2005 for the 12- to
17-year-olds, and I think that\'s an important thing. We\'ve made steady
progress in the decrement in use in that age group, and it\'s not clear
what specific intervention. We think it\'s a holistic thing, multiple
factors, and of course, parental involvement, media messages, faith
community, and perhaps prevention efforts are making headway.

When you look at the illicit drugs used, they include the range of
substances you see on the slide. You\'ll note that psychotherapeutics,
which are the nonmedical use of prescription medications, is the second
most prevalent area. We\'re quite familiar with marijuana and cocaine,
hallucinogens, and inhalants. I\'d like to remind people that this is a
substantial problem.

There are roughly 6.4 million people, or 2.6 percent of the population
aged 12 and older, who use prescription psychotherapeutic drugs
nonmedically. Of these, 4.7 million use pain relievers. 1.8 million used
tranquilizers and 1.1 million used stimulants. I think something that we
need to keep in mind is that nonmedical use prescription drugs continues
to be an issue.

There are 2.4 million current users of cocaine aged 12 and older, and
that\'s up from 2 million in 2004. It fluctuates a little but it\'s not
statistically significant.

Hallucinogens continue to be an issue at a lower level at 1.1 million
people aged 12 and older, including Ecstasy at 0.2 percent. These
estimates are similar to 2004.

The rate of use of inhalants by persons aged 12 and older is 0.3
percent, and that did not change.

The past month use of methamphetamine by ages 12 and older showed a
slight decline from 583,000 people to 512,000, but what is most striking
about meth continues to be its inexorable march from the West Coast to
the East Coast. Using our TEDS data, these are treatment episode data ‑‑
so we have a bit of a discontinuous presentation. The maroon indicates
148 admissions per 100,000; the red, 55 to 147 admissions per 100,000.
As you can see, the TEDS data shows 1994, and 10 years later, the great
Midwest has a tremendous number of admissions.

Even though the rate of use from the Household Survey data shows a
decline, the fact is, as our Household Survey points out, those people
who are using tend to have more problems and are presenting for
treatment. That shows you the sort of delay that occurs between those
people who use and those people who \"crash and burn\" and present for
treatment. So the delivery system needs to be prepared to handle the
individuals who present. Here\'s a sort of another vision of that, and
you can see the prevalence rate.

Now, the past month nonmedical use prescription type drugs by ages 12
and older reflects an overall increase from 2.5 percent to 2.6 percent.
Again, pain reliever is a major issue, but we also discovered something
fairly startling about the nonmedical use of prescription drugs. It was
assumed that a lot of people were getting their drugs from doctor
shopping and the Internet, et cetera. Well, it\'s turning out that when
you ask people where did they get their prescription drugs, most of them
got them from a friend or relative for free. So it\'s fairly startling.

This has actually been supported by other studies looking at stimulants.
As you know, college students are into stimulants now because it \"helps
them study.\" They regard them as smart pills.

So our data are showing that a large number of individuals, 60 percent,
are getting their pain relievers from friends or relatives:
tranquilizers, a little more than 60 percent; and the amphetamine
stimulants, about 50 percent.

And the key issue is, in terms of our education campaign, how do we get
physicians to begin to educate their patients and patients to understand
that prescription drugs might best be treated like if you have a gun in
the house: you lock it up and you don\'t leave it around for popular
consumption and you also don\'t share. But as you can see from the data,
this is an issue.

And buying drugs from the Internet is turning out not to be as major of
a problem as once thought, but of course it remains an issue and the
National Synthetic Drug Strategy is going to be dealing with Internet
purchases. I think as people get things from the Internet, not all
things that you buy from the Internet are what they claim to be, and
maybe that\'s one of the reasons people rely on friends and relatives
for their drugs because they\'re more likely to be what they claim they
will be.

For pain relievers, drug dealers are not big on prescription drugs. They
are a bigger source for methamphetamine and not for prescription
stimulants.

This slide indicates the illicit drug category is among the largest
number of recent admissions among persons 12 and older for nonmedical
use of pain relievers. It\'s obviously the largest category. These are
past-year initiates, and pain relievers exceed marijuana. Although these
estimates are not significantly different from the numbers in 2004, it
does remind us that there\'s an upsurge in the nonmedical use of pain
relievers, and we need very much to be aware of that.

When we look at the ages where people start using, we know that people
who begin using drugs and alcohol at a younger age are more likely to
develop problems as a result of their use. So we should be, of course,
concerned about that. We also note that the mean age of use of pain
relievers is 21. The mean age of use of heroin is 22. But inhalants,
PCP, and marijuana are at much younger. So we should be very much aware
of that.

So whatever efforts that we use to discourage people from using drugs
should continue. Again, there are questions about single strategies, but
I think, as Mr. Curie used to say, there are many pathways to recovery.
There are many pathways to communicating to the public about the dangers
of substance use.

In 2005, an estimated 22.2 million persons, 9.1 percent of the
population aged 12 and older, were classified with either substance use
or substance dependence. Of these, 3.3 million were classified with
dependence on or abuse of both alcohol and illicit drugs; 3.6 million
were dependent on or abused illicit drugs, but not alcohol; and 15.4
million were dependent on or abused alcohol, but not illicit drugs.

The specific illicit drugs at its highest levels of past-year dependence
in 2005 continued to be marijuana, followed by cocaine at 1.5 million,
but then you can see pain relievers continues to be the third most
commonly abused or dependent drug at 1,546,000, which is just barely
below the cocaine level. So I think in terms of dependence and abuse, we
need to be very much aware that prescription drugs have a high
prevalence.

So what we\'re seeing in this particular slide suggests that people are
doing more than just taking one or two pills. The problem with national
surveys is all you have to do is take one pill one time nonmedically in
the past 30 days and I\'m a current user. But abuse and dependence means
I\'m having problems. So these data say that even though you may
challenge them, because there are people who challenge the Household
Survey, you can challenge the magnitude of the problem, but the abuse
and dependence is not attached to mere use. It\'s attached to decrements
in function. So this particular slide points out that, indeed, we have
decrements in function.

Abuse and dependence by males continued to be significantly higher than
females in all age groups, something that we need to keep in mind. But
you should also note that those 12 to 17, the 7.8 and 8.3, is really
quite close.

And what about treatment? There are 3.9 million persons aged 12 and
older, or 1.6 percent of the population, who received some kind of
treatment for a problem related to alcohol or illicit drugs in 2005.
More than half, or 2.1 million, received treatment in self-help groups.
However, 20.9 million people did not receive treatment, and of the 20.9
million people in 2005 who were classified as needing substance use
treatment but did not receive treatment in a specialty facility, the
vast majority felt that they did not need treatment. This is where our
SBIRT strategy comes into play, and we\'ll hear from Dr. Stein later
about SBIRT.

The key issue is that we know that because of decrements in function,
that people are having physical, psychological, employment, or legal
problems as a result of their drug use. Yet, the overwhelming majority
of these individuals do not perceive a need for treatment. So we have to
identify individuals elsewhere, whether it\'s the emergency room, the
primary care setting, the church or religious setting, temple,
synagogue, what have you. The key issue is that somebody somewhere knows
that this person is having a problem, and even though this person says
I\'m having a problem, they don\'t endorse the need for treatment.

So the key issue here is that if everybody showed up to a treatment
program who truly needed it, our treatment programs would be terribly
overwhelmed. Many people talk about the waiting list, but the waiting
list is actually fairly minor compared to the large number of
individuals who need treatment.

From a public safety point of view, I\'ve always contended the engine
that drives the illicit drug market is the big red slice. I can\'t get
heroin and methamphetamine and cocaine from the 7-Eleven or the CVS, so
I\'ve got to get it from my dealer. I\'m less likely to turn my dealer
in if I\'ve got a problem with abuse and dependence and I can\'t get my
drugs from elsewhere. So I\'m less likely to do that.

I\'m fond of pointing out that the people who will remember moonshiners
‑‑ some of you my age can remember moonshining. You\'re less likely to
turn your still in to the revenuers if that\'s where you get your booze.
So it creates a public safety problem because then the attendant public
safety issues that go from drug dealing go unaddressed because people
are unwilling to rat out their dealers because, after all, they won\'t
be able to get their drugs. It\'s only the people who are ambivalent
about it who are more inclined to do something.

So of the 1.2 million people who felt they needed treatment for illicit
drug and alcohol use, only 296,000 made an effort to get treatment, and
865,000 reported they made no effort to get treatment even though they
felt they needed treatment. A key issue. People aren\'t always
motivated.

Of those people who made an effort to get treatment, the reasons for not
receiving substance abuse treatment. It\'s a minority of people, but for
that minority cost and insurance barriers play a major role, other
access barriers. Some are still not ready to stop using despite the fact
that they know they should stop using. And then while it is an issue,
stigma is, only at 18.5 percent, cited as a barrier.

I really think that we\'ve got our work cut out for us in dealing with
early intervention, and that is changing people\'s attitudes about the
misuse of psychoactive substances.

So we continue to have serious problems with alcohol and illicit drug
use in this country, and as we continue our discussions today, we will
talk about many things.

This slide shows you basically our budget because, despite the fact that
we\'ve got a problem, we also have to deal with the issue. As you know,
FY 2006 is almost over. We discussed the President\'s budget when we
talked last. The House and the Senate full committees have met, and
these are the numbers that you see for our budget. Our FY 2006 budget
was \$2.156 billion with \$1.76 billion going into the block grant and
the other into the discretionary portfolio. For the 2007 budget, the
President\'s budget, we had \$375 million in the PRNS line or the
discretionary line, with \$1.76 million going into the block grant, for
a total of \$2.134 billion. The House gave us roughly \$26 million more
than the President\'s budget. The Senate mark is \$3 million less.

The full House and the full Senate budgets do not continue the Access to
Recovery Program. So you\'ll see a reduction in funds to the Access to
Recovery Program in the Senate side and the House side. But what the
House did was to reallocate the money that was targeted for Access to
Recovery to the block grant. So you see in the budget a substantial
increase in the block grant. There\'s a \$30 million increase in the
block grant on the Senate side. So we are still trying to impress upon
the legislative process through official channels the importance of the
Access to Recovery initiative, so we\'ll have to wait and see what we
are doing.

SAMHSA is converting to a new HHS unified financial management system
for the new fiscal year. We\'ve already made our grant awards for FY
2006 and we\'ll be making progress to shift over to the new system.

As you know, we have mid-term elections coming up. This probably
indicates that we won\'t have a budget until the start of the new
calendar year. So we will probably be on a continuing resolution now.
There are reports that there will be a lame duck session, so it is
possible that we will have a budget as early as December. But this is
all speculation. The Congress moves on the Congress\' time table. We do
know that when they\'re in recess, there will be no business. So that
much we can count on. There\'s no business during recess. So there will
be a pre-election recess, and then if there\'s a lame duck session, they
may act on our budget. If not, we won\'t have a budget until the first
of the year.

You should know that both houses have agreed with the President on a
\$25 million methamphetamine program, but they would leave voucher
decisions to the states and the grantees. Again, we won\'t have any
final action on any of these budget issues until after the conference
when the House and the Senate get together and decide what they\'re
going to do.

We\'ve already begun our planning for \'08. In fact, we\'ve submitted a
budget to the Office of Management and Budget last week, and this is
going to be part of the process where we deal with the 2008 budget
request, which is going to be announced in February. So that process is
now well underway. So this is something I\'ve always found fascinating.
We don\'t have an \'07 budget, and yet, we\'ve got an \'08 budget in the
works. So we\'ll see what actually happens.

Are there any questions? Budget questions, Household Survey questions?

(No response.)

DR. CLARK: No questions. So very good.

MS. JACKSON: I have a question. Perhaps I should know this. It\'s on the
Household Survey. When the Household Survey is conducted, is it
conducted in different languages?

DR. CLARK: I don\'t know the answer to that. That\'s a very good
question.

MS. JACKSON: Can we find that out?

DR. CLARK: Yes, it\'s conducted in different languages.

DR. KOPSTEIN: At least in Spanish.

DR. CLARK: At least in Spanish. How about Hmong? No? Okay.

Thanks. That was Andrea Kopstein back there and she used to work on the
Household Survey, at least for OAS.

DR. McCORRY: Do we have, Dr. Clark, a sense of all dollars spent all
sources on substance abuse services in the country? Is there such a
figure?

DR. CLARK: Yes, we do. Is Rita back there?

MS. VANDIVORT: Yes, I am.

Yes, we do. SAMHSA does a report that looks at all public and private
spending on mental health and substance abuse. In fact, we\'re going to
be coming out, probably in the next two months, with our next report
which will be looking at the period from 1993 to 2003.

In addition, for the first time, the SAMHSA spending estimates is going
to look at projections and will be projecting the public/private
spending to major payers out to 2014.

DR. McCORRY: Rita, will that include criminal justice dollars, public
welfare dollars, HUD dollars? When you say public, it will include if
HUD is running a substance abuse program in some of their housing stock.
That would be included?

MS. VANDIVORT: It is hard to drill down to a lot of detail, and we try
to do specialized studies for that. We\'re right now trying to tease
out. We tend to look at the major payers, Medicare, Medicaid, other
federal, which includes our block grant, Defense. We look at private
insurance. We look at foundation funding and then self-pay.

We are trying to drill down more. We have had some studies, for
instance, looking at utilization in employer-sponsored, which clearly
indicates the decline in inpatient that we\'ve seen in the field, but
surprisingly also declines in inpatient. So we do a number of special
studies that try to drill down.

We\'re working right now with Rick Harwood to try to see if we can find
any good data around criminal justice. It\'s a very important area, but
unfortunately, the data sets don\'t seem to be out there to do the
quality work we like to do.

DR. CLARK: Melody.

MS. HEAPS: Well, certainly you\'d be able to get corrections department
dollars spent for treatment that they\'re sponsoring, institutional. You
ought to be able to get that relatively ‑‑

MS. VANDIVORT: The problem with corrections is the multi-layers. You
know, you have federal prisons, you have state prisons. We\'ve looked at
some of the prisons and what often happens is they have a health plan
which covers health services, but the substance abuse they often carve
out into a separate contract. You know these things. It is hard to
identify that in the data sets.

But I\'m not the expert. I\'m having my experts look at this, and I hope
to come back with something. Perhaps we can chat. If you have some
suggestions, I\'d love to hear them.

MS. JACKSON: I assume that also means that you have state general funds.
You didn\'t mention the state general funds, but that\'s easy to get.

MS. VANDIVORT: Yes, other state and local is the other category. I\'m
sorry if I didn\'t mention it. In fact, for substance abuse, it is the
largest payor. It\'s like 40 percent of all spending.

Now, again, we build, in the specialty area, off of TEDS, and we think
some of that state and local is probably criminal justice correctional
funding that they\'re paying for those providers. But the way that TEDS
is reported, we can\'t identify the segment that comes from corrections.
We know that referral sources, but not the dollars.

Any other questions? I\'ll stop trying to walk away.

DR. CLARK: All right.

MR. DONALDSON: Dr. Clark, I had a question. You say the Senate did not
want to approve ATR moving forward, or neither?

DR. CLARK: Neither the House nor the Senate included a voucher
initiative in their appropriation proposal. These are the full
committees.

MR. DONALDSON: What was their reasoning? Because I know, according to
your report, 48 percent more clients than were originally targeted. I
know a quarter of those have been the faith-based. I know we had a rough
start, but it seems like there\'s a lot of momentum. Why is that
sentiment there?

And number two, what are we doing to perhaps recoup it?

DR. CLARK: Well, the Congress moves in its own way. So their rationale
is not clear. One has to conclude that given the tight budget times, the
House decided to put the money in the block grant. The Senate decided to
limit the increases. So if individuals want to know the rationale for
the full committees, they need to talk to the staffers of those
committees.

The administration is having ongoing discussions with members of
Congress on both sides of the aisle on both sides of the Capitol so that
the hope is that they\'ll change their minds when the bill comes before
the full Senate or the full House. And then there\'s the conference. So
when the bill becomes before the full Senate, there\'s an opportunity;
the full House, there\'s an opportunity. Then there\'s a conference. So
the administration is discussing these matters.

Yesterday we met a number of staffers at a meeting that was convened on
Capitol Hill to inform the House and Senate staffers about ATR and gave
them the facts that you recited. ONDCP was present. We were present, and
Teen Challenge was present.

MS. HEAPS: I hate to make this more controversial, but it is. One of the
reasons, I think, that you are seeing the action of the Congress has to
do with the way the funding was attached or opened up the block grant.
For natural constituencies of treatment providers who would have
supported ATR, that has become a major red herring. Had it gone forward
without that, you might have seen it, but most of the provider groups or
organizations that support them, NASADAD and other groups, are opposed,
therefore, to ATR as it stands and has been proposed by the
administration, which is too bad.

DR. CLARK: In fact, we\'ve heard that same rationale, and the hope is
that there will be some discussion. If the administration is flexible,
if the Congress is flexible, they can arrive at a consensus that would
be acceptable to all parties. But I think Melody\'s point is well taken.
The use of the block grant is, indeed, controversial. I think I can
safely say that.

I was in Iowa and I was talking to Janis Vick, who was pointing out that
a number of rural providers, they\'re the only game in town and they
need to have maintenance, what they get from the block grant. Even with
performance contracts, you\'ve got a maintenance of effort. You need a
core financial in stream to keep your doors open. If you go out of
business, then that whole community is without a provider. So that\'s an
issue. So we need to think in terms of it. Whereas, as a grant program,
it didn\'t affect that and the provider had its maintenance income, if
you will. So it would have enough money to keep its doors open.

So those are issues that are being discussed. The administration thinks
that its proposal is a good one, but the legislative process is a
hazardous one. So there are times when you have to make compromises, if
that\'s possible, or if necessary. So those discussions are going on
now.

At this point, without any further discussion, why don\'t we take our
break? Then we\'ll be back at 10:40. Thank you.

(Recess.)

DR. CLARK: All right. Before our next presentation, our very next item
of business on the agenda is to vote for the minutes from our June 23rd,
2006 meeting. The minutes were forwarded to you electronically.
Hopefully, you had an opportunity to review them. If so, I entertain a
motion to adopt the minutes.

PARTICIPANT: So moved.

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

PARTICIPANT: I second.

DR. CLARK: I have a motion and a second. Any discussion?

(No response.)

DR. CLARK: May I get a vote? All those in favor?

(Chorus of ayes.)

DR. CLARK: All those opposed?

(No response.)

DR. CLARK: All right. The minutes were adopted as presented. That\'s it
for the minutes.

So we will move to our next presentation, which is our alcohol
initiatives.

Obviously, alcohol continues to be a major issue in our society, as you
noted from the Household Survey data. Psychotherapy treatments for
alcohol dependence have been expanded with the recent FDA approval of
acamprosate in 2005 and naltrexone for extended-release injectable
suspension, otherwise known as Vivitrol for 2006. We have Cephalon here
for Vivitrol. These are the first new medications for treating alcohol
dependence available to physicians for over a decade.

We\'ve embarked on a project to update our 1998 treatment improvement
protocol, naltrexone in alcoholism treatment, to include the newer
medications, along with oral naltrexone and disulfiram. Eric Strain,
Professor of Psychiatry at Johns Hopkins University, is the TIP chair.
He\'s also associated with the American Psychiatric Association\'s
Council on Addiction.

Also, the use of experimental biochemical measurements to objectively
assess patients\' current or past alcohol use holds forth the prospect
for measuring acute alcohol consumption and relapse. These are issues
that we title \"biomarkers.\" The idea is to treat people with alcohol
dependence adequately using medications where indicated, and clinicians
need tools to properly assess recent and past drinking activity and
family history of drinking problems. Biomarkers, if appropriately used,
can be a good indicator of alcohol use, presupposing that there are no
other illnesses or problems.

When we talk about biomarkers, we\'ve got a draft of our advisory. Some
of you may have got copies of this. It\'s in your book. The Role of
Biomarkers in the Treatment of Alcohol Use Disorders.

The advisory summarizes there are indirect measures of alcohol problems
like liver function tests, mean cell volume tests, or the
carbohydrate-deficient transferrin test. There are direct measures of
alcohol exposure or use using breath alcohol, looking at alcohol present
or ethyl glucuronide or ethyl sulfate or phosphatidyl ethanol. These
latter three are relatively new in the marketplace of strategies to
address alcohol issues.

Following my presentation, Dr. Skipper will give a perspective on the
regulatory side.

The issue of the biomarkers has come to our attention from a number of
different directions, and those directions have been in the media.
There\'s a Wall Street Journal article in the back which summarizes the
discussion.

The question is why do we want to use biomarkers. It complements
self-report measures, clinical history, self-report questionnaires, and
it can give you an objective laboratory test to assist in outcome
measures for treatment and studies and to screen to detect problems and
some evidence of abstinence.

One of the things that we quickly have learned from reviewing the
literature and synthesizing this report is, of course, there are
limitations to any of these strategies. In a clinical context, these
limitations have to be kept in mind, and in a forensic context, they
have to be especially kept in mind. A forensic context is when you\'re
doing workmen\'s comp evaluation. When people\'s liberties or freedoms
or property rights are in jeopardy, then you want to make sure that
whatever test you use, the limitations of those tests are well
understood. Objective tests can assist us in the clinical context
because we have a lot more flexibility. In the forensic context, where
there\'s a lot less flexibility, you want to make sure your biomarkers
are more rigorous.

In the clinical context, in treatment we can screen for alcohol use
problems. We can use the feedback, motivating change in drinking
behavior. We can use it to identify relapse to drinking, and we can use
it to evaluate interventions.

The issue of relapse. I\'m fond of citing the situation where in a
clinical context it was a drug test. A gentleman came to my office when
I was at the VA, and I asked him to go get a drug test in the morning
and that I would see him later that day. So he went over and got his
drug test and it was not an observed specimen. It was a voluntary
specimen. So he shows up in my office. I pull up his file on the
computer, since the VA went to electronic health records. For those in
the audience, remember that, the electronic health record. We\'ll talk
about that later. So I asked him, have you used any drugs lately? His
first answer was no. I said, well, can you explain this positive? He
said, okay.

So we talked about that. It was a non-punitive context, and I think
that\'s the key issue. Sometimes people are embarrassed and sometimes
people don\'t like to admit it. He could have just as easily not taken
the test. He could have gone and come back and said, look, there was a
long line. I didn\'t have it. But instead, he did take the test and it
was an awkward moment. I was able to work with him to address that
issue.

You can use biomarkers to identify relapse to drinking, evaluating
interventions, and to document abstinence.

Now, the legal reasons. That\'s the forensic context. That gets to be
tricky under the age of 21, child custody for an identified impaired
parent, court-mandated abstinence, monitoring, and treatment, and
impaired providers/professionals who are trying to continue to work.
These legal reasons or these forensic contexts are reasons that we need
to pay close attention to in terms of outcomes.

In the clinical context, you have flexibility, and you can work with the
individual. In the forensic context, some decisions have to be made.
Should a mom retain her child? Usually it\'s a mom. Should a visiting
parent be able to visit usually it\'s his child? Should a professional
continue in a monitoring program?

I used to be in the State of California and I was on the monitoring
board for almost 10 years. So monitoring was something that we used very
extensively. We did not use biomarkers as such. We did use drug tests.
We didn\'t use alcohol biomarkers. We used breathalyzers.

When you\'re using biomarker testing, as Ken Hoffman points out, we have
to look at the issue of sensitivity, how many true positives we pick up,
specificity, how many true negatives we pick up. We need to be able to
look at the positive predictive value of a test. Those are the true
positives over the true positives plus false positives.

You want to be able to estimate the prevalence of a problem based on the
test within the population. So different populations have, obviously,
different risks of showing positive. For instance, if you do a test for
PCP, which is not a drug that\'s used very often, you want to make sure
that that positive is a true positive because it\'s more likely than not
to be an error actually, or the patient may say, well, as I have had
patients say, look I do marijuana. I did marijuana. So the patient
actually may not know what they\'re doing. So it really gives you the
information in the clinical context to work with.

We have to understand the relationship between sensitivity, specificity,
positive predictive value in trying to address a test. In the low
prevalence rate, positive predictive value can be low with 100 percent
sensitivity and high specificity. These are all things that we talk
about in our advisory because, indeed, what we don\'t want people doing
is relying on absolute values.

Prior to coming to Washington, I used to have a small forensic practice.
One of the companies that I was a consultant for ‑‑ one of the
supervisors would say, well, if the test is positive, I don\'t need an
MRO to tell me anything. The test is positive. The test is marketed as
being an absolute statement of a condition when, in fact, it turns out
there are other reasons for that. It\'s an important thing for us to
keep in mind that if we don\'t understand the relationship between
sensitivity, specificity, and prevalence, we\'re liable to essentially
challenge someone\'s credibility when that\'s not the case.

For direct biomarkers, the idea is to be able to detect the presence of
the biomarkers after ingestion of alcohol. So the biomarkers listed in
the advisory include EtG, EtS, and PEth. The idea is that after the
alcohol is ingested, it\'s metabolized and it produces a moiety and a
chemical end product which can be detected. It is argued by some of the
labs that it\'s absolute, when you look at the website. The website
says, well, gee, this is proof of consumption. Well, beer and wine and
alcohol and liquor will give you the alcohol.

But what they don\'t talk about is what other products will give you
alcohol. Remember, the other thing that we\'re dealing with in terms of
positive predictive value is the lower level we get in terms of the
particular product, you may get environmental exposure. So there\'s
alcohol-free beer and wine. There\'s aging juice, over-the-counter
medication. It was brought to my attention that the propellant in an
asthma inhaler contains alcohol. Lorie Garlick got me involved in this
mess. It turns out Dr. Mike Liebman pointed out that Purell ‑‑ 62
percent alcohol. Well, Dr. Liebman\'s point is that it vaporizes and
that you inhale it, and it actually registers in your body and produces
a low level positive. He\'s done some studies.

Other people point out that if you do a lot of hand washing, your hand
gets rough. Indeed, the skin absorbs alcohol. In fact, a number of
pharmaceuticals rely on the assistance of alcohol propellants to move
other drugs into the body. So alcohol is a fairly ubiquitous thing.

The difference between a breathalyzer, which basically registers blood
alcohol, and these biomarkers, which essentially registers the exposure
to alcohol, is quite substantial. A breathalyzer requires a lot of
alcohol to give you a reasonable positive. They\'ve got some fairly good
studies correlating the amount of alcohol. If you operate motor
vehicles, the DOT says if it\'s .04 or above, you can\'t operate the
motor vehicles. For DUIs, it\'s .08 or above.

But with some of the biomarkers, we\'re down to levels of detection
which is 50 nanograms. Some labs pride themselves at 50 nanograms. So
the question is how do you get 50 nanograms of alcohol in your body.
Well, the 50 nanograms has no relationship with intoxication. In fact, a
couple drinks will give you tens of thousands of nanograms. So when
you\'re down to very, very low levels, if you\'re using it as a
biomarker, you can\'t distinguish whether a person has been exposed to
over-the-counter medicine, whether they\'ve been exposed to foods cooked
with alcohol, whether they\'ve been exposed to household products.

Does anybody know about Lysol? Did you know Lysol has 70 percent alcohol
and 62 percent to 70 percent in Lysol spray? The Lysol people tell you
to spray the stuff all over the place. Spray it in the air. Spray it on
the hard surface. Get rid of those germs and the viruses. Well, you
know, if you spray, you\'re getting high.

(Laughter.)

DR. CLARK: No. You don\'t get high. But you\'re exposed to aerosoled
alcohol.

The problem with the biomarkers is how much do you need to detect
innocuous use. Most of the people I treated who had an alcohol problem
did not drink 50 nanograms per milliliter, but they drank for effect.

So household products, personal care items, professionally required
products may contain very low levels. The other point that we know is
that you can\'t always determine how much alcohol is in a product. There
are foodstuffs that have low levels of alcohol that the FDA does not
require a declaration of alcohol content.

So if a biomarker is picking up low levels, because unlike in drug
testing ‑‑ in drug testing, we have cutoffs. We have these cutoffs that
distinguish between \"mere exposure\" to opiates.

Does anybody know about poppy seeds? The poppy seed opiates. Well, the
poppy seed is a very interesting thing. When the labs first started
doing opiates, no, poppy seeds could never give you a positive. Somebody
decided to test that thesis out. They ate a lot of poppy seed bagels and
it gave them a positive for opiates. There is morphine in poppy seeds,
incidentally. So the key issue was that we\'ve established a cutoff so
that people who ate poppy seeds would not be mistakenly accused of using
morphine or heroin or codeine.

So there have been no cutoffs established that could distinguish between
consumption of alcohol from exposure to alcohol or other products. We
talk about that in our advisory.

We need to identify possible factors that may influence an individual\'s
biomarker response to alcohol because we also don\'t know much about the
metabolism of some of the alcohol at these low levels. Everybody knows
about the high levels, .08, .04, .02. Dr. Liebman was able, in inhaling
Purell, to get a .01, which you can pick up from a breathalyzer. Some
breathalyzers have a .005, but not below that. They don\'t really
register. You start getting noise.

We need to identify the window of assessment associated with various
alcohol levels of use. Even low levels won\'t be positive at three days
out because the argument is we can pick up drinking from three days
before. But if you\'ve got asthma and you use an inhaler that day of
your test, even though it\'s low levels, it will indicate a low level.
The assumption is that at some time earlier you drank, but that\'s not
true.

We have to determine the reliability of the laboratory testing
procedures. Right now there are just a few labs. When you look at the
literature, there are only a few labs that are writing about this. So
basically it\'s like the only game in town, and it\'s like trust me, I
make no mistakes. When is the last time you relied on that? So that\'s
an issue.

We have to determine which products can give a positive test result at
specific cutoffs. The notion of cutoffs is very, very important. Since
methamphetamine is a major issue ‑‑ I wish Donna Bush was here ‑‑ we
have to establish a cutoff at a high enough level so that people who
took a lot of ephedrine didn\'t test positive for methamphetamine. So
the labs adjusted to this.

So the issue of alcohol biomarkers has become very important. From my
point of view, if we don\'t establish good cutoff values, the risk and
benefit of a correct label to the patient needs to be taken into
consideration. You have to look at, well, what is the cost of working up
a false positive? If someone took an asthma inhaler and registered 50
nanograms per milliliter, the lab says, see, that\'s evidence of
consumption. We interpret consumption generally as being they drank.
Some of the labs are very, shall we say, adroit in asserting that.
Others say, well, this is alcohol drinking. We have to look at the cost
of missing a false negative case.

And we have to look at the test-only alcohol detection program. So if
we\'re going to rely on something, we have to look at the possibility of
getting 100 percent specificity for no false positive if you\'re going
to sanction somebody as a result of a single test.

Again, in the clinical context, we have this flexibility. We don\'t rely
on a single test to make a determination. It is evidence of something,
and now the question is what is it evidence of. Let us find out what
that is. But if you market something as foolproof and absolute, then
you\'ve got people who are willing to rely on that and then people are
sanctioned.

So our advisory talks about the biomarkers and the limitations of it,
and I commend you to the advisory because we want people to not focus on
the absolute nature of biomarkers, but their utility as a part of the
general clinical construct rather than, well, the test says you\'re
this, therefore you are. As we know, that can be problematic.

Injectable naltrexone for the treatment of alcohol dependence.
Naltrexone is an opioid antagonist and it\'s often prescribed as an
anti-craving medication for patients dependent on alcohol. It used to be
called Trexan. Then it became ReVia. This is the oral medication.
Compliance with oral medication for people who generally were in the
health professions and trying to recover was pretty good, but for the
general population, compliance with oral medication was very poor
historically. With the advent of Vivitrol, then the new medication is a
long-acting, one-month injectable formulation. It\'s available.

And we\'ll have an advisory that notifies the field and compares oral
with injectable naltrexone. We believe that the injectable has good
utility for the field because it\'s less dependent upon the, shall we
say, I decide maybe I want to drink today, so I stop taking the
medication. Well, the injectable reduces cravings. There is developing
research that this is a good approach to treating alcohol dependence.

We\'re going to have a TIP for medications for use in the treatment of
alcohol dependence because these medications are available, and we will
review some of the older medications like disulfiram. Acamprosate is
available, as I mentioned earlier. The two forms of naltrexone, the oral
medication and the injectable.

This TIP integrates the use of these medications and testing of
evidence-based treatment of alcohol dependence in primary care and
addiction medicine settings. As many of us know, a lot of medications
are now prescribed in the primary care setting. So we want to make sure
that primary care docs have adequate information from an addiction point
of view, and we\'re relying on experts in the field to assist us in
putting together this treatment improvement protocol. So when Bettye
Fletcher teaches her course, her students will have the latest
information by consensus, and this is important.

So with the exciting developments with biomarkers and the new
developments in medications, we think that we can have a more robust
field. We can assist people in their recovery, and we recognize that not
all people recover the same way. There are many pathways to recovery.

The other point that we need to make with the biomarker point is if, in
fact, people are not using and they\'re accused of using, then it
creates a tension in the recovery process. If our biomarkers are so low
that we are now picking up environmental exposure, then basically
you\'re telling the person who\'s in recovery that their recovery
efforts are for naught. I\'m in recovery. Well, you got a 50 nanogram
positive. Well then, but if I\'m not drinking and I\'m going to be
sanctioned for drinking, I might as well drink. That doesn\'t help the
larger society. It doesn\'t help the person, and it doesn\'t help the
recovery process because, indeed, honesty is one of the basic tenets of
the recovery process.

So we need to be scientifically honest about what it is that we do and
recognize the limitations of what we do so that, indeed, we don\'t
create the conundrum which undermines the whole effort because, above
all, we should be doing no harm. The advent of biomarkers will help us
in our relationship with our clients and the advent of new medications
will help our clients in their efforts to reduce craving and to recover
from alcohol abuse and dependence.

Greg, do you want to come up here and discuss with the council some of
the, shall we say, technical regulatory issues associated with
biomarkers?

DR. SKIPPER: Thank you, Dr. Clark. I\'ll just take a couple minutes.

In my work, I\'ve worked with health professionals, pilots, other
professionals for about 25 years, these people that have problems with
alcohol and drugs that come to the attention of their profession and get
treatment and then are allowed to go back to work contingent upon their
abstinence.

In 2001, I had been arguing with a malpractice insurance company who
stated to me that they were no longer willing to insure doctors who had
alcohol problems even after treatment because they were worried that if
there was a malpractice case, there was no effective way to really
document that that doctor was abstinent and they were worried because
the judges in that state were allowing the recovery history into the
malpractice case. Without solid proof of abstinence or the ability to
prove that, the company didn\'t want to insure these doctors.

So that was the setting in which I heard about new markers, including
EtG at an international conference in Italy. So I was very interested in
studying this marker to see if it would better serve us to prove
abstinence to the benefit of professionals who could then prove better
and more absolutely that they were succeeding in recovery and be able to
have additional privileges. So that\'s the context in which I supported
this test and thought it would be very valuable, and I think it is
valuable in that context.

I presented on this here at this council a couple years ago, and Dr.
Clark prophetically cautioned that there could be problems with false
positives.

Indeed, as labs took this very rapidly after its introduction, much more
rapidly than most things go from lab to field, this thing has caught on
like crazy. I talked one lab into running the test, I think it was, in
2003. NMS up in Philadelphia started running the test, and now there are
more than 10 or 12 labs and more than 20,000 to 30,000 tests a month
being done mainly in the context, rightfully, of monitoring people who
have agreed to be abstinent.

Again, it\'s very successful when the test is negative. The question
comes along, when it\'s positive, what do we do? And particularly the
low positives.

So what I wanted to say is that the problems that have emerged regarding
EtG testing really have in many ways highlighted intrinsic problems with
drug testing in general, not just for alcohol, and the substance abuse
field at large. The most prominent problem that it\'s highlighted is the
inherent discordance between the legal/moralistic and the
medical/clinical approaches to substance abuse problems. Lawyers,
judges, regulatory boards and others using drug testing as evidence want
certainty. They want it to be black and white. A positive test means
you\'re guilty; a negative test means you\'re innocent. If a drug test
is positive showing the presence of a drug or alcohol, they want to know
it means relapse to substance use, much like they rely on fingerprints
and DNA testing.

Alternatively, doctors and other clinicians know that you must treat the
patient, not the lab test. All laboratory tests have limits. We call
these limits sensitivity and specificity. Dr. Clark has gone through
that. This applies to drug and alcohol marker testing as it does to all
other lab tests. Therefore, when a health professional receives a lab
report that doesn\'t fit the clinical situation, they wisely question
the lab report, repeat it, and/or attempt to understand why the test may
or may not be accurate.

Therefore, in a sense we can see drug testing in the same dilemma as the
entire field of substance abuse where we\'re trying to decide whether
we\'re dealing with a crime or an illness. Is punishment or treatment
warranted? It\'s really what it kind of boils down to. We\'re at the
interface between the legal and the clinical.

Being involved in introducing EtG and EtS testing in the United States,
studying this marker and reporting on its potential benefits, using the
test in the field to monitor physicians ‑‑ we use it in our program
currently ‑‑ consulting with laboratories, moderating an e‑group where I
met some of the people here today regarding EtG testing, and finally
coming to realize how quickly the test has been marketed and used,
sometimes inappropriately which has harmed some individuals, actually
many individuals, has been an education to me. I\'ve learned many things
from this experience, but the most disturbing has to been to witness the
rigid and sometimes punitive manner in which the tests are being used by
some agencies.

Another thing that I\'ve learned that\'s disturbed me is the very
limited role that MROs take in trying to resolve these problems. I
commend Dr. Clark and his staff for their interest in this problem.

I personally issued an advisory in 2004 and in 2005 warning agencies
that positive EtG tests could be from incidental exposure to alcohol,
and a positive test does not always mean beverage alcohol consumption.
Some of these agencies wrote me and said that I was a traitor, that I
brought this test here and now I\'m changing sides. I didn\'t ever mean
to be on one side or the other. I was really trying to bring something
valuable to the field.

I was impressed how little my personal advisory was actually heeded. I
felt like I had started a locomotive moving and was now unable to slow
it down. I met with Dr. Clark last fall and discussed SAMHSA issuing a
more authoritative advisory, and I\'m delighted that a proper advisory
is going to now be available.

Because of my role with EtG, I\'m being contacted daily by no less than
10 or 15 unique people every day who claim they are being falsely
accused of drinking. Many of these individuals are being returned to
prison, losing custody, or losing their licenses. I\'m hopeful that this
advisory will positively influence those in positions of authority to be
thoughtful and careful about using these really potentially very
valuable tests.

More research is needed to perform. Proper research funding is
desperately needed.

Finally, I strongly recommend that SAMHSA organize a meeting inviting
regulatory licensing boards, representatives from criminal justice, and
others using these tests to participate in a workshop or presentation.
Donna Bush and I were talking about this but we need this workshop to
fully help them understand this advisory and to know how to properly use
these tests. The advisory here is an excellent first step, but I believe
we must pursue this additional effort to help slow this locomotive, to
educate people who use these tests so that individuals will no longer be
harmed by this valuable test that should be meant to help and not to
harm.

I might also point out that even low positives, when used by a clinician
that understands this, can be useful. For example, last week I had an
EtG test reported on one of our doctors of 115 nanograms, a low
positive. When I called him to do my MRO function, I fully expected him
to say, because the media now has promoted this idea, it was Purell or
something like that. In fact, when I said, Doc, you have a positive test
for drinking, he said, I\'ve been drinking beer. I need help. So it can
be a very valuable test to detect early relapse, but we\'ve got to
address this issue of clinical use to support people and inappropriate
legal use to slam people and take things away from them.

Thanks.

DR. CLARK: It also could be a useful test to advise people about
incidental use. Many people aren\'t aware of the alcohol in their
environment. If you\'ve got a problem with alcohol, the question is how
much alcohol do you need to prime the pump, if you will. So if I\'m
unwittingly consuming alcohol, I may be predisposing myself to relapse.
But that\'s the clinical context. If you use it in the forensic context,
then it\'s a different matter altogether.

DR. SKIPPER: Can I mention one other thing about that? I\'m currently
doing a study with Purell, which you mentioned, and I\'m having people
use it every 2 minutes for an hour. That\'s heavy use. I\'m having them
use it close to their face, as some people often do with hand gels, and
we\'re doing it in a small room. The breathalyzer we\'ve had go up to
.2, very high. .2, yes. We think a lot of that is because the ethanol is
actually in the airway, in the vapor and it\'s not really a blood level,
as a matter of fact, because drawing a blood alcohol at that time shows
like .01 or .02. So the breathalyzer is not effectively measuring blood
alcohol when you are exposed to vapor.

The other issue I\'ll bring up is that there is a product being marketed
now called AWOL, Alcohol Without Liquid, where you basically nebulize
vodka. It\'s in bars in Europe. I think it\'s being marketed in the
United States as well. If you look on the Web, look at Google, AWOL
alcohol and you\'ll see this product. But we should worry about alcohol
vapor I think and what it\'s doing to people\'s brains.

Right now it\'s being promoted to be used frequently in hospitals. Some
nurses say they use it 40 times a day, even pregnant nurses. We don\'t
know what that could mean. So that needs to be looked at too.

DR. CLARK: Council?

DR. SKIPPER: Dr. Clark, would it be possible to have public comment now?

DR. CLARK: We\'ll move to the public comment right now. The following
members of the public would like to address the council at this time:
Lorie Garlick and Nancy Clark. Dr. Garlick and Ms. Clark, you may come
to the standing microphone and address the council. If there are other
members of the audience who wish to address the council, please form a
line behind Ms. Clark.

DR. GARLICK: I\'d like to first thank the council for allowing me to
speak today. My name is Lorie Garlick. I\'m a pharmacist from
California, and I\'d like to read a prepared statement about some of the
problems with EtG and how it\'s affected me personally.

My journey in recovery began in 2003 with a jump start from my licensing
board. I was monitored through random testing, and in May of 2005, I
tested positive for EtG. As a result, my license was immediately
suspended and has remained that way for the past 16 months. The
second-chance opportunity that had been so graciously given to me was
taken away through no fault of my own.

I can\'t begin to describe to you how this has devastated my life. I am
said to represent a risk to the public in my role as a professional
pharmacist should I return to work. I have a license revocation hearing
scheduled for next month which threatens to end my 20-year career.

Not only had I not consumed any alcoholic beverage to precipitate this
test, but I couldn\'t come up with a single credible thing that should
have caused me a problem. I was aware that EtG was sensitive, and I was,
therefore, extremely careful with what I ate.

My search for answers led me to the Internet where I discovered Dr.
Skipper\'s website and discussion group, and I found that there were
others across the country who were experiencing exactly what I was.
While it was comforting to know that I was not alone, it was also very
disturbing to hear that in light of what was happening to people\'s jobs
and licenses as a result of erroneous diagnoses of relapse, nothing was
being done to help them.

At Dr. Skipper\'s suggestion, I did self-testing for EtG at home on some
things that were being tossed around that were thought to be
problematic. I elicited positive tests from foods that contained vanilla
extract, as well as from applying Purell. I volunteered then to undergo
testing in an inpatient facility where I again tested positive using
Purell at levels of 440 and 770, the latter being over three times what
my licensing board had used to suspend my license.

When Dr. Skipper introduced EtG to this council in 2004, he hoped the
cutoff of 100 that the labs had chosen to use would only be able to be
positive if an alcoholic beverage had been consumed. I believe he
expressed that the intent was to be positive only if more than 1 ounce
of alcohol had been consumed. While I believe that these hopes were
genuine, the post-marketing experience over the past two and a half
years has rendered this cutoff inadequate. The labs\' own toxicologists
have testified in hearings that levels below 1,000 are in the gray area
and that you cannot just look at a number in and of itself and decide
whether it was incidental alcohol or beverage alcohol.

I learned through my own research and inquiries that EtG testing is
regulated solely by peer-reviewed scientific literature. So I would
refer you to that literature to read the studies that support a cutoff
being placed at 100. However, you would find that no such literature
exists. In fact, there are no published studies on the effect of
medications, gender, endogenous alcohol production, and individual
variations in metabolism on EtG levels. I\'ve reviewed all of the
published articles on EtG and they provide a good correlation that if
you drink, you will test positive. What the literature is sorely lacking
in is research that would give you one reassurance that if you don\'t
drink, you will test below the cutoff of 100.

Some say that the problem does not lie with the cutoff but in how the
results are interpreted. Plain and simple, EtG is being utilized as a
diagnostic test and not as a screening test, eliminating any opportunity
to assess any clinical correlation of relapse.

My own licensing board has adopted a disciplinary guideline that \"any
confirmed positive test for alcohol or for any drug shall result in the
automatic suspension of practice,\" mandating action based solely upon a
number.

It should also be noted that EtG use, as these gentlemen have
recognized, is growing by leaps and bounds in criminal justice programs
where severe consequences of a positive screen are the mainstay.

In light of what we have learned about EtG over the past two and a half
years, the labs continue to staunchly defend their test, stonewalling
inquiries for information, and quietly pretending that there is not a
problem. The test continues to be used. The cutoffs remain the same.
There\'s been no research over the past two years. People continue to be
told that \"false positives just don\'t happen with EtG,\" and people\'s
lives continue to be torn apart. I would ask you if a new drug were
causing this kind of chaos and damage in people\'s lives, would we sit
idly by and watch it happen without any intervention.

While I applaud your issuance of this new advisory, I ask you to
continue to facilitate the flow of information with regards to the
limitation of this test to all licensing boards, third party
administrators, MROs, and criminal justice programs. Clinical
correlation must be required and not suggested. It must be specifically
defined and concretely identified. Denial, prior relapses, and a past
history of substance abuse do not qualify as valid clinical correlators,
but these are the only things that I\'m hearing used as such.

I urge you to issue letters to all laboratories currently doing the
testing, warning them against the unethical marketing practices which
they currently employ, and reminding them of their duty to educate and
inform their clients of what they know, both good and bad.

Since the science behind EtG is so lacking, I would urge you to
encourage NIAAA to include this in their research portfolio. It is
peculiar to me that a test, whose use is practically exclusive to the
United States, was developed and researched almost wholly in Europe.

I\'ve heard the problem with incidental alcohol compared to that of
poppy seeds and opiate testing before. There\'s one big difference. I
believe that the avoidance of poppy seeds is fairly simple, while that
of ethyl alcohol is not. The National Institutes of Health has a
comprehensive listing of household products containing ethanol that is
13 pages long and contains literally thousands of items, and that
doesn\'t include any of the food sources. I hope that the 1998 change in
the opiate cutoff in response to the poppy seed issue taught us that
post-marketing recognition of a problem with drug testing necessitates
swift action in the area of research and remedy and that government
intervention is both possible and necessary.

Thank you.

MS. CLARK: Hi, everybody. My name is Nancy Clark. I would like to
acknowledge Dr. Clark and all the distinguished members of this
committee. I would like to say since September is Recovery Month, I
would like to applaud all the good things that SAMHSA has done to
promote recovery.

I know when I started a 12-step program, a lot of people that would come
into the program would say they don\'t understand the difference between
religion and spirituality. It was said one time ‑‑ and I really like
this definition ‑‑ religion is for those people who don\'t want to go to
hell, and spirituality of recovery is for those people who lived in hell
and don\'t want to go back. You know, for me that\'s very true.

Recovery has been the best thing that has happened to me in my life. It
was a little over five years ago, and my life has changed incredibly.
That\'s a hell that I don\'t want to go back to, is addiction.

The reason I\'m here today is also to make a statement on EtG. I feel
that I\'m here not only to speak for myself, but to be a voice for a lot
of the people that have been falsely accused by a positive EtG and did
not drink. One of the most devastating things to the human spirit I have
found is not being listened to, not having your truth heard, and not
being acknowledged. That is something that we have lived with the EtG
thing for almost two years.

When I signed a contract, I admitted my addiction, and I signed a
contract that I would abstain from alcohol and drug use. In that
contract was that any positive urine would be an irrefutable violation
of contract. When I signed that contract, I believed that I would be
treated ethically and I would be tested ethically. I believe that if I
didn\'t use or if I didn\'t drink, I would do fine in the program. And
that didn\'t happen. I ended up with a positive EtG. To this day, I
still do not know what caused my positive. I actually had two positives.
I had my license suspended twice with positive EtGs. And I wasn\'t
listened to. There was no clinical correlation done. By contract, a
positive is an irrefutable violation of contract.

Honesty and accountability is the foundation of recovery. I would like
to ask if the labs who promote this test shouldn\'t be held to the same
level of honesty and accountability that the recovering addict is.
Laboratories say that boards and monitoring agencies are responsible for
interpretation of the test. Yet, I have in my hand the lab report that I
lost my license on the first time, and it was a positive of 370. On the
bottom of the lab slip, it says, any value greater than 250 indicates
ethanol consumption. I ask with that statement, where does that leave
room for a board to interpret these results if their main focus is to
protect the public?

I think compelling evidence of the way labs have been marketing this
test and the lack of knowledge by the boards are showing that the boards
and the monitoring agencies are almost as much victims of EtG as we are
because they just don\'t know and they\'re being told the wrong things.

A lab expert at a recent hearing had stated that \"there are no
published studies to show a level as high as 780 can come from
incidental use.\" A truthful statement should have been there are no
studies on incidental use, individual variations, age, gender, or
variations of pathway metabolism. A lack of studies doesn\'t mean that
it\'s proof that there aren\'t any.

We know that there are studies on Purell, as Dr. Skipper has said, but
they\'re not yet published. That study was brought up at the ASAM
convention in May and this lab expert testified after that conference.
So the knowledge was there. You know, it just wasn\'t published.

Dr. Skipper, as you said, had put out the advisory in 2005, and I really
applaud him for that. He\'s been really great in trying to help get this
out and word on EtG what\'s happening. As he said, there wasn\'t very
many changes from that. The ASAM conference that brought up the issues
with Purell and a lot of the questions that are happening around EtG ‑‑
things aren\'t changing. The lab websites, as Dr. Clark had pointed out,
still say that it\'s proof of alcohol consumption.

I did look up the word \"consumption\" and I should have brought it
along because Webster\'s says it\'s not like consumption is equal to
exposure. Consumption means that you partook in something and it says
actually in an excessive amount.

Without the changes in marketing, there have things that haven\'t
changed besides the marketing, and that\'s the amount of people that are
being prosecuted and hit over false EtGs. Since the recent Wall Street
Journal article, things I don\'t think are changing other than people
are finding the website and finding help. Since the Wall Street Journal
article, two people from Pennsylvania have tracked me down and asked for
help in fighting this and support because they had nowhere to go. They
thought they were alone in this. Thank goodness that that came out and
increased public awareness.

ISBRA had the 206th World Congress on Alcohol Research. The conclusions
of that read: \"The findings suggest that direct ethanol metabolites
have potential in detection of previous ethanol intake in a variety of
situations and settings. Their combined use and conjoint use with
traditional markers and self-reports might be promising.\" Yet, U.S.
labs continue to market this test as the stand-alone gold standard.

I question how many more victims have to be crushed by this test. My
first positive test, I had three years in recovery. When I started
recovery, I embraced recovery because I knew that was the only way I was
going to live. To get through this, I used every tool I had in recovery,
a really strong spiritual connection, and the support of my home group
in a 12-step recovery program, and recovering friends. Unfortunately, a
lot of people that are caught in this early in recovery don\'t have
that. It could jeopardize their recovery.

The foundation of our legal system is innocent until proven guilty. We
are innocent and we have been labeled guilty and we have suffered
devastating consequences. I personally have lost my license, lost my
job, lost my reputation because it was publicly printed in a newsletter
from the state board that I also am unable to practice because of
unreasonable safety and skill due to the positive EtG test.

I\'m here today to also express my concerns over a lot of the things
that Dr. Clark brought up. When I heard Dr. Clark talk, I thought that
you looked at my statement and did everything from here because you did
put in a lot of things in my statement that I wanted to have looked at.

When you had said about being non-punitive, I was told that if I would
admit to alcohol use, I wouldn\'t lose my license, but I could continue
in the monitoring program. I didn\'t drink and I wasn\'t going to admit
to drinking. Therefore, my license was suspended.

Clinical correlation, as Lorie brought up. There has to be a definition
of clinical correlation. The clinical correlation that was used against
me in my second hearing was I knew about incidental alcohol, so
therefore, I should have known the thousands and thousands of things
that contained alcohol and should have been able to avoid them.

I really liked Dr. Skipper\'s suggestion as far as promoting education
on this test. I think that\'s where we\'re having a lot of the problems.
The boards and monitoring agencies look towards the labs for information
on this test, and the labs are marketing it as the gold standard, proof
of alcohol consumption. There has to be education on these biomarkers.

Also, Dr. Clark has up there as far as it needs to have a defined
cutoff. I ask in the interim, until we do research and have the defined
cutoff, what happens. The labs are running the cutoffs at 100, 250. Some
have put it up to 500. Yet, Purell makes a 770 and higher. So what
happens in that interim until we have adequate cutoffs set?

Like I said in the beginning, I believe that recovery should be the
focus of any addiction program. Recovery has changed my life.
Unfortunately, a lot of the monitoring programs are not looking at
recovery. They\'re looking at the negative test. Just like somebody
brought up, if you have a positive test, that\'s it. You\'re guilty. A
positive test equals guilty. We have to go back to recovery is the issue
here. We need to look at somebody\'s recovery basis.

Actually I believe that\'s all I have. Thank you.

MS. SCHROEDER: My name is Tina Schroeder, and I\'m an R.N. from Wichita,
Kansas.

Actually I was just about ready to give up my license due to the fact my
first test was a 963 nanogram. That one was the state. Our Kansas Nurse
Assistance Program gives out a letter saying avoid Benadryl and
over-the-counter cold products. I avoided everything they did. I didn\'t
change any other routines, continued to rinse out with Listerine, got a
963. After evaluating, when I go in to take my urine test, I\'m not
worried at all. I haven\'t drank anything. I get this value back. You
drank two to three drinks. You tested at a 963. I did not.

I was dumbfounded. I couldn\'t figure out why I tested so high. So
immediately I\'m searching on the website. Everybody says what did I do.
We start reading every label in the house, going crazy. What did I do? I
found it was ‑‑ I go to bed at night. Oh, my God, it\'s my Listerine. I
quit that immediately. I\'ve had several negatives for a while.

My next positive was 147. They gave me a warning on that one and said
one more positive, I go get diversion, state board.

My next positive was a 310. This is over two years. That\'s 20 tests,
three positives. I\'m now in a diversion. One more strike and I\'m out.
I\'m not a nurse anymore.

I was ready to say, heck with it, go back to school, become an
accountant, something else. I\'ve got a good head on my shoulders. Not
very good at public speaking, obviously. But a quadriplegic patient of
mine begged me, don\'t do it, said I\'m an awesome nurse and I should
not give it up. So I\'m fighting. What do I got to lose? One more bad
test and I\'m out anyway. I\'m going out with a bang.

DR. CLARK: Council?

DR. SKIPPER: Can I make a recommendation on the advisory, just one
suggested addition, if it is still a draft.

DR. CLARK: Sure.

DR. SKIPPER: On page 3, bottom right corner, where it says, \"until
considerable more research has occurred, use of these markers should be
considered experimental,\" I\'d like to add after that a comma \"and
legal or disciplinary action based solely on a positive test should not
occur. These tests should currently be considered valuable clinical
tools, or potential clinical tools, but their use in legal settings is
premature.\"

DR. CLARK: Dr. Fletcher?

DR. FLETCHER: I\'m not knowledgeable in this area, but I\'d like to ask
are there data available on the test. If so, are there gender
variations?

DR. SKIPPER: We do not know if there are gender variations at this
point. What\'s been looked at on this test is we\'ve looked at alcohol
use shows up positive, and in the small groups that have been looked at
that haven\'t drank, they\'re negative. What\'s not been looked at
adequately is larger groups, different genders, medications, diseases,
and what all these kinds of incidental exposure actually do. We\'re
looking at Purell, but we need a much bigger study before we can know
where cutoffs should be for different kinds of systems. I should
emphasize that because low cutoffs are fine if you take a clinical
approach and you\'re not punitive, but in a punitive system, as with
poppy seeds, we\'re going to need a much higher cutoff I believe so we
don\'t harm people as we\'ve done.

DR. CLARK: Melody?

MS. HEAPS: This is draft even though it looks final?

DR. SKIPPER: It\'s a pretty draft.

MS. HEAPS: Yes, it\'s a pretty draft.

Actually without looking at page 3, if you look at page 1, the second
column, last sentence, currently in determining abstinence, \"There is
no biomarker test that sufficiently proves specificity for use as a
primary.\"

So it would seem to me that the purpose of this as an advisory ought to
have, starting out, what the advisory is highlighted. That paragraph
that I just referred to ‑‑ or that sentence, as well adding then what
Dr. Skipper was talking about I think ought to be up front. It ought to
be emboldened. This is the advisory.

Part of the problem I had in reading this is if I were a judge, if I\'m
a person who wants to reach for an easy, quick fix, I don\'t know that
I\'d get through this paper. I need something up front that says the
biomarkers are this. There are tests. You may be using it in
professional, regulatory, and/or justice-related things. This advisory
is for the purpose to let you know that, and then go on to all of the
detail. I really think we need to get that up front.

DR. CLARK: Val?

MS. JACKSON: Yes, I really agree with what Melody is saying. I also
would like to recommend Dr. Skipper\'s recommendation to SAMHSA that
perhaps ‑‑ I don\'t know if it\'s a workshop. I don\'t know exactly what
method it is, but some way of actually taking a stance on this as you
have described the lack of answers and to try to get this out. Hearing
these stories and understanding the issue a little bit seems like a
serious issue that may be impacting a lot of people\'s lives.

DR. CLARK: Well, we will take into consideration Dr. Skipper\'s
suggestions and those of Melody and yourself before we do the final
publication copy. This is a prepublication copy which we wanted to get
before this council. We would not want to make substantial changes in
the document since it\'s been approved.

Frank?

DR. McCORRY: I\'d also like to suggest that I\'m not quite sure who the
audience is on this because it seems like this audience is very, very
large because people are being affected, whether it\'s through criminal
justice, through licensing boards, through courts, through public
welfare, that there has to be a very, very strong education campaign
here because it\'s undercutting the people in recovery based on a test
that doesn\'t have merit for that kind of action.

Another suggestion, I think the suggestion about NIAAA moving on this.
We are the services branch of the federal government ‑‑ to recommend
strongly to NIAAA that they find a way to fund some studies that can
start to get at this issue of cutoff and trying to draw some
distinctions as well around the use of these kinds of markers for legal
sanctions as opposed to clinical sanctions.

DR. CLARK: We have discussed the content of this advisory with NIAAA and
part of the consensus process involved their opinions on the matter.

I think the key issue from our point of view is to focus on the science,
and if the science is absent, we need to stress that. That\'s what Dr.
Garlick has brought to our attention. As a result of that, Greg and
others have done a fairly exhaustive review of the literature and we
keep coming up with the same conclusions that you\'ve heard, that if,
indeed we\'re going to use these tests, that they need to have a
stronger basis in the science because it does undercut recovery, both in
terms of criminal justice and in a non-criminal justice context.

DR. McCORRY: Statements like a score above 250 is proof positive of
alcohol consumption, which by the science is ‑‑ I\'m not sure if we\'d
say it\'s false. It\'s false. As we understand the science today, it\'s
false. Whether there\'s some legal opinions that can be rendered to that
from SAMHSA or CSAT around just the scientific basis that, in fact, that
is not the case, that consumption of alcohol is not proved at those
kinds of levels, whether it\'s in the advisory or some other ‑‑ I agree
with Melody. We\'ll read this, but that drug court judge or that
licensing board wants ‑‑ like it\'s got to be there, and also perhaps
advising the labs that in fact those statements are libelous. I mean,
those are actionable in terms of legal if they are defining something
which in fact isn\'t in evidence.

DR. CLARK: Ms. Bertrand?

MS. BERTRAND: I just want to say to the ladies that spoke here today
that I commend you for being the voice for those people out in the
community who have probably experienced the same thing that you have.
I\'m in recovery for 16 years and I can only imagine what it\'s like to
have overcome the most difficult challenge of my life to go back and
have my profession sort of taken from me because of some measure that\'s
not accurate.

Dr. Clark, you said this at a conference I was at a while back about how
alcohol and other drugs actually hijack your brain, and to overcome that
and then deal with the stigma that\'s attached to being in recovery and
then the oppression from not being able to practice in something that
you\'ve spent many years and you\'re like in that lower ‑‑ you know, one
of the few. So I just encourage you to continue to be the voice for
those that are also experiencing what you are.

And I encourage the council for us to put something together to advise
the licensing boards that there are no absolutes in the way that we
measure the things that we do. The work that we do is odd. I tell people
all the time it\'s not right or wrong. It\'s really just our discretion.

DR. CLARK: Melody?

MS. HEAPS: I\'d like to move that the council initiate leadership in
this working with, of course, CSAT on creating an educational campaign
to professional and criminal justice bodies with regard to the
limitations and the properties of this test and its effects.

MS. JACKSON: Second.

DR. CLARK: It\'s been moved and seconded that CSAT ‑‑ do you want to
repeat?

MS. HEAPS: That the advisory council with the Center for Substance Abuse
Treatment staff help develop an educational campaign for professional
regulatory bodies and criminal justice agents around the country
regarding the limitations of this test and its potential for negative
and adverse effects.

DR. CLARK: It\'s been moved and seconded that CSAT and its council
develop materials to inform and educate professional bodies around the
country.

DR. McCORRY: Melody, what are your ideas on it?

MS. HEAPS: I want to be clear that we\'re talking more than materials.
The idea would be that we would help in the development of some
materials, user-friendly materials, and then plot out whether we can ask
Dr. Clark to write letters, for instance, to the American Probation and
Parole, the American Correctional Association, or the single state
agency directors, saying you have been informed. Many of you may be
using. This is an advisory. So there are those kinds of ideas. So it\'s
more than just the materials. It\'s the dissemination and the method of
communication.

MS. BERTRAND: I just wanted to say like a news alert.

MS. JACKSON: And I was going to add the physicians\' assistants, the
lawyers\' assistants, the clinical boards. I mean, those are all
identifiable groups that can be warned, so to speak, or advised ‑‑
let\'s not use the word \"warned.\" These ladies might want to use
\"warned,\" and I\'m not too sure if I would blame them. However, I
think that it definitely needs to be widespread among those licensing,
anyone who could be considered punitive, black/white kinds of decisions.

DR. SKIPPER: I would like, if it\'s possible and not too costly, to have
an educational program where we would invite representatives from each
state to come and at least educate one person from each state about
this, maybe spend a day with them and go over it in more detail.

DR. CLARK: It sounds like we\'ve got a complex motion. What I\'d like to
do is table the motion and bring it back up later this afternoon so
you\'ll all have an opportunity to reflect on it. I\'m assuming everyone
is going to be here. And then we can bring it to a vote.

MS. HEAPS: Dr. Clark, I\'m not sure I agree that it\'s complex. The
actual activity may be complex, but this concept of working with CSAT to
develop an educational campaign is ‑‑ I don\'t know how complex that is.

DR. SKIPPER: We could work out the details of what the educational
campaign included later.

DR. CLARK: All right. Well, then we\'ll take it to a vote. All those in
favor of the motion?

(Chorus of ayes.)

DR. CLARK: All those opposed?

(No response.)

DR. CLARK: The vote is unanimous. Thank you very much.

With that, we will adjourn for lunch and we will see you this afternoon.
I have a competing meeting at 1 o\'clock, but I\'ll be back later.
George Gilbert is going to chair the meeting. Thank you.

(Whereupon, at 11:57 a.m., the meeting was recessed for lunch, to
reconvene at 1:30 p.m.)

[AFTERNOON SESSION]{.underline} (1:38 p.m.)

MR. GILBERT: I think we\'ll go ahead and get started again. Welcome
back, everybody, for the afternoon session of our National Advisory
Council meeting. We want to try to get started because we have a
conference call set up and our conferees are on the phone waiting for
us.

This segment of our meeting relates to the Proposition 36 in California.
The State of California, Department of Alcohol and Drug Programs
supported a cost/benefit analysis of the state\'s Proposition 36. Prop
36 has offered drug treatment rather than incarceration for nonviolent
drug offenders since 2000. In reviewing the information from over
135,000 individuals who have entered the program, the UCLA analysis has
found that there is significant cost savings for all who entered the
program, with the highest cost savings realized for offenders who
complete treatment. This information has significant implications for
the substance abuse community, as well as collaboration with the
criminal justice field.

We have on the line today staff from the California Department of
Alcohol and Drug Programs and UCLA\'s Integrated Substance Abuse
Programs. Larry Carr, Ph.D., is the Deputy Director, Office of Applied
Research and Analysis at the California Department of Alcohol and Drug
Programs, and Angela Hawken, Ph.D., is an economist and policy analyst
at the UCLA Integrated Substance Abuse Programs and also an Assistant
Professor of Economics and Policy Analysis in the School of Public
Policy at Pepperdine University. We\'re delighted to have them with us
today to present the results of this analysis.

Larry and Angela, are you on the phone with us?

DR. CARR: Yes, we are.

DR. HAWKEN: Yes, we are.

MR. GILBERT: Great. Welcome. Thank you for taking time out of your
schedules to make this presentation today. We\'re sorry our video hookup
didn\'t quite work, but we do have your PowerPoint presentation. So
we\'re going to follow along as you present the study. Anne Herron from
our Division of State and Community Assistance is going to play the
Vanna White role today and flip the slides for us.

So, Larry and Angela, it\'s all up to you. Thank you.

DR. CARR: Good afternoon. I\'m Larry Carr with the California Department
of Alcohol and Drug Programs. I would like to thank the meeting
organizers for inviting Dr. Hawken and me to present today.

You\'re about to hear a brief overview of the cost/benefit analysis
conducted by the University of California at Los Angeles about
California\'s Proposition 36 initiative. We should still be on our title
slide here. This analysis is part of a much larger five-year statewide
evaluation of this initiative. The final report will be published in
January of 2007. Previous annual reports are available on our website at
www.adp.ca.gov, and we can come back to the website at a later time if
people didn\'t get a chance to write it down.

Let me direct your attention to slide 2. I\'d like to acknowledge the
Proposition 36 Evaluation Advisory Group. This is a group of scholars
and academicians who have helped us over the past five years. They asked
critical questions of UCLA as the evaluation is being conducted and the
analyses were being conducted.

Also, I\'d like to acknowledge the authors of the evaluation: Dr. Angela
Hawken, who we\'ll hear from in just a moment; Darren Urada of UCLA; and
Douglas Anglin of UCLA; and finally, Douglas Longshore of UCLA, the
principal investigator. We lost Doug Longshore to cancer in December of
last year, and we miss him very much. He has provided for us one of the
most stellar works that has been seen in the drug abuse area regarding
Proposition 36 and alcohol and drug abuse in association with the
criminal justice system.

I\'d like to direct your attention to slide 3 at this point. I don\'t
know if I want to read this to you, but this just provides you the
background of Proposition 36 for those individuals that aren\'t familiar
with it. Proposition 36 was passed by the voters of California in
November of 2000 and enacted into law as the Substance Abuse and Crime
Prevention Act, lovingly called SACPA. Adults convicted of nonviolent
drug-related offenses and otherwise eligible for SACPA may be sentenced
to probation within the community drug treatment system instead of
either probation without treatment or incarceration. Offenders on
probation or parole who commit nonviolent drug-related offenses or who
violate drug-related conditions of their release may also receive
treatment under this initiative. An independent evaluation of SACPA\'s
implementation, fiscal impact, and effectiveness was also mandated by
the initiative.

I\'d like to direct your attention at this point to slide 4. This is
considered such a landmark study that the 2005-2006 California budget
trailer bill language was enacted to highlight the critical importance
of this analysis.

At this point, with those introductory remarks, I\'d like to turn the
discussion over to Dr. Hawken who will take us through the substantive
areas of the analysis.

Dr. Hawken?

DR. HAWKEN: Thank you, Larry. Good afternoon, everybody. Thank you for
beaming us in this way. It\'s a pleasure to be speaking with you all.

Before I begin, I\'d just like to make one comment and that is I do
apparently have a slight accent. So what I\'m going to do is try and
slow this down as much as possible, but if anybody in the room is having
a hard time understanding, if someone can wave something to me over the
phone, that will help.

Just to give you an overview, the newsworthy aspects of this, here are
our key findings. I\'ll now start speaking to you from slide number 5.

SACPA substantially saved costs in California.

DR. HERRON: Angela?

DR. HAWKEN: Yes?

DR. HERRON: Excuse me, Angela. Would it be possible for you to slow down
just a little bit? People are having a little bit of difficulty.

DR. HAWKEN: Sure.

Our first key finding is that Proposition 36 saved a lot of money. We
estimate that during the first five years of the law, we saved the state
about \$800 million.

Our second key finding is that outcomes were much better for certain
kinds of offenders than for others. SACPA doesn\'t work equally well for
everybody.

Our final key finding is that this policy can be improved, and one of
the purposes of the evaluation is to identify ways to keep on refining
this law to make it a more and more efficient law.

Bringing your attention now to slide number 6, just to give you an
overview of this talk today. I want to start by describing the
cost/benefit analysis to you describing three studies that we performed,
including details of our comparison group and why this research is
really quite different from any other treatment evaluation research
you\'ve seen before. I\'ll walk you through our study design, share with
you our findings, and then finally move on to our conclusions and our
recommendations.

The first study we conducted we called SACPA, an evaluation of the
policy. What we did was compared outcomes for anybody who was convicted
of a Proposition 36-eligible crime and compared their outcomes to a
group of comparison offenders. Where our comparison group comes from is
a group of individuals who were convicted of the same charges but just
prior to the time that Proposition 36 was implemented. So this really
looks at the effect of SACPA on the entire policy environment. We don\'t
only study people who had opted into SACPA. Everybody here is included.

In the second study, we looked at how costs and outcomes changed based
on the offender\'s degree of participation in SACPA. Here we compare
outcomes for those who never entered treatment, for those who entered
treatment but did not complete, and for those who went all the way
through the treatment program and successfully completed treatment.

Our final study, study 3, we refer to as our cohort comparison study.
The goal of this study was to try determine whether cost outcomes
changed as the Proposition 36 policy matured. We were concerned that we
might have seen changes as law enforcement or the treatment community
reacted to the implementation of Proposition 36. We were concerned that
we might find that the first year following implementation was quite
different from follow-up periods. So we did an outcome analysis of the
people who were convicted during Proposition 36\'s first year and
compared those outcomes to what we observed during the second year after
the law had been implemented.

Just to give you a highlight of our study findings, when we evaluate
SACPA as a policy, here we look at outcomes for anybody who was
convicted of a Proposition 36-eligible crime irrespective of whether or
not they accepted Proposition 36. The idea here is to provide an
evaluation of what we in the research community call an
intention-to-treat model. The benefit-to-cost ratio here was 2.5 to 1;
that is, we found that \$2.50 were saved for every dollar invested in
the program.

Our second study, which considered outcomes based on the degree of
participation in Proposition 36, found ‑‑ and this is probably no
surprise to any of you in the room ‑‑ that outcomes were much better for
individuals who managed to go all the way through the treatment program.
For treatment completers, we find a benefit-to-cost ratio of \$4 for
every dollar invested.

And finally, our cohort comparison study. We did find some small changes
in the second year. In particular, we found improvements in arrest and
conviction costs in the second year, but by and large, the cost/benefit
ratio was quite similar from year 1 to year 2.

I\'m now going to slide number 9. One of the strengths of this
evaluation was our ability to identify a very closely matched comparison
group. The SACPA group got Proposition 36 offenders that we\'ll be
describing to you today for those who, in the primary analysis in our
first two studies, were individuals who were sentenced during the first
year of Proposition 36, that is, between the 1st of July 2001 and the
30th of June 2002. Our comparison group were individuals who were
convicted between the 1st of July 1997 and the 30th of June 1998. The
reason we had to roll back so far to pick up our comparison group is we
wanted to allow sufficient time to follow offenders up in our
post-period for 30 months. We had to roll back in time to give ourselves
enough room to follow up those offenders before Proposition 36 kicked
in.

Moving on to slide number 10, to give you details of our design, a
further strength of this analysis was our ability to secure
administrative data on all of our offenders across many, many outcome
domains. The limitation of some of the other research you\'ve seen is
that many treatment evaluation studies rely on self-reporting from
offenders. This isn\'t necessarily very reliable and would certainly be
a problem when you\'re looking at a study that looks forward and
backwards as long as our does, which is a 30-month follow-up and
follow-back period. Our ability to rely solely on administrative data
really gives added credibility to the findings that we present today.

The study perspective was an interesting one. In California, we have
been in an era of tight budgets. The Governor and certainly our policy
makers in Sacramento have been very concerned about the fiscal
implications to the state of the implementation of Proposition 36. Our
study perspective that we chose was called a taxpayer perspective. What
this means is that only costs and benefits that directly affect state or
county budgets are included in the analysis. So, for example, we did not
put a value on the benefits of changes in quality of life because people
have received treatment. We only make a tally of any cost of benefits
that has a direct budget effect.

The unit of analysis in this study is a per-offender analysis, and at
the end, we aggregate up based on the number of individuals who are
sentenced each year under SACPA. In California, we sentence each year
just under 70,000 individuals who are convicted of a SACPA-eligible
crime.

Our follow-up period for year 1 and year 2 is a 30-month forward and
back window. Study 3. This is our cohort comparison between year 1 and
year 2 uses a 12-month follow-up and follow-back period. The reason we
switched to a 12-month window in the final study is that for year-2
offenders, there was not 30 months of data available for that group.

I\'m moving you now to slide number 12. This is a cost analysis. Costs
and benefits are made up of two components. The one is a quantity. Here
we used our administrative data to provide us with counts of numbers of
days in jail, numbers of days in prisons, number of days in treatment by
modality, et cetera. We count how many days or how many crimes,
depending on the outcome variable for the 30 months following and the 30
months before the offender was convicted of their SACPA-eligible crime.

To this we attached a price. In some of the outcome domains, we
collected prices directly ourselves as part of the evaluation, and for
some of the domains, we relied on some authoritative source and went to
the literature for those.

Because of the strength of the data and the very large databases that we
were able to secure and because of our comparison group, we were able to
implement a study design that allows us to make very strong calls or
statements about the effect of Proposition 36. To do this, we
implemented what is referred to as a difference-in differences design.
What this means is that we look at the outcomes for Proposition 36
offenders in a follow-up period. We compare that to their follow-back
period, and we compare that difference for the Proposition 36 offenders
to the difference that we observe in the comparison group. The
difference between those differences is what we attribute to being the
causal aspect of Proposition 36 and each of those outcomes (inaudible).

I\'ll move you to slide number 14. Everything you\'re going to see here
today is going to be represented as a very simple bar chart. Just trust
us ‑‑ go on faith ‑‑ that underlying each of these bar charts is a lot
of highly sophisticated statistics that we will not make you march
through today, but for those of you who are interested, the report is
available online and our technical appendix is forthcoming in our
five-year evaluation report that\'s due out at the end of this year.

Moving to slide number 15, what I would like to do is briefly walk you
through how you would interpret the values that you\'re going to see
here today, how you interpret the difference-in-differences estimates.
For example, if you see on a hypothetical module an estimate of minus
1,000, how you would interpret that value is at the per-offender costs
on that outcome are \$1,000 lower than what we would have expected to
see had Proposition 36 not been implemented. In other words, any
negative sign is a cost savings to the state; any positive sign is an
additional cost that the state has borne as a result of Proposition 36.
Again, this is compared to what we would have expected had the law not
been implemented.

I bring you to slide number 16. These are the domains over which we were
able to cost our offenders. Anything in green we were able to collect
data on and were able to use the data as part of the evaluation. The
numbers you will see reported today include prison costs, jail costs,
probation, parole, arrest and convictions, drug treatment costs, health
costs, and taxable earnings.

UCLA was able to obtain information on welfare. Unfortunately, we were
not able to include this even though it\'s clearly a very important
domain. We were not able to include this in our final numbers because it
was impossible for us to disentangle the effect of Proposition 36 from
the effect of California\'s welfare reform. What we observed when we
looked at that data are individuals tumbling off of the caseload. Now,
we were not able to attribute the tumbling effect cleanly to Proposition
36. We have a descriptive report where we show what happened to welfare
for our Proposition 36 offenders. Fewer of them received welfare
following their entry into Proposition 36, but the benefit of that
welfare reduction is not in the 2.5 to 1 that I mentioned earlier.

Finally, a domain that we had very much wanted to include is mental
health. Many of our offenders entering Proposition 36 have mental health
issues, mental health problems. We were not able to include mental
health costs into our analysis because of the way the data had been
collected. Our Proposition 36 offenders had good data in terms of mental
health, but in our comparison group, unfortunately, in 1996, 1997, they
were not collecting that data electronically. Given that we were
studying hundreds of thousands of offenders, it was simply not feasible
for us to capture that data to include it into the study.

Moving you now to the findings, would you please move to slide number
18. This is what we have found.

Study 1, just to remind you, is our evaluation of SACPA as a policy.
This is an intention-to-treat model here. We studied anybody who was
convicted of a Proposition 36 crime irrespective of whether they
accepted participation in SACPA. This is a study of the entire policy
environment.

What we find, moving quickly to slide number 19, is an explanation of
how the difference-in-differences model works. I\'m going to do this for
just prison costs and jail costs and then take you to an executive
summary slide where you can see a snapshot of our findings across all of
the domains.

If you look at the prison cost module here, the first thing to notice is
the values that you\'re seeing here are averaged over all offenders.
That means it\'s averaged over individuals who did have a prison stay,
as well as those who did not. If someone was not sentenced to prison,
they would have had a zero cost assigned to them for prison costs.

What I\'d like to do to start is direct you toward the left of the
graphic that you\'re seeing where it says \"comp.\" That means
comparison group. If you have the benefit of color on your end ‑‑ I\'m
not sure what you\'re seeing ‑‑ if you look at the most left-hand bar
there ‑‑ on my screen it\'s colored in blue ‑‑ what you\'ll see there is
a value of \$3,250. This is the pre-period average cost over all
offenders for prison stays. For the 30-month period prior to their
conviction, the average comparison group offender had a \$3,250 prison
cost associated.

The purple bar or the lavender bar ‑‑ I\'m not sure what you\'re seeing
‑‑ is the second month follow-up cost for a prison stay that\'s averaged
over all of the offenders. You\'ll see that there\'s a big increase
following the date of conviction of this nonviolent drug arrest. The
average prison cost over all offenders is about \$9,000. In the
comparison group, what we saw is the difference between the follow-up
period and the follow-back period was about a \$6,000 increase in prison
costs over the group.

If you now go on to the right-hand side of the bracket, you\'ll see the
SACPA. That\'s the Proposition 36 offenders. From that group we found
there\'s a \$2,300 increase in prison costs per offender.

In the difference-in-differences model we\'re now concerned with the
differences between those two values. What we find is a \$3,500
reduction in the average prison costs for Proposition 36 offenders. That
is, we spent \$3,500 less on average than what we would have expected to
spend on them for prison costs had the law not been implemented.

To walk you through some of the details here, for example, for this
prison costs module, we were able to obtain the number of days served in
prisons for each of our Proposition 36 offenders, as well as for the
comparison group, and for those days ‑‑ the counts now, the quantity of
days they spent in prison, we attached a price. And the price we
obtained from the California Department of Corrections, and in 2005
dollars, it was \$84.74 a day.

A very similar pattern we see for jail costs, a much more significant
cost in the comparison group ‑‑ this is now slide number 20 ‑‑ a much
larger increase for the comparison group than for the SACPA group, and
what we find here was about \$1,500 reduction in the average jail costs
for our offenders.

Moving now to slide 21, you\'ll get a snapshot of our findings across
all the domains. The easiest way, just to remind you, to interpret this
graphic is the X axis, the X bar, you can think of as being cost
neutral. Anything above the line is an additional cost to the state as a
result of implementing Proposition 36. Anything below the line is to be
interpreted as a cost saving.

What you see very quickly, very clearly is that, by and large, the
savings because of Proposition 36 are due to incarceration. Very
significant reductions in costs due to prison and jail.

Looking at probation, we see a slight increase in the average offender
cost for probation. It\'s absolutely to be expected. SACPA is an
alternative sentencing policy. More individuals are on probation because
fewer of them were incarcerated.

We see a reduction in cost, the savings, for parole. This too is not a
surprise. There were fewer individuals under Proposition 36 who made it
into prisons and therefore, as we follow them out, fewer of them turned
into parolees. There was a slight parole savings as a result of
Proposition 36.

Looking next to arrest and conviction, what we find is the uncomfortable
bump in the middle of the graphic. This is arrest and conviction costs,
and what we find is compared with what we would have expected if
Proposition 36 had not been implemented, we\'ve got a \$1,300 increase
per person in arrest and conviction costs.

Now, clearly this was an issue of concern for us, so we spent much time
at UCLA trying to understand what it is we were seeing here. Compared
with the comparison group, there were many, many more Proposition 36
offenders who stayed on the streets rather than being diverted to a jail
or prison. Simply by virtue of being on the street rather than in jail
or prison, individuals have more opportunity to be arrested for a new
crime. They\'re on the street. They\'re available to commit new crimes.

What we did do was make an adjustment for ourselves just to make sure we
really understood what was going on there and converted this to a dollar
per day spent on the street. If you adjust for incarceration time, what
we do find is that there\'s really no difference. Indeed, the
Proposition 36 offenders were significantly less costly in terms of
their crime costs overall.

Still, we wanted to understand the arrests and convictions better.
Clearly, there\'s a public safety issue in this regard. So we did a very
careful analysis of who was driving these arrest and conviction costs. I
would love to be before you right now with a white board and scribble
this down for you. But what we found is that most of the offenders
commit very little crime and contribute very little to crime costs
overall, but there\'s a tiny group of offenders who really bump up the
arrest and conviction costs, a small group of them who are responsible
for a significant contribution to that end.

UCLA was quite concerned about that and did an in-depth study to try to
figure out whether we would be able to determine the characteristics of
the individuals who were most likely to be in that high crime cost
category and compare those individuals to individuals who contributed
nothing or very low amounts to overall costs.

We initially did a study. We looked at demographics, and what we found
was that there was very little difference based on gender. There were
high crime costs individuals who were slightly less likely to be female.
In other words, there were slightly more males. They were very slightly
younger. There was no difference based on race/ethnicity to help us
predict if someone would be a high-cost offender or a low-cost offender.
We did find one characteristic of that group, that very high-cost group,
that had a striking policy implication, and it\'s highlighted in our
recommendations in our report. The best predictor of whether or not
someone was going to be a high-cost offender was the number of prior
convictions they had had in the 30 months preceding their current
conviction after their Proposition 36 offense.

We then looked to see how crime costs changed as the number of prior
convictions increased, and we found a very clear threshold effect, a
huge jump in the person\'s follow-up crime costs. We went from four
prior convictions ‑‑ now, this is convictions, not arrests ‑‑ to five
prior convictions in the 30 months preceding. We find that the group of
individuals ‑‑ they\'re a very small group ‑‑ about 1.6 percent of
Proposition 36 offenders have five or more prior convictions. And that
group itself contributes hugely to the overall arrests and convictions
that we find in the follow-up period. This proportionally contributes to
that cost.

But clearly we have a recommendation there and have suggested that that
group of individuals either be made ineligible for Proposition 36 or
that they be monitored much more strictly in the community if they
remain under Proposition 36 (inaudible).

Moving now to the next bar where we see treatment, this is treatment
programs, the treatment alternatives. We are not surprised to see an
increase in treatment costs per offenders, although we did indeed find
that.

The next module, health, is an interesting one. As we started this
analysis, we wondered what would be our a priori expectations. What we
mean by that is before we look at our data, what would we expect to see
in terms of health outcome. The recent literature on this domain was
quite mixed. A number of studies you\'ll hear referred to as the cost
offset study mention the benefits of treatment, and one of the benefits
that you\'ll see lists expenditure on health care, suggesting that we
would find here an additional savings to the state. Other literature had
movement in the opposite direction, that if someone enters treatment,
they\'re more likely to seek out health care, and that literature
suggested to us that we would find an additional cost here.

We did the analysis and what we found is that there was an increase in
health care costs associated with Proposition 36. We disaggregated this
data into monthly costs where people were contributing and found
something quite interesting. We found that at the time the individual
entered treatment, there was a real spike in their health care costs.
Clearly, individuals are showing up for substance abuse treatment and
their providers are encouraging them to seek out the other kinds of
medical care that they need.

What we find very quickly, though, is that health care costs start to
settle down, and this really speaks to the importance of longer-term
evaluation so we can get past those spike points to see how
individuals\' health care costs then start to fall as they\'re receiving
the care that they need. They\'ve had their health care needs taken care
of, and now they become much less costly over time in that health
domain.

The final module we looked at was employment earnings. We only studied
the taxable portion of that. To be consistent with our taxpayer
perspective, we looked at how much money they had paid to the state.
You\'ll notice it\'s below the line, which suggests that the cost
savings to the state for the tax one. What this means is that
Proposition 36 offenders paid more in taxes than the comparison group
offenders and more people were employed under Proposition 36 than were
employed in the comparison group. Individuals were more likely to keep a
job.

This was not a very high-earning population. The tax implications of
Proposition 36 are not significant, but clearly there are benefits here.
The greater benefits come in just having people employed. They\'re less
likely to be on welfare. It\'s good for a child to see their mom and dad
getting up in the morning and putting on a suit or putting on lipstick
and heading out the door. So there are certainly greater social
implications of the tax module even though the tax savings or the tax
gain were not very large.

Just the last point on that slide 21. Across all of the domains, when we
tally up, we found about a \$2,800 per-offender savings across all the
domains. What that leads us to conclude, once we do all the math, is
about a 2.5 to 1 benefit/cost ratio. That is, about \$2.50 saved for
every dollar invested.

Briefly, to walk you through our second study, the second study we
looked at how outcomes changed based on the individual\'s participation
in treatment. If someone was referred but never entered treatment,
comparing those to individuals who went in but didn\'t go all the way
through, and the individuals who make it all the way through the program
and successfully complete treatment.

In this slide number 24, you\'ll see a summary slide of our findings
based on treatment participation. For the first 2 months, for prison and
for jail on the left-hand side of your screen, you find exactly what you
would expect to see. The yellow bars are the individuals who completed
treatment all the way through, a much larger savings for those who go
all the way through the treatment program. For those who have some
treatment but don\'t complete, we see more significant savings on prison
and jail than for those who don\'t receive any treatment at all. But
it\'s interesting to note that across all three of those groups, there
were sizeable savings in terms of incarceration costs. Again, this is
not a surprise. This is an alternative sentencing program. Individuals
were being offered treatment in lieu of incarceration.

There\'s not much to write home about in terms of probation and parole.
You\'ll see the savings there reported.

The module I\'d like to direct your attention to, which is an
interesting one, is the arrest and conviction module. What you\'ll
notice for arrest and conviction is that the yellow bar here is our
treatment completers. They add much less to arrest and conviction costs
than do those individuals who don\'t complete treatment.

But what\'s striking about this module is the purple bar in the middle
there. Those individuals who entered treatment but did not complete are
more costly in terms of criminal recidivism than those who never entered
treatment at all. This looks like a surprising finding, but clearly we
went back to our offices to try to figure out what was going on. There
are a few underlying explanations for this module.

The first is individuals who never entered treatment at all were much
more likely to land back behind bars. Once they were taken off the
street, they had less opportunity to commit new crimes.

The second issue was the nature of the individuals who chose never to
enter treatment following their referral into Proposition 36. We studied
the characteristics of those folks who never appeared, and they broke
out into two very clear, distinct groups.

The one was a group of individuals who had squeaky clean histories, very
little going on, no priors, very little in the way of prior treatment
history. These were individuals who figured out for themselves that if
they never arrived at treatment, that nothing was going to happen to
them.

The other group of individuals were exactly opposite. They were the
really bad apples. They had long criminal histories, all sorts of
nonsense going on. The bad apples who just decided that they weren\'t
going to go to treatment anyway. It just wasn\'t for them.

The good apples in that group really messed around with our averages
there because they decided not to go to treatment, but they were moving
forward and being picked up again, and between the two effects of having
a group of individuals who didn\'t get to treatment who had quite clean
histories both in their priors and their follow-up period and the effect
of those who were the bad apples very quickly being reincarcerated, we
found that unusual result in arrest and conviction.

Finally, for our treatment module, we see exactly what you would expect
to see. Those who go all the way through treatment cost more, in terms
of treatment, than those who never enter or those who don\'t go all the
way through.

Small differences by health. Those who complete treatment had slightly
more expenditure on health. Again, that\'s very likely to be the effect
of actually going through substance abuse treatment and having service
providers encouraging them to get their other health needs taken care
of.

And then finally, we see more significant tax returns from those who go
all the way through treatment.

So, by and large, no real surprises in this, the treatment completers
doing much better than everybody else, and on slide number 25, we find
the benefit-to-cost ratio for those who finished the program of about
\$4 to \$1. That is, \$4 were saved for every dollar that was invested
in the individual who made it all the way through treatment.

Study 3. This is our cohort comparison study comparing how outcomes
changed during Proposition 36\'s first year with outcomes during the
second year. This study used a 12-month follow-up and follow-back period
I mentioned earlier. We didn\'t have data for a 30-month follow-up study
for our year-2 offenders.

What we see is that looking at slide number 27, outcomes are really
quite stable, some improvement in terms of arrest and conviction costs,
but our benefit-to-cost ratio is really quite stable from year 1 to year
2. That was about \$2.20 saved for every dollar invested looking over a
12-month window.

Moving into slide number 30, I\'m going to talk about conclusions and
recommendations that followed from our cost analysis and recommendations
included in the final UCLA evaluation. I\'m breaking these up into three
sections. One is those that followed specifically from the cost
analysis, and I\'d like to separate those out from the other UCLA
evaluation recommendations that we\'ve been making.

Our first recommendation is that with Proposition 36, funding has
yielded a favorable cost ratio and that, at least on fiscal grounds,
continued funding of SACPA is justified.

Our other recommendations are to improve treatment entry and treatment
retention in the program. One of our concerns at the moment with
Proposition 36 is how many individuals are gone and never set a foot
into a treatment provider facility. We lose about 50 percent of our
offenders between the date of conviction and time of treatment entry,
and 30 percent of them never receive care. So we have recommendations to
improve treatment entry as well as completion.

Following from the findings on arrest and conviction, we found that a
very small percentage of offenders are responsible for a large
percentage of the new crimes committed. There was 1.6 percent of the
offenders with five or more prior convictions who were really driving up
our follow-up arrest and conviction costs. We have recommendations that
speak to managing this difficult population differently. For those
individuals with many prior convictions, we suggested either changing
eligibility of SACPA to exclude them from sentencing under SACPA or to
have greater offender and agency accountability, possibly putting them
into residential care rather than outpatient care to start.

Moving now to UCLA evaluation findings not based on the cost study, one
of the recommendations that UCLA is making is to improve treatment
matching. Following the implementation of Proposition 36 ‑‑ and I\'m
sure you can appreciate the shock that Proposition 36 resulted in in the
treatment community. We had 2,000 individuals convicted of Proposition
36 each year, a huge, huge shock to the system. The number of
individuals referred to treatment through criminal justice doubled the
year following implementation of Proposition 36.

As a result, we simply ran out of capacity very quickly in terms of,
particularly, residential care. One of the recommendations we\'ve made
is increase the use of residential placement for our high-addiction
severity offenders.

Proposition 36 not only led to many, many more people entering treatment
through the criminal justice system, but also resulted in big
differences in the kind of individuals entering care. This is, by and
large, a much more seriously addicted population than what we\'ve seen
before.

We\'ve also made a recommendation of an expanded use of a narcotics
replacement therapy. In California, if an individual refers to treatment
with an opiate addiction and enters care, 87 percent ‑‑ that\'s 8-7, 87
percent ‑‑ of those individuals are put into a narcotics replacement
therapy program. Among Proposition 36 offenders, that same rate is 14
percent. That\'s 1-4. So 14 percent of those offenders are receiving
maintenance care. So we\'ve made recommendations to try to understand
better the barriers to expanding that kind of care.

Finally, looking to address cultural issues to make sure that our
offenders are being placed in a facility that is sensitive to their
cultural needs and where they feel comfortable and more likely to
complete treatment.

Looking at slide number 37 now, we would like to make sure that there is
an improvement in assessment and treatment show rates. Our
recommendations here really seek to reducing the hassle factor of
getting people into treatment, to make it as easy as possible for folks
to succeed.

Our first recommendation is to locate assessment either at the court or
near the court. We\'ve found that for a number of individuals, if the
treatment assessment center was located far from the court, they were
much less likely to ever put their foot through the door to be assessed.
So we found that in those counties that made the practice of pushing
assessment centers right close to the court, outcomes were much better.

To the extent that it\'s possible and fiscally feasible, we\'d like to
see the incorporation of drug court approaches, wherever possible.

Certainly allowing walk-ins, as well as scheduled assessments, making it
possible for someone to be assessed whenever it\'s convenient for them.

And also to require only one visit. We did find that in a number of
locations, individuals were required to come back multiple times to
complete their assessments, and when that happened, we were much, much
more likely to lose our offenders and never see them in treatment.

We have a number of other recommendations in our report that are not
based on UCLA\'s group that rely on outside research.

The first, and this is something which is quite controversial, is our
recommendation of expanded use of sanctions. Our treatment providers
themselves have been calling for increased use of sanctions under
Proposition 36, looking for an incentive package that includes both
rewards, as well as sanctions to help them encourage offenders to comply
with the terms of their treatment. So we\'ve recommended a graduated
sanctions package of rewards and sanctions, as well as frequent drug
testing to make sure that the offenders view that it\'s being a fair
process.

To be credible, we want to make sure that this is consistently applied,
that it\'s sure and it\'s swift. It\'s at a point now beginning. The
call for increased sanctions is not coming from the criminal justice
community. This call for increased use of sanctions is coming from our
treatment providers themselves.

MR. GILBERT: Dr. Hawken?

DR. HAWKEN: Yes.

MR. GILBERT: This is George Gilbert. We\'d really like to have a little
bit of time for council member questions, and we\'re running a little
short of time. I\'m wondering if you might be able to wrap up in a
minute or two so we could have a little bit of time for dialogue.

DR. HAWKEN: That\'s perfect. I\'ll wrap up in a second.

MR. GILBERT: Thank you.

DR. HAWKEN: Our final recommendation is what the study was able to do
was show us how we could improve this law. So our final recommendation
was to have this ongoing evaluation cycle of really understanding our
offenders to keep making refinements to Proposition 36. So we\'ve
recommended this quality improvement cycle, which is currently underway.

Finally, just to sum up, the bullet take-away here is that Proposition
36 has saved California taxpayers a significant amount of money. Most of
those savings were due to prison and jail. It resulted in much greater
cost savings for those who finished the program. To the extent that we
were able, we want to make sure individuals have every opportunity to
get all the way through their treatment program.

Finally, this law can certainly be improved, and UCLA will be working
away at this to figure out how to make Proposition 36 work as well as it
can for California.

Thank you for your attention. I appreciate the opportunity to speak with
you today.

MR. GILBERT: Well, Dr. Carr and Dr. Hawken, thank you very much for that
very comprehensive presentation on Proposition 36.

I think we\'re having a little bit of difficulty with the connection.
Dr. Hawken, your voice was breaking up a little bit there at the end,
but we have a few minutes questions, if there are council members that
would have some questions for our presenters.

Val Jackson?

MS. JACKSON: Yes. I was wondering. You speak of treatment in very
general terms when you talk about it. Did you define treatment in this
study?

DR. HAWKEN: Right. One of the issues with Proposition 36 is we really
think of it as being perfectly eight different models. Each county in
California has autonomy to make these decisions on their own. So there
was no consistent definition of treatment. If the individual had
complied with the terms of their county\'s program, they would have been
deemed to have successfully completed treatment. But each county has its
own determination for what this would be. We have 58 Proposition 36
models in the State of California.

MS. JACKSON: Well, you still had success. That sounds good. But it would
be very interesting to know a breakout of criteria, for instance, using
ASAM criteria and/or what kind of assessment instruments were used, that
kind of information on the other side. That could be very helpful in
terms of looking at the population and its outcomes also.

DR. HAWKEN: The next round of the evaluation, which is about to begin,
is going to have a significant portion of that evaluation dedicated to
looking at best practices. In that section, we will definitely be
digging down into a much more detailed analysis of what was going on
there and what kind of approach seems to be working for most offenders.
So if you stay tuned, that will be forthcoming a year from now.

MR. GILBERT: Any other questions?

(No response.)

MR. GILBERT: Well, I guess that\'s it then. Oh, we have one question
here very quickly. Ali?

PARTICIPANT: I was just curious to find out whether the patients
received any mental health treatment at all or not.

MR. GILBERT: Did you hear the question?

DR. HAWKEN: Could you repeat the question? I\'m sorry.

PARTICIPANT: Did the clients receive any mental health treatment?

DR. HAWKEN: Yes. I mentioned early on they didn\'t receive mental health
care under Proposition 36, but a number of the Proposition 36 offenders
had co-occurring disorders. We do have mental health data, and we are
currently working with alcohol and drug programs to define a study to
really understand that better. A number of our offenders did receive
mental health treatment. We were not able to include that in our study
for the reasons I explained earlier. The comparison group did not have
electronic data available on their mental health services. We do have
data for the Proposition 36 offenders, though, and we have a report that
will be coming out on mental health for the Proposition 36 offenders.

MR. GILBERT: Melody Heaps, please.

MS. HEAPS: I just have some comments and I\'d be happy to call Mr. Carr
or Dr. Hawken with it.

I also just want to comment on Doug Longshore. I think this is
absolutely one of the seminal studies in our field, and we owe so much
for him and his vision and obviously to UCLA, but he was a remarkable
man and I just want to say thank you.

Two very brief comments and then I\'ll call further. When you look at
your increased conviction and arrest costs, I take it one of the things
that you\'ve considered is that when you engage the system in mandating
treatment, for those people who have failed or are not completing all
the way through, you have extra costs in bringing them back to the
system and in further prosecution. Of course, that\'s going to raise
those costs.

The question is are those costs now being borne by the county alone and
we have to take a look at that in terms of how the state funds these
kinds of things.

The second is when you talk about the recommendation on residential
care, having gone through this extensively and intimately in Illinois,
one of the things we looked at is we were always screaming about
residential care and we continue to do so. But what we also discovered
is that by intensive case management and by putting in place a managed
care kind of system where we could move people from least intensive to
more intensive, back down, and include recovery homes and so were living
environments, always within case management, we were able to cut the
costs of pure intensive residential treatment. We were able to increase
it but not absolutely rely on it alone. So there\'s a whole continuum in
the management of treatment which is very important in this.

DR. HAWKEN: Well, thank you for those comments. To respond to that, in
terms of the county costs, the costs of processing, UCLA has ‑‑ and
it\'s coming out in our report that we just finished and submitted to
the state now. We do have an analysis of divvying up the costs and
benefits between those that fall on the state and those that fall on the
counties. So much of the new arrest and conviction costs have been
allocated to the county and the state certainly is keeping an eye on
where is the county saving money, where is the county bearing more cost
as a result of Proposition 36. The study will be kept in mind as we move
forward thinking about funding rates and also the allocation formula.

One of the important issues in that, though, when it comes to county
savings, when you look at our data, you\'ll see that the counties
benefit from a significant reduction in jail costs. The counties don\'t
end up really experiencing that as a significant reduction. Our jails in
California are so overcrowded, that if you take away Proposition 36
offenders, someone else is still there because we\'re so overcrowded.
The counties may not experience that kind of cost savings as a real
bottom-line change to their budgets. So we have brought these kinds of
issues to the attention of the state, particularly in our cost-sharing
report that you\'ll see in a couple of months.

On the issue of residential care, our concern there was that in
California we\'re running huge (inaudible), individuals who really do
need that kind of care. We simply just don\'t have the capacity to do
it. We are gearing up to make that become available, but we\'re
certainly adding more on the demand side than we are on the supply side.
But certainly the continuum of care is something we\'d want to do and
can do with the resources that we have.

Thank you for your question.

MR. GILBERT: Well, Dr. Carr and Dr. Hawken, again we thank you very much
for being with us today, and we enjoyed your presentation. Thank you.

DR. HAWKEN: Thank you so much for having us.

DR. CARR: You\'re very welcome. Thank you.

MR. GILBERT: Bye-bye.

A little bit of problem with the sound there towards the end, but let\'s
move along then.

The next item on our agenda is for an update on e-therapy, and Val
Jackson chairs the council\'s E-therapy Subcommittee, and she will be
reporting on results of meetings held with CSAT staff over the summer
regarding e‑therapy. Captain Stella Jones in the DSI in CSAT is the
government project officer for this initiative.

Val and Stella, we turn the program over to you.

MS. JACKSON: Come on up, Stella.

First of all, just for purposes of memory, I wanted to remind the
council that when we developed the subcommittee, which I believe was ‑‑
I can\'t remember ‑‑ it was at the last council meeting. I agreed to
chair. Ken DeCerchio is on it. Melody is on the subcommittee. Chilo
Madrid, who is not here today, and also Judge Eugene White-Fish from
Wisconsin are the advisory members who all wanted to be on the
subcommittee. I think our sense was that this was an important mission.

I know all you need is another PowerPoint here, so I\'ll try to flip
through it quickly.

What we did through the summer was to basically try to get a handle on
what it was we really wanted to accomplish with the e-therapy. Everybody
says, gee, it\'s a great idea. We need to go someplace, but where do we
need to go? So Stella and I know Tom Edwards was part of the staff and
MayaTech worked very hard on this. We had a conversation with a few
experts. What we did was we came up with some goals and objectives. I\'m
going to report to you briefly on the activities to date and the
outcomes. So just to let you know this is really what we did this summer
in terms of progress.

I think it\'s important, though, to mention that we had to go looking
for experts who were in the e-therapy profession and also had knowledge
about either related or specific areas of substance abuse because, in a
sense ‑‑ you know, we can all go on the Internet and find all of these
things. I remember when Sheila Harmison showed us a lot of Internet
advertisements for e-therapy, but some of them were probably scams, and
we really had no idea. So we went to look for some experts. This is the
list of folks who were found and participated in this summer\'s work.

Add something if you want to. If I say anything wrong, add to it. Okay?

Some of the things that the e-therapy expert panel put together were
some definitions. To preface that, I\'ll say that it was very important
that we get some of the basics down because we felt what we needed to do
was to come out with a guidance perhaps ‑‑ that came up in the first
meeting ‑‑ that would either go to providers or to states ‑‑ I don\'t
know that it was totally defined exactly the recipient and who it would
be distributed to, maybe both ‑‑ that would come up with the issues, as
well as a definition, and some of the things that needed to be
addressed. So that\'s primarily what we\'re going to talk about today.

E-therapy is the use of electronic media and information technologies,
for instance, the Internet, PDAs, text messaging, telephone,
videoconference, to provide services for participants in different
locations. It is used by skilled and knowledgeable professionals, and we
need to, of course, address who are the counselors and the therapists,
who are the people that use it, to address a variety of individual,
familial, and social issues.

I\'ll try not to read all of these to you, but a couple of them I think
are important.

There\'s a range of services that e-therapy can do. I think we\'ve
talked about them before. In my sense, it can be used to engage. It can
be used to treat and stand alone. It can be used as a following and
continuing care. It can be used in relapse. So there are many, many uses
for this. The challenge is to pin those down and to find practices and
ways to make it work at a cost that we all feel comfortable with.

The expert panel came together with this really as the areas of
resources that had to be looked at. We have to look at the community
resources. I think regulations and legislation. One of the issues that
has to be looked at is that each state has separate regulations about
whether or not, for instance, they can even use e‑therapy as a paid
service in that state. And there may be many other regulations that I\'m
not even aware of and we haven\'t investigated yet that each state would
have to look at individually as well as federal laws that may apply in
this area. Obviously, cultural, linguistic kinds of competence. The
administration. Is it state run, privately run, however it is. One of
the very difficult things about e-therapy is that it needs rigorous
evaluation. That is a challenge in and of itself and it\'s something
that needs to be addressed in the guidance I believe.

The community resources. Of course, going through the state agencies,
the expert panel identified different resources that might be used in
e-therapy.

I want to hit this regulation and legislation just a little bit because
if we get into it and if it\'s state-regulated, it means that quite
likely there would be mandated reporting requirements. Obviously, we
have the client confidentiality requirements, requirements for
practitioners. I mentioned that before. Informed consent. How do you
handle that in an e-therapy mode when you may never have seen the
person? In some cases, the people that were the experts had a
face-to-face session before they agreed to any other kind of session,
but of course, that would limit your location. In a rural location, that
would make it more challenging to try to run e-therapy. The insurance
liability and legal protections, in terms of malpractice, are also very
important issues that the panel came up with.

Elements of cultural and linguistic competence. I think that these apply
to most of the interventions that we do, including the ethnic and
cultural, being able to face and find answers to real and artificial
barriers to cultural competence.

Administration. Again, insurance, electronic billing, how you do that,
client record keeping. These are all issues that just as a panel the
folks came up with that are challenges that we\'re going to have to
somehow come up with either some answers or some suggestions for if
we\'re going to go forward with e-therapy. I\'m believing that we do
need to go forward with e-therapy, but I\'m also seeing that there\'s a
lot of issues here. It\'s a very complex proposition. However, SAMHSA
can do anything.

(Laughter.)

MS. JACKSON: Evaluation was discussed, and I think, again, that\'s one
of the most difficult things in terms of e-therapy. At lunch we were
talking with Jack Stein, talking about how do we come up with
demonstrations or evaluations for this kind of service, and if we do,
particularly in e-therapy, it may be very, very difficult for us to look
at exactly all of the indicators that we want to look at for evaluation,
elapsed time, the retention, such things as that, substance use. You
know, you don\'t have someone on hand to do urine testing or other kinds
of testing. You may not even see the person in terms of their
functioning.

The targeted outreach. We started out this particular topic very early
in June when we talked about it. Dr. Clark, of course, has always talked
about the need for rural populations. If you recall, at the last
meeting, there was some controversy about that. Well, controversy. I\'ll
say that because Judge White-Fish isn\'t here, but he\'d probably agree
with me because I remember very specifically him saying, gee, I don\'t
know that I would want e-therapy in my neck of the woods. He doesn\'t
necessarily believe that on the tribal reservations that e-therapy would
even be appropriate. And yet, rural is probably the first thing that
comes to mind.

If you talk to me and ask me about it, I think of adolescents who are in
urban Miami, because I come from Miami, who do not have transportation
or the ability to continue their care, let alone even get primary care,
and probably could use e-therapy as a modality if we were to develop
that kind of thing.

The group looked at other kinds of underserved and hard-to-reach
populations. So, again, that\'s a question that we have. We don\'t have
all the answers yet.

To sum it up and try to keep it moving, I really was pleased with the
provoking thoughts and challenges that the group came up with this
summer. I think that it tells us that we have a really complex issue
here. However, we are all on the Internet. At least, I would suspect all
of us are on the Internet. We know that our adolescents are so
Internet-friendly, so text message-friendly, that if we do not do
something about Internet therapy or e-therapy, because it\'s a lot
bigger than the Internet, we\'re way behind the times. So I would hope
that maybe we can put our heads together this afternoon and move
forward.

I think that a couple of the suggestions have been, number one, to ask
SAMHSA to continue and to work towards a guidance that spells these
issues out more and perhaps down the line ‑‑ I\'m not too sure if we\'re
ready for it yet. I\'d be happy to hear your comments on it, whether or
not we are ready for an evaluation or a demonstration or a pilot. So
what are your thoughts? I think I\'ll open it with that.

Sorry. I missed a slide I guess. This is the e-therapy staff: Anne
Herron, Stella Jones, Reed Forman, Ruby Neville. And then the MayaTech
staff also worked on it too. I thank you very much. They did a great
job.

So with that, any questions?

DR. FLETCHER: Thank you, Val, for a very instructive presentation.

You noted the significance of moving towards some rigorous evaluation of
this program, but at this juncture, do we have any sense of or any
preliminary data on the extent to which e-therapy is being utilized and
what some of those experiences are preliminarily? Are we finding it
works better with one population group than another subpopulation group?
Do we have any of that kind of data at this point?

MS. JACKSON: I\'m going to defer to Stella for any information that came
out of the group that I was not at. However, my sense of it is that, no,
we don\'t.

Stella?

MS. JONES: There is really no research that we have to say that
e-therapy is effective, also in terms of the different kinds. But what
we hope to do in our guidance is to identify some providers or
practitioners who have had some success with various modes of technology
with specific populations, but not considering it research per se.

MR. GILBERT: Melody?

MS. HEAPS: My concern ‑‑ and it\'s not all that different from our
discussion on the alcohol biomarkers ‑‑ is that people come up with what
they say are solutions or new treatment techniques and they begin to
sell them. There is a gullible group out there ‑‑ and that\'s almost 90
percent of the population ‑‑ who buys them. Oh, this is a new thing.
This will work. And there is no group or anybody who is saying, wait a
minute, there\'s no research. Wait a minute. We need to look at this.

It would seem to me that CSAT has a responsibility at least to issue
advisories on these kinds of things. Is NIDA presently engaging in any
research on this question? What are the states and state directors doing
about this question? I\'d like to know that baseline. And then think
about what CSAT can do when this and other silver bullets or promising
potions come down the line. What is CSAT\'s responsibility in alerting
people that just because somebody says it works doesn\'t mean it works
when there are proven methods and best practices out there?

I feel like sometimes our population, the men and women that I serve in
terms of my clients, can be experimented on. It doesn\'t matter. You
name it. If it works and you say it works, what the heck. Let\'s use
them. It makes me very uncomfortable.

MS. JACKSON: I appreciate what you\'re saying. I do think that we have
to consider that, yes, e-therapy is here. It is being practiced. I guess
I would suggest that CSAT needs to be aware, at least as you had
mentioned, of what is going on and perhaps we can put some parameters on
what might be a practice that could work. Perhaps they can go from
service to science in this one.

The concern I have at this point is that while there is a little
research that shows e-therapy is promising and it has worked, it\'s just
not enough to really make any grand statements about it. You\'re
absolutely right. It compares somewhat with the previous conversation we
had.

MR. GILBERT: Dave?

MR. DONALDSON: Thanks, Val. I tell you I\'m a big proponent of this. I
think that for many people this will be the front end of the continuum
of care. In the faith community, you look at even the context of a
church where people value their anonymity, and many pastors have a
difficult time getting to those people that need help because of the
stigma in the church. I think you would find a highly receptive audience
to this in the faith community as well.

But good work. Please keep going with this. You\'re on the right track.

MR. GILBERT: Melody?

MS. HEAPS: Yes. I don\'t want to appear that I don\'t agree necessarily
that this may be a very promising method. I just think we need to
exercise some discipline as to what, how, when, and where its promise
can be fulfilled as opposed to just generically so then we have
everybody coming out saying, I do e-therapy, and it may not be the best
kind.

MS. JACKSON: So perhaps all I need, as chairing a subcommittee here ‑‑
George, I\'ll take your guidance ‑‑ is that we had started out and the
group seemed to talk about a guidance which would address some of these
issues and give us some more details about that. It would go further
into some of the research and we could further refine that. I think that
there is a commitment to go forward that way. So if that works, I\'m
happy to continue working with that, but I didn\'t want to do that
without the council feeling that that\'s an appropriate way to go.

MR. GILBERT: Greg, did you have a comment to that?

DR. SKIPPER: I\'ve recently seen a demonstration of a technology that I
think I should mention because it\'s a little more comprehensive than
just e‑treatment, and that\'s technology where drug testing is reported
through an online mechanism, notification for when to test. People log
in and get notification. Interested players, employers, people that are
monitoring an individual can have their own log-in and see how the
person is doing. Therapists can log in attendance. It\'s not so much
just the treatment in an online setting, but it\'s a management system
that I was very impressed with. So I think we\'ve got to expand our idea
too beyond just treatment online or aftercare online to a comprehensive
sort of package where drug tests reporting, in and out reporting, and
management, attendance. All that could be very effective, and I\'m very
much in favor of using the Internet to coordinate all that. So good
work.

MS. JACKSON: Thank you. I like that.

MR. GILBERT: Anita?

MS. BERTRAND: Yes. Just a suggestion. I was thinking about like some of
the groups that are having online support, such as Weight Watchers has
online meetings, 12-step programs have. They\'re calling it support. So
I guess my suggestion is that when the committee meets again, maybe
study what have they done to overcome some of the barriers that I guess
the council was thinking about.

I think that when we look at technology and where it is today, it\'s
something that we really need to continue to think about because if we
don\'t plan ahead, we will have people moving forward doing things that
they\'re labeling as therapy because I\'ve heard of inappropriate
therapies online. So if we\'re going to have that, we need to have
something to counter it too.

So just when the group meets again, maybe look at what Weight Watchers
is doing. I mean, they have online programs, online 12-step support
groups going for people that travel and who can\'t get out and all that
other stuff.

MS. JONES: In the expert panel work group, there were many discussions
with regard to e-therapy using other means or other clinical
interventions other than just saying treatment. Also, there was a
discussion around patients or clients with addictions having other
addictions as a result of using the Internet system because there are
other ways they could go in and get information. Sex might be one of
those, just as an example. So there was a lot of discussion more broadly
around some of the areas you\'ve mentioned, and we will continue to do
that work and continue to do literature reviews to finalize our
discussion and report on our guidance.

MS. JACKSON: Greg, is it possible for us to get the name of the person
that gave you the demonstration? That\'s very interesting.

DR. SKIPPER: I\'ll get that to you.

MS. JACKSON: Yes, we\'ll discuss that.

MR. GILBERT: Bettye?

DR. FLETCHER: Thinking about the students that I interact with, it
surely would be instructive for me to have also a better understanding
of the knowledge transfer mechanisms that are out there as it pertains
to this issue, as well as how is professional development taking place,
in what form, what does it look like, and how does one access that? If
this is a modality that surely has potential and value, then those two
questions become very important to me.

MS. JACKSON: Well, thank you very much. I think that this is good
discussion information, Stella, we can carry forward.

MS. JONES: Yes.

MS. JACKSON: All right. Thank you so much.

MR. GILBERT: Thank you, Val. Thank you, Stella, and thanks to the staff
on CSAT who have been working on this as well, and also to all the
committee members who have been working on it.

I think we\'ve reached the point in our schedule where we\'re supposed
to take a short break. We are scheduled to start public comment at 3
o\'clock. Do we have public comment? Okay, yes. We do have at least one
member of the public who wants to offer a comment. I\'d like to suggest
that we come back in 10 minutes please. Thank you.

(Recess.)

DR. CLARK: If we can return, we have a lot of things to do before the
session ends today.

We are at the public comment section of our agenda, and it\'s my
understanding that Ms. Thelma King Thiel from the Hepatitis Foundation
would like to make comments. Now, if there are other members of the
public who wish to address the council, if so, please come to the
standing mike and form a line behind Ms. King Thiel.

MS. THIEL: Thank you, Dr. Clark. I really appreciate that.

As you know, I\'m probably better known as the \"liver lady.\" I\'m
going to go to my grave saying they didn\'t know enough about their
liver. But again, we have found that you can\'t change what you don\'t
know, and there\'s such a lack of information that\'s not being taught
in the schools, in colleges. Parents don\'t know how to communicate with
their children about it, and we really have found that our unique
approach of using humor and analogies and information that people can
relate to is helping them to assess their own risk behaviors and
actually to change some of their behaviors.

Of course, we are looking forward to collaborating more with CSAT. We
have trained over 2,500 of CSAP\'s grantees and have more on our docket.
I just did a program recently for an AIDS group down in Dallas, Texas
for case managers, and they asked us to come back again. We\'re on their
docket for next year and for the next few months. But they ordered 125
of our videos.

We have 14 videos that are all on liver wellness, hepatitis B and C, and
substance abuse prevention. We\'ve won awards with them, and we\'re
really very excited about the success that we\'re having with them.
They\'re being used in STD clinics. They\'re very inexpensive. For a
\$35 video in an STD clinic, you can reach hundreds of people that are
participating in high-risk behaviors to at least inform them so that
they can assess their own risk behaviors and possibly change some of
those.

We had an opportunity to collaborate with Dr. Jody Rich up at the
University of Rhode Island, and one of his colleagues, Dr. Nick Zaller,
who is running a methadone clinic with a CSAT grant. He invited us up to
do a training session for 40 of their methadone counselors. I would just
like to read for you his comments following that training. Of course,
we\'ve done on our own evaluations, and I would be happy to send you a
copy of that, if you would like. But I just thought I would like to
share his comments with you.

\"The methadone clinic staff has taken the knowledge and strategies
presented in the Foundation for Decision-Making Program run by the
Hepatitis Foundation, and is using them in their client counseling and
group sessions. Given that this clinic has nearly 700 methadone
patients, the potential to reach many people who are at high risk for
viral hepatitis and liver disease is great. I highly recommend Mrs.
Thiel\'s presentation to all CSAT, HIV, TCE, and CSAP grantees and that
Mrs. Thiel be included in all future meetings among CSAT and CSAP
grantees as a presenter, as a wonderful resource.\"

Of course, I\'m wearing my crown now, and I think that\'s wonderful.
It\'s so nice to get that kind of feedback.

But, again, we are excited about the fact that we are filling a gap.
There\'s a definite gap in what we\'re trying to do to attack substance
abuse prevention and treatment. We find, too, we\'re getting feedback
from some folks that when people are on the treatment for hepatitis,
which is difficult to take, they are complying more with the medication
once they find out how important it is to themselves and to their liver.

So we really are looking for ways that we can collaborate. We met
recently with Dr. Clark and showed him some of our videos. We have a new
one for adolescents that really rocks. It\'s exciting. It\'s upbeat and
positive, and we\'ve already received several hundred orders for copies
of it. But we are looking for more collaboration with you folks and we
just are excited about the success that we\'re having.

Thank you.

DR. CLARK: Thank you, Ms. King Thiel.

Any other public representative, member who would like to comment? All
right. Going once, going twice.

(No response.)

DR. CLARK: We\'re moving on to the next item on the agenda. Next we will
have a presentation about substance abuse treatment services for
individuals with disabilities. Ruby Neville, our public health advisor
at SAMHSA and CSAT in the Division of State and Community Assistance,
will discuss CSAT\'s position on this important issue.

Ruby?

MS. NEVILLE: Good afternoon, everyone.

First of all, I guess the first thing that may come to your mind, as it
has for others, is why the focus on the disabled. Why do we need to do
that? Well, first of all, it comes from the administration.

In 2001, the President had the President\'s New Freedom Initiative. The
purpose of that initiative was to promote access to community life, and
they were to use the efforts to implement the Supreme Court\'s Olmstead
decision to actually do that. Are all you familiar with Olmstead? Anyone
who isn\'t? Okay.

So basically that initiative was not only implemented to help states
implement the Supreme Court\'s Olmstead decision as far as helping
individuals with disabilities gain full access, but it also had a
component as far as integrating Americans with disabilities into the
workplace.

In June 2001, there was another executive order that expanded the New
Freedom Initiative. This one directed federal agencies to work together
to tear down barriers to community living. This actually called for a
government-wide framework to help the elderly people with disabilities
and again to help the elderly people, as well as those with
disabilities, to fully participate in community life.

In 2005 ‑‑ and you\'re all familiar with the Deficit Reduction Act.
There\'s a component in that for Welfare to Work. Basically the states
now are being encouraged to get individuals who have disabilities fully
engaged in the workplace. This DRA is informing that what they need to
do is to ensure that they provide support services for these
individuals. For those individuals who have substance abuse needs,
they\'re asking them to increase screenings and assessments and to
actually tailor substance abuse treatment for the Welfare to Work
population.

So right now, I\'m just going to give you a little idea of what it\'s
like for individuals who are seeking substance abuse treatment services
who happen to be disabled.

Look at this one here. We have an individual with a seizure disorder and
a history of traumatic brain injury. This particular individual is
denied inpatient treatment while taking a prescribed anticonvulsant,
phenobarbital. These are real-life cases.

We have another here of a young man with work and alcohol-related
blindness. Now, this person was denied treatment because of his visual
impairment. He was told to actually wait one year, then come back when
your vision improves. A little hilarious, but real-life cases.

I just want to say also there are folks out there who are doing a great
job, but we still need to improve or enhance services to this
population.

Here\'s another one. A man with a mild mental retardation and late-stage
alcoholism was denied treatment because of medical problems requiring
regular visits by a nurse or visits to a clinic.

This last one. An individual with lower extremity paralysis was denied
inpatient treatment because he would need assistance transferring to bed
at night and would require minimal assistance from a personal assistant.
And he was denied also because he wasn\'t able to do the required
housework, which was also a component of the program. For individuals
receiving treatment, they had to do housework, and he couldn\'t do that.
So those were the reasons why he was denied services.

So now, this brings us to the ADA. What is the Americans with Disability
Act, and why is that so important to individuals with coexisting
disabilities?

Well, I think, first of all, we need to look at exactly what it is. Back
in 1990, the Americans with Disabilities Act provided comprehensive
civil rights protections to individuals with disabilities in the areas
of employment, state and local government services, public
accommodations, transportation and telecommunications.

So now who is protected under ADA? A person who has a physical or mental
impairment that would substantially limit their major life activities.
The person would have to have a record of such impairment or is regarded
as having such an impairment.

So, again, the relationship of ADA and substance abuse addictions, drug
and alcohol addictions alone would not count for a disability. I think
you all may be aware of that. Back in 1996, the law was changed stating
that ‑‑ at one time prior to 1996, individuals who had a substance abuse
addiction, that was considered a disability. But after that, it was no
longer back in 1996 with new legislation. So are disability benefits
denied to an individual with a disability and an addiction? Those are
questions people ask. No. It would only be if the drug or alcohol
addiction is a contributing factor material to a finding of disability.

So the fundamental question one would have to ask when they\'re trying
to determine who\'s considered disabled or not, as far as the
populations we should want to serve, is would the disability have
remained in the absence of drugs or alcohol. And that\'s the fundamental
question.

So this brings us to barriers. This is one of the reasons why we\'re
here today because there are barriers out there as far as individuals
with coexisting disabilities or those with a substance abuse and another
form of disability as far as them accessing services. Providers like
information in really determining what the level of service is for their
particular disorder. Cognitive and physical disabilities are at high
risk for substance abuse disorders. However, they are less likely to
receive effective treatment for substance abuse problems than those
without the coexisting disability disorder.

Now, for the TBI, or the traumatic brain injured, they\'re challenged to
didactic training and group interventions, and we know that that takes
place in substance abuse treatment systems. Also, in the TBI population,
there\'s a lack of abstract reasoning abilities and reduced ability to
solve problems that may be undetected by providers. Providers have to
know how to serve their population. So these are the types of situations
and the characteristics of these different populations and for this one
in TBI. So you can understand why they will need to understand that
population in developing a treatment plan.

Another barrier for the blind and the visually impaired. There\'s
actually a potential to receive a misdiagnosis. In other words, what we
have found or the literature is saying that oftentimes they are
prescribed mood-altering drugs as opposed to recognizing that they have
a substance abuse treatment issue. There is, again, a lack of treatment
professionals with the expertise, of course. Again, referrals are not
made oftentimes for the blind and visually impaired.

What happens normally is rehabilitation professionals tend to focus on
the disability and they miss the signs of substance abuse, which is sort
of natural, if you think about it. If you\'re not used to dealing with a
certain population and they come in with a serious disability, it\'s a
natural thing to focus on that disability as opposed to what they really
need. That\'s the reason why, again, we need to talk about it and need
to develop some plans and training and all of that to assist these ones
in conducting accurate assessments, as well as treatment plans.

Now, the deaf and hard of hearing. Here the providers lack formalized
assessment tools that are designed for that population. They are
unfamiliar with the deaf community and the specific treatment needs.
They\'re not fluent in American sign language. There are problems with
interpreter availability, and then the interpreters who are available
sometimes lack appropriate qualifications.

And then there are just general difficulties with a third party as part
of the assessment process. You can imagine that. The person would have
to know a little bit about substance abuse treatment in order to have
this effective communication going to and from between the person who
needs the assistance and the provider. So that\'s needed as far as
accurate interpretation.

Now, Debra Guthmann was an expert in the field of substance abuse
treatment for the deaf and hard of hearing, and she still is. She was
the former Director of the Minnesota Chemical Dependency Program for the
Deaf and Hard of Hearing. This is what she found. Debra said the deaf
individuals lack a familiarity with assessor terminologies that exist.
She said but the deaf hesitate to seek clarification. So, again, another
barrier is imposed when they come for treatment. So there\'s something
that\'s needed on the client\'s end as well.

And then self-report and computerized tools. Some people feel, well, why
don\'t we just stick to that, that that probably works. But the problem
there is that oftentimes these tools are based only in the English
language. What about for other populations who do not use English as a
first language? There\'s another barrier.

I\'m going to talk now a little bit about what we have done in CSAT, as
far as working with the individuals with coexisting disabilities or
substance abuse and a disability. We had the Minnesota Chemical
Dependency Program for the Deaf and the Hard of Hearing. They were a
grantee of CSAT. This program provided inpatient and outpatient
substance use disorder treatment. We look at our N-SSATS, and we know
this is for all public and private substance abuse treatment facilities,
behavior health treatments throughout the country. This is what we
found, that 29 percent of them provide hearing impaired services with
sign language capabilities, and 39 percent had on-call interpreters. So
there are some programs who are targeting these populations, but again,
there\'s always room for improvement.

Then CSAT awarded a three-year grant to the Ohio State University. Of
course, the purpose was to study methods for improving the ability to
actually engage the TBI, or the traumatic brain injured, in treatment
for coexisting substance use problems.

Then CSAT also supported the Wright State University School of
Medicine\'s SARDI program. That\'s the Substance Abuse Resources and
Disability Issues program. SARDI is committed to improving the lives of
people with disabilities and those affected by substance abuse.

They have a few programs under SARDI. One is the CAM. As you see, here
is a community-based outpatient alcohol, drug, and mental health
treatment program. And then we have PALS. PALS is an award-winning model
for substance abuse prevention training activities for youth.

Then SARDI also provides technical assistance on the state and local
level regarding program evaluation as it relates to substance use
disorders.

CSAT also supported the Brothers to Brothers/Sisters to Sisters program,
and this particular program addressed the risk of minority populations
in the U.S. as they relate to contracting HIV/AIDS.

CSAT also funded an exemplary treatment model program called the
Chestnut Health Systems. This is Bloomington, Illinois. This program
provides substance abuse treatment services that would extend, because
it\'s not only these populations, to the attention deficit,
hyperactivity disorder and the ADHD combined adolescents.

Then we have the Anixter Center, which is a component of Chestnut Health
Systems. The Anixter Center actually receives funding indirectly through
the SAPT block grant program, through the SSA in Illinois. Again, they
provide in- and outpatient substance abuse services for the deaf.

We look at our SSTAP, or our technical assistance. CSAT has provided
technical assistance to the states who are in need of that as far as
targeting the coexisting disability population. In North Dakota, there
was TA that actually improved vocational rehab services, and then in
Massachusetts in 2005, there was TA to help Massachusetts develop a
three-year strategic plan and mentoring program that focused on
providing services for the deaf population.

Now, this brings us back again to why we need to focus on this
population of individuals with coexisting or individuals with substance
abuse and a disability. In addition to what we mentioned earlier, as far
as the executive orders, the Surgeon General actually put out last year
this call to action to improve the health and wellness of persons with
disabilities.

There were four goals that came out of that Surgeon General\'s call to
action. Number one was to increase understanding nationwide that people
with disabilities can, of course, lead lives like most of us, long,
healthy, and productive lives; and two, to increase knowledge among
health care professionals and provide them with the tools to screen,
diagnose, and treat the whole person with a disability and do that with
dignity. And then the third goal was to increase awareness among people
with disabilities of the steps that they have to take to develop and
maintain a healthy lifestyle. The fourth goal in this report was to
increase accessible health care and support services, and this was to
promote independence for people with disabilities.

So the question now is what\'s next to increase access to substance
abuse treatment for these individuals with disabilities. There\'s a
group of us who work here in CSAT on what we call our disability group.
We felt that it\'s important to encourage inclusion of all of these
populations, the TBI, the traumatic brain injured, the blind, the
physically impaired, and include them in treatment programs. That\'s
number one. And then provide support to programs like the Brothers to
Brothers/Sisters to Sisters to participate in cross-agency activities
for the disabled. That\'s very important. That way we\'re looking at
their needs holistically as opposed to just the behavioral health care
needs. And encourage grantees to target services to coexisting
populations. Also, to encourage linkages among substance abuse treatment
providers and other providers who are serving this population. We feel
it\'s important for us here to initiate inclusion of the coexisting
populations within some of the CSAT activities we\'re focusing on, some
of the most significant ones, like the criminal and juvenile justice,
workforce development, cultural competence, children and families,
suicide prevention.

Of course, we want to continue to support the Olmstead Supreme Court
decision, which is very significant. It\'s something we\'re encouraged
to do on the administration level. Encourage and expect CSAT funded
providers to include in their strategic plans efforts to extend
treatment to these individuals, and then to provide training by way of
ATTC and TA and to also explore development of additional publications.
We have had TIPs and TAPs, particularly TIP 29 that dealt with substance
abuse with this particular population and we need to explore that a
little further and other resources that would assist providers.

That\'s pretty much my presentation. I hope you were able to get a sense
of the needs for this population.

DR. CLARK: Thank you, Ruby. Lovely presentation. Very comprehensive.

DR. McCORRY: I was going to ask a question of Ruby. In New York, as part
of our adoption of evidence-based practices, we put in place a traumatic
brain injury screen for a while, and a few providers, who volunteered to
do it from Mount Sinai Medical Center, developed it as part of their TBI
center and a number of individuals screened positively. There was a high
incidence of traumatic brain injury in our population.

The problem came up was that they screened positive, and in many places
there were no psychologists who were available to do the neuropsych
assessment. Then the CEOs of these provider agencies started saying,
well, here I got my treatment plan. I have a positive screen for TBI. I
can\'t find, particularly outside of New York City, someone to do the
assessment. So now I\'ve created this kind of vulnerability because now
it\'s in the treatment plan and they have no way to address it.

That\'s one issue. I wanted to see what CSAT might thinking about how we
get assessments done.

Secondly, it seems that a lot of providers just don\'t have any
knowledge really of how to modify their treatment services to
incorporate people with these kinds of cognitive deficits, to really
speak to that abstract reasoning and not really seeing how they engage
folks just is not going to be as really helpful. They\'re not going to
be able to participate in treatment as fully as they should because they
just haven\'t been able to modify the treatment plan to reach those with
some cognitive impairments.

I was wondering if you would just comment on both issues. One is around
getting the assessment done. The other is just really a lack of skill, I
think, in our system around working with people with cognitive deficits.

MS. NEVILLE: Well, one of the things I could say, when I was conducting
my little literature review, I found that there are some states who have
some promising practices in their area. I think basically it calls for
collaboration, as well as getting ideas from other states as far as how
are they doing this, because there are folks who are doing it. We have
provided, as I mentioned earlier, TA to other states just around some of
the questions you\'re talking about now. So I think it\'s important for
us to look at what others are doing and I know that was mentioned
earlier, e-therapy, but we need to look at what other states and other
programs are doing and then try to work together as far as getting other
folks to replicate what\'s working out there. I think that\'s very
important.

Then, of course, TA. Again, that was included in my presentation.
Technical assistance is valuable to helping providers.

As far as modifying treatment plans, again, I go back to looking at what
other folks are doing. That\'s how we work in the behavioral health care
system. We find out what\'s working and then it gets to be replicated.
So I think it\'s important that we replicate what\'s already working.

Again, the TA, the ATTCs, as I mentioned to Dr. Carr, those are very
good avenues as far as teaching providers and states on what is needed
to develop appropriate assessments and appropriate treatment plans
because that\'s what this whole presentation was about, how do we do it.
So with the TA, the ATTCs. There was the SARDI program I mentioned
earlier. They also provide technical assistance to states around that
particular population. So we have to call on the folks who are doing it
and replicate what they\'re doing.

DR. CLARK: All right. Thank you, Ruby. Any other questions?

(No response.)

DR. CLARK: All right. We will move to our next presenter. The council
requested an ATR and SBIRT update to be included on the agenda for this
meeting. We do have significant developments to report today. Jack
Stein, the Director of the DSI, will discuss these developments.

Jack?

DR. STEIN: Well, good afternoon, everyone. Thank you for inviting me,
and Dr. Clark, thank you for entrusting me to speak before the council
after being here for less than four weeks. I think that\'s a vote of
confidence, I hope. I promise not to say anything that I shouldn\'t say.
Thank you very much.

I think I\'ve actually had a chance to meet most of the present council
members, and I had the fortunate opportunity to fill in for Dr. Clark
just yesterday at the Latino Behavioral Health Institute Conference that
was being held in Los Angeles and got a chance to spend a little time
with Chilo Madrid, who is one of the council members. So we got a chance
to speak a bit more about the direction of the council. So that was a
nice opportunity.

Well, again, thank you for having me. It really is a delight to be here
finally at CSAT. I think one of the things I\'ve learned very quickly is
to be a good manager, the key is to surround yourself by really good
people. In the audience are some of the key staff that are involved in
both SBIRT and ATR. So, in fact, when some of those hard questions come
up, we\'ll be able to turn to them as well. So I thank you for that.

That\'s also one of the things that I quickly noticed once I came to
CSAT just a couple of weeks ago, the strength of the staff here, and
it\'s been a delight to work with them and to have them orient me.

I understand the council was interested in hearing a bit about what\'s
gone on with SBIRT and ATR, and we\'ve put together a very brief
presentation to just kind of highlight some of the activities in that
respect and then, hopefully, we can respond to some questions.

So let\'s tackle the SBIRT program first, which is Screening, Brief
Intervention, Referral, and Treatment Initiative, which is a very
exciting one. It was launched several years ago in FY \'03 and I\'ll
explain and show you who, in fact, we initiated some grants to.

But just as a quick overview, for those of you who are less familiar
with the breakdown of SBIRT, what\'s unique about it is it really
demonstrates, we view, a paradigm shift in the provision of treatment
for substance use and abuse, particularly because as initially
presented, the new target audience was targeting those individuals with
nondependent substance use as an opportunity to really triage them,
identify them early in the stages of drug abuse problems, and triage
them to the appropriate services. So it really was the implementation of
a system within communities and/or specialty settings, such as the
primary care arena, emergency departments, et cetera, to screen for and
identify individuals with or at risk for substance use-related problems.

At the core of SBIRT is really some very, very specific components: a
screening process that can occur in a variety of different types of
settings, and based on what we learn from that screening, using some
very, very specific type of screening instruments ‑‑ and there are quite
a number of them out there ‑‑ to engage the individual in either a brief
intervention, a brief treatment, or in fact, if we do see dependency
operating, a referral to a more comprehensive type of treatment. So this
really is the concept that\'s been operating here, and through our
assessment to date, we\'re seeing some very, very promising results.

In terms of who received the initial several awards, it went to several
state agencies and one tribal organization. You see them listed before
you. I had a chance to chat a bit with Melody over lunch in terms of
what\'s happening in Illinois. I believe it\'s with the Cook County
Hospital. Is that right? Each of these grant recipients have very, very
unique models, and that\'s what\'s exciting about the SBIRT program.
Even though we had a very specific intent in mind, each of these states
and the tribal organizations were empowered to actually create a model
that in fact, hopefully, can be useful and effective.

In FY \'05, we launched a very exciting component to SBIRT, which was
targeting colleges and universities. You see before you all of the ones
that in fact were recipients of that award process. What\'s exciting
about this is recognizing that we\'re seeing certainly a growing
problem, if not an existing problem, amongst young people who are in the
college/university sector and often one that\'s not targeted. So really
targeting screening and brief intervention in that arena is a newer area
for us to all target, and again, I think it\'s a very, very promising
opportunity.

This is just a map that gives you a sense of geographically where we
have placed those. Those with the red dots are the original SBIRT
grantees, the states and the tribal organizations. The green boxes are
the screening and brief intervention grantees, which are the colleges
and the universities. Or did I get that backwards, Tom?

MS. HEAPS: You\'ve got it backwards.

DR. STEIN: I got it backwards, okay. Sorry.

MS. HEAPS: You\'re missing Cook County.

DR. STEIN: They\'re backwards, but yes, you\'re a green box, Melody.
Sorry.

But you can see that geographically spread out. We are very pleased to
announce at the Latino Behavioral Health Institute that many of them are
serving Latino/Hispanic communities.

Data is being collected on an ongoing basis. I was quite impressed when
I came to CSAT a couple of weeks ago to understand our data collection
system, what we call SAIS, S-A-I-S, which perhaps some of you have heard
about. It\'s a very efficient system that really collects GPRA data in a
very nice manner. Just, to date, what we\'re seeing is that the total
number of SBIRT screenings that have been conducted cumulatively is over
165,000 and already we\'ve exceeded the target for this year. So the
management of these grants and the operation of these grants is really
right on target. I think Tom Stegbauer could really help us if we have
some questions in terms of some more of the outcome data that\'s coming
out of these grants.

Just in terms of some newer activities that are happening, one, we\'ve
recently launched a new cohort of states. We\'re developing a tool kit
with the American College of Surgeons and also a website. Let me just
share briefly with you some of those findings.

One is that new grants to the states, which were just recently awarded,
one to Colorado, Wisconsin, Florida, and Massachusetts. So we\'re
anxious to see those get up and running.

With the American College of Surgeons, we have been working on a tool
kit, and this has been done in collaboration with the National Highway
and Traffic Safety Administration, as well as the Centers for Disease
Control and Prevention, CDC, a nice collaboration targeting again the
medical arena.

One of the neat things that I\'ve seen that Tom Stegbauer has shared
with me is a quick guide for trauma surgeons and coordinators. This is a
draft version of it. It\'s not been distributed yet, but it\'s in the
process of being developed. The goal here is really to be targeting
physicians who are working in trauma centers to really allow them the
tools to actually conduct screening and brief interventions.

Training modules are under development, as well as a web-based screening
and brief intervention tool kit for primary care practitioners.

So this is, I think, a really great initiative that\'s really reaching
out way beyond the specialty sector of the substance abuse treatment
arena and allowing us to again see new pathways to enter treatment.

Let me move on to Access to Recovery, and then I think if we have some
time, we can open it up to any questions that may arise or issues.

ATR, of course, is probably well-known to everyone here on the council,
a presidential initiative that was established in 2004. To my
understanding, it\'s a \$300 million initiative for a three-year period
of time, which will be ending in August of \'07.

As you know, it\'s a discretionary, voucher-based grant program and with
three major goals.

One is to expand capacity of treatment.

The second is to support the client\'s choice in where, in fact,
treatment is actually delivered.

And the third is to increase the array of faith-based and
community-based providers for clinical treatment and recovery support
services. Those are very two distinct type of service delivery
mechanisms: actual clinical treatment that\'s being provided by licensed
clinicians or recovery support services. Sometimes it could be done by
the same entity. But recovery support services would be other type of
services, vocational assistance, et cetera, that in fact really expands
what I think all of us in this room strongly believe is the appropriate
approach to recovery model, a very comprehensive approach.

The goal of ATR is a relatively simple one. Achieving it is no easy
task, of course. But 125,000 clients over a three-year period of time
was the overall goal for ATR.

The grantees consist of the following. I believe there are 14 states and
one tribal organization, the California Rural Indian Health Board, and
these are the 14 states that have been up and operating over the last
several years.

This table quickly summarizes how well I believe the staff here at CSAT,
the technical assistance that\'s being provided, and the hard work of
these grantees has been to actually achieve some really remarkable
results in terms of at least the process that\'s gone on over the last
number of years. Clients served as of June 30th are over 92,000
individuals. The target that we agreed to set was only 62,500
individuals. So already we\'ve really met the expectations. And if you
look at the three-year target of 125,000 that has been set, I think
we\'re well on our way to really achieving the ultimate process goal of
reaching individuals who perhaps would not have been reached through
other types of mechanisms. So I think that\'s kind of some very exciting
findings in that respect, and again, a lot of acknowledgement needs to
go to the CSAT staff for managing what I think has been a very, very
challenging process to get up and operating in such a very quick period
of time.

The data that are being collected from our SAIS system are rather
impressive as well. Let me just share a little to date and keep in mind
that data are very preliminary. We can\'t do any comparisons with other
type of treatment programs that are out there. So we really want to be
very careful in how we interpret all of our data. But look at what
we\'re seeing to date.

Over 63 percent of the clients have received recovery support services,
so a very large percentage of individuals are actually receiving
services beyond the actual clinical arena.

In terms of where the dollars are being spent, 48 percent of them,
nearly 50 percent of the dollars paid, were for these recovery support
services.

About 25 percent of the dollars paid were to faith-based organizations,
again a big goal of what ATR is all about.

And faith-based organizations accounted for 23 percent of the recovery
support services and 35 percent of the clinical treatment providers. So
I think it\'s a very nice breakdown of that.

But in terms of what we\'re actually seeing in outcomes which, of
course, is what\'s most important, and again preliminary data, and this
data reflects really changes reported only among individuals who came in
with an existing problem at intake. What we\'re seeing to date is a 64
percent increase in abstinence rates, an almost 28 percent increase in
stability of housing, a 30 percent increase in employment, an almost 67
percent increase in social connectedness, and an over 80 percent
reduction in criminal justice system involvement. Very impressive.
Again, very early, difficult to make comparisons, but it\'s quite
impressive. Again, I need to really recognize how the staff have worked
to compile such information in such a short period of time.

I think I\'m going to stop at that point. This was a very quick
overview. I thank the staff for compiling it so quickly for us.

Dr. Clark, if we wanted to entertain any discussions, I think myself or
some of the staff here could help.

DR. CLARK: Council members?

(No response.)

DR. CLARK: Will the SBIRT staff stand up? Tom is back there and Eric.
Those are SBIRT staff.

Will the ATR staff stand up, those who are back there? Natalie Lu, and
contracts. All right. Very good.

I agree with Jack that our staff has been doing yeoman\'s duty in both
areas, both SBIRT and ATR.

In regard to SBIRT, one of the original conceptual thoughts was that it
was to reach nondependent users, but as I pointed out with the big red
slice, the fact of the matter is dependent users don\'t show up for
substance abuse treatment. So they\'ve got to show up someplace.
They\'re more likely to show up in emergency rooms and community health
centers and alternative settings than they are to show up at a substance
abuse treatment program. So I think we are picking up dependent users in
alternative settings since the data point out that we\'ve got 20 million
people who meet criteria for abuse and dependence requiring treatment
and we\'re only treating a minority, 3 million of those.

So where are those other people? We know when you are having physical
and psychological problems, they\'re going to be manifested and you\'re
going to seek help someplace else, even if it\'s a headache in the
emergency room at the primary care setting, as a substitute for dealing
with the real issue, as it were.

So that\'s the exciting part about it is it\'s much broader than its
original conceptualization, and it\'s been welcomed by the community,
which is also an appealing aspect. It\'s not as if people feel that this
is being thrust down their throats. So both SBIRT and ATR are doing a
good job, and ATR, of course, is reaching a broader population and
involving alternative practitioners.

We had Donald Kirk at one of the council meetings present his model, his
conceptualization for ATR, which is a very good conceptualization in
terms of normalizing the experience of a person in treatment, not simply
relying on acute intervention, but by using community support,
stretching out the period and decreasing the need for acute intervention
because the person stays in the continuum of care longer, you just
don\'t need the more expensive, higher professional treatment. What you
do is you normalize that person\'s experience. That is, again, what
we\'re also trying to do is to delay relapse, if not eliminate it.

So these two programs are quite appealing and very successful. As Jack
pointed out, while the ATR program is not a research program, but when
we look at SAIS data, the results are satisfactory. If we can be modest
in talking about ATR, the results are satisfactory, and it isn\'t just
to say which treatment is the best treatment. It is to say, given the
goals and objectives of ATR, and when it\'s meeting those goals and
objectives, those goals and objectives from a policy point of view are
important in and of themselves. Therefore, ATR is a justifiable
strategy.

So then we will move to the council roundtable. Before we get into other
topics, Melody, do you want to give us a fentanyl update?

MS. HEAPS: With the knowledge that you know what\'s going on in the
nation and I know what\'s going on in Illinois.

DR. CLARK: Illinois was the bellwether. It\'s the only state that
signaled to the rest of us that there was a problem.

MS. HEAPS: Really?

DR. CLARK: Yes, because Illinois, it turns out, collected the basic data
and other states did not collect that data until Illinois pointed it
out.

MS. HEAPS: I didn\'t realize that.

In the late fall and early winter, the press, the state, and providers
were noticing an increase of overdose deaths, as well as admissions to
our hospitals, with the new compound substance of heroin and fentanyl.

Fentanyl, as most of you know, is a major, major pain killer that is
used in surgery. It is X times more powerful than morphine, et cetera.
It reacts with heroin and has almost an immediate suppression of the
cardiopulmonary effects.

So on the street, it was being known as a fabulous high. It was the bomb
of all bombs. People were flocking to certain distributors, at least in
Chicago, because that\'s where it was centered, who were supposedly
supplying this fabulous high.

The progress of both deaths and hospital emergency room admissions
increased so that within a period of five to six months, we had over 100
deaths due to heroin/fentanyl. The press started to pick it up and it
crescendoed. You know me. There\'s nothing like media pointing out a
drug problem to get people talking. It crescendoed with a terrible
tragedy of a police officer in one of our wealthy suburbs. His son, two
days after graduation, died in a car having just shot up with heroin and
fentanyl. That then blew it out of the box for the press.

Luckily our state administrator, Theodora Binion-Taylor ‑‑ and I\'d like
to ask that the council invite her next time to talk about her response
and continued response ‑‑ realized the importance of this and called
both the state public health officials and the county public health
officials with some of the leaders in our treatment agencies together to
talk about what we might do. There were some mobile methadone units,
some AIDS community outreach people, and other treatment outreach people
that went to the streets to try and get the word out that this was a
dangerous drug and that addicts should be absolutely careful about what
they were doing.

The problem occurred from the street standpoint and from the consumer
standpoint that while the press was talking about this, then the police
and the DEA began to talk about it. There came to be a natural paranoia
with the population that said, oh, this was all just made up, that this
wasn\'t true. This was just a way to get us as addicts, that the police
really are lying about it.

So we saw, for a brief few weeks, even more of an increase. Some of the
hospital emergency rooms that had seen on any given day three to five
admissions for overdoses were up to 15 to 20. It was amazing. It
continues today, although we\'ve seen some indicators that it\'s
subsided.

We went on two tracks. The state was doing its public health piece. Then
I contacted Congressman Danny Davis, who has been very active in the
area of demand reduction both nationally and in Illinois, and we
convened a press conference of public officials, treatment agencies to
talk, to warn the community about it, to appeal to public funders to
increase treatment.

It\'s my understanding the Illinois delegation sent a letter to SAMHSA
asking for more money for treatment, partly because our methadone
treatment programs have 8- to 12-week waiting lists. So while we\'re
saying to everyone, come to safe harbor, come to treatment, we\'re also
saying, oh, by the way, you can\'t get into treatment. There was a real
mixed message and concern for what we were doing.

The newspapers have diminished their attention, as they will on any
idea. There has been a slight decrease, to my knowledge.

In addition, while this was going on, the DEA was calling people from
around the country for a DEA conference in Chicago, local police and DEA
agents. One of our TASC vice presidents attended it to look at where the
source of the heroin and fentanyl was. There was a major lab in Mexico
that actually had been taken down, but it was appearing in other areas.
It was coming out of Mexico in many ways but also in other parts of the
country. So the DEA has been very active in this.

I had requested of the DEA and it didn\'t ‑‑ partly because I didn\'t
follow through enough, maybe, but I intend to do it ‑‑ that the DEA sit
down with a treatment provider to talk about this and to give some
indication about what we can expect. Is this going to increase? Is this
going to decrease? Where is this?

And I would like to recommend that, in general ‑‑ not just about heroin
and fentanyl ‑‑ we ask periodically that the DEA come here to talk to us
about the latest trends on what drugs are coming in, what drugs are on
the street, what they\'re anticipating, and also how some of the routes
of transportation go. It\'s a fascinating discussion and I think it\'s a
real alert to those of us in the community who need to prepare for this.
So I really would like to suggest that at least once a year the DEA be
brought in not to describe what they\'re doing that\'s so good, which
may be fine, but to describe what the problems are, where they\'re
seeing it, and what\'s coming down the pike.

And I\'d like to have a briefing on the heroin/fentanyl because it was
not only Illinois. It was Philadelphia, Detroit, New York, and on and
on.

DR. CLARK: We have Bob Lubran and Ken Hoffman who can help you flesh out
the specific jurisdictional spread, and they\'ve been actively involved.
When you finish, I\'ll ask them.

MS. HEAPS: I\'ve finished.

DR. CLARK: So, Bob, Ken, do you two want to say anything about this
matter?

DR. LUBRAN: Yes. I\'m actually going to ask Ken to give you an update on
what we\'ve been involved in.

We got involved early on in the process. It was originally CDC that sort
of was spearheading the effort, and then they asked SAMHSA to really
take over the responsibility for a more integrated federal response. So
what we did was engage DEA, Department of Justice, ONDCP, CDC, and then
state and local officials to get involved. So we\'ve been holding a
weekly conference call with ‑‑ I don\'t know the number. It\'s over 50
public health and law enforcement officials to really give a weekly
update on what is happening around the country.

Ken has been asked to chair that effort on behalf of SAMHSA, and we are
starting to discuss and discuss with Westley and others some ideas for
what we might do to extend the effort beyond what we\'re currently
doing. So I\'m going to ask Ken to give you a little bit more background
on some of the details.

DR. HOFFMAN: I\'m not sure where you began, but in terms of the
activities in Chicago, I\'m well aware. Actually I attended that DEA
meeting. It was basically geared towards law enforcement. It kind of
exponentially grew, I think, even from what their expectations were.

But basically, as I can pull things together at this point, there are
drug buys that go on kind of for the sense of what\'s happening in the
world today. Somewhere this past October, there was actually a detection
in Detroit of some fentanyl-laced heroin, and it turns out that Detroit
and Chicago are probably the ones that first received this kind of
unwanted supply, which turns out to be surprisingly deadly in the sense
that what would be a little dime bag of heroin, which you could actually
see in terms of 100 milligrams, converts to about 125 micrograms of
fentanyl in terms of equivalency, which is actually like literally three
grains of table salt. So the mixing of that can actually be quite deadly
quite rapidly, to the point that death can literally take place as fast
as it takes to inject the contaminated.

So, anyway, the Epi-X system that CDC has, which is for public health,
picks up a message in April from the New Jersey poison control. So
initially we were looking at a locus of problems in the New Jersey,
Camden, Philadelphia area. CDC then launched the first of several
telephone calls, which we\'ve carried on weekly after that, which has
incorporated people at the state from poison control, emergency response
systems, actually fusion centers, which is a Department of Homeland
Security effort. So there\'s been a conglomerate from the law
enforcement side, DEA of course, and then from the treatment side,
you\'ve had some treatment providers, Detroit, Chicago, Philadelphia.
Actually Delaware has been engaged and now New York. Then with that, you
also bring in the public health departments. So we\'ve had a real
conglomeration, I think, of people with different information sources.
NIDA with its Community Epidemiology Work Group has been involved with
it, along with FDA.

Bob Lubran mentioned the other organization, ONDCP. This actually led
recently to an ONDCP fentanyl-laced forum that was in Philadelphia for a
day the end of July. And the activities, I think, of what people had
been involved with were presented at that, with the idea of how do we
continue to kind of look at this in terms of an early warning detection
and response mechanism, which was something that came out of the
Synthetic Work Group about a year and a half ago. In the context of what
Dr. Clark talked this morning about, the methamphetamine problem, but
actually a lot of the same issues have arisen in the fentanyl.

So I\'ll shut up now, and if there are any questions, I\'ll be glad to
answer.

DR. CLARK: Any questions?

MS. HEAPS: I just hope CSAT would support the efforts of our single
state agency director who jumped on this with all hands on deck, and
whatever that support means, whether it\'s official recognition or
including her in some of the discussions, et cetera, she really did
grasp this issue as a singularly dangerous issue and really has tried to
mobilize around it. I think inviting her here to talk about it would be
a good idea.

DR. HOFFMAN: And in fact, the public health officer, the medical officer
from the Chicago health department was at the DEA meeting. And certainly
the single state authorities I think have all been made aware, and as
you say, some have been very actively participating in the conference
calls.

DR. CLARK: I\'ve talked with Theodora on this. She was convening a
meeting from the public health end of the spectrum, recognizing that law
enforcement tends to focus on the public safety end of the spectrum, but
also recognizing there needs to be ongoing communications from both ends
at the middle. So focusing on the unique needs of the public health
community while recognizing the importance of the public safety
community was her objective.

So with our staff, working closely with DEA, ONDCP, and others and with
the single state authority, Theodora, and other jurisdictions, we\'re
trying to come up with practical solutions that we can contribute.

We did note that in some jurisdictions, the single state authorities
were not aware of some of the issues. That was one of the things that
we\'re trying to help foster, is increased awareness. The non-substance
abuse public health authorities were aware that there was a problem, but
were not communicating to the substance abuse public health authorities.
So they were not aware. I called up several. Did you know there was this
problem? Oh, it\'s not a problem in our state. We haven\'t heard
anything about it. These were two different jurisdictions. Yet, we had
data that adverse events were occurring in both jurisdictions.

So part of our role inherent in DSCA and the other divisions is, when we
get this kind of information, we want to involve the single state
authorities as quickly as possible. Just as with other disasters, if you
will, we can ask what role we can play, what kind of technical
assistance we need to provide and be a part of that net of information.

So I appreciate all the work that Bob and his crew are doing, and of
course, DSCA and John Campbell also responding to this issue in terms of
TA.

In terms of client reaction and my big red slice, as you pointed out,
it\'s a killer drug. Where do I find it and try to figure out how to
communicate the message it\'s not a killer drug. It will kill you. But
the notion of a killer drug is different in their minds. So we have to
figure out how to communicate that in such a way that it\'s not seen as
hysteria or an exaggeration because, as Ken pointed out, the problem
with the fentanyl is that it doesn\'t homogenize and it only takes a
small amount. So if they\'re used to homogenizing drugs so I can inject
it and I just get a buzz, well, if you get those three grains all in the
same bolus, you\'re gone. Those three grains are really quite powerful,
and if they concentrate at one end of the syringe, you\'re dead. That\'s
what was happening.

As DEA points out, it\'s very difficult to mix, if you will, fentanyl
unless you know what you\'re doing. They know how to make it, but they
don\'t know how to distribute it in such a way that it\'s not fatal. And
it\'s poor business if you kill off your customers.

Val?

MS. JACKSON: One thing Melody said I thought was really important, and
that is, it seems like it would be very beneficial for us to hear,
perhaps on an annual basis, whether it\'s the DEA or whoever you would
deem appropriate, to take a look at, hey, what\'s coming, what\'s new,
what\'s increasing, what\'s decreasing. The National Household Survey is
a wonderful instrument and, of course, we all hear things, but it would
be a great report I think.

DR. CLARK: Well, we\'ve heard from the DEA before. They\'ve been willing
to participate. I\'m sure that we can make that request and we could
couple what we find from DAWN, from the National Household Survey, the
National Survey on Drug Use and Health, and our TEDS data with their
arrest information. So that would be useful.

I also commend you to the DEA\'s website. They periodically update it on
various jurisdictions and they have state-specific information about
what drugs are popular in a particular community. You can see again the
regional variation in drug activity. Take methamphetamine. In some
jurisdictions, methamphetamine is the big drug; others, prescription
drugs; others, it\'s heroin; and still others, it\'s cocaine.

So we work closely with other federal agencies in the service of this
information. So, yes, we\'ll put that on there and make a request.

Any other matters that the council wants to address? Did we finish EtG?
I think we finished it.

MR. GILBERT: I was just going to say, I was scribbling and I noticed
both Cynthia and Westley were scribbling this morning when Melody and
Greg were giving us your recommended changes. I didn\'t get it all down.
We probably have it in the transcript, but if you have written out the
changes you want, if you could make those available to us before you
leave, that would be very helpful to have.

DR. CLARK: Donna Bush has some of those changes. Donna, do you want to
read those changes to council? Even though we no longer have a quorum, I
think we can get some consensus as to the acceptability of those
changes. Donna?

DR. BUSH: Thank you, Dr. Clark.

A bunch of us put our heads together with the advice and good counsel of
the advisory council and put together, I guess, this almost like a black
box notice, a summary statement at the top.

Currently the use of an EtG test in determining abstinence lacks
sufficient proven specificity for use as a primary or sole evidence that
an individual, prohibited from drinking in a regulatory compliance
context, has truly been drinking. Legal or disciplinary action based
solely on a positive EtG or similar unproven test is inappropriate and
legally and scientifically unsupportable at this time. These tests
should currently be considered as potential valuable clinical tools, but
their use in forensic settings is premature.

DR. CLARK: Melody?

MS. HEAPS: That\'s very good. Do you want to add criminal justice after
you say professional regulatory? There is a difference between that and
the ‑‑ you may want to just add that. It\'s a wonderful statement.

DR. CLARK: All right. Criminal justice is added.

Any other comments? Val.

MS. JACKSON: This is not on that.

DR. CLARK: All right. Before we finish that, that essentially captures
the sense of council when you made your vote earlier.

MS. HEAPS: Well, the vote had two parts. I mean, it was the language but
it was also what does it mean to have a public education campaign about
this. One of the recommendations would be simply to have a conference
call among those of us on the board that are interested, as well as your
staff to suggest mechanisms for how to distribute the advisory, et
cetera, ways which may be revenue neutral but would at least get the
word out.

DR. CLARK: All right. We can follow up on that. I like that phrase,
\"revenue neutral.\"

(Laughter.)

DR. CLARK: The people who write the checks will be very glad that we
think in those terms.

But, yes, we\'ll talk about the distribution subsequently after we
finish.

If there are no other issues on EtG, Val, you had something you wanted
to discuss.

MS. JACKSON: I had something a little bit more on a personal note. Many
of you knew a person who I think was very important to this country and
has passed from us. The Miami Coalition was known as the first coalition
that really gathered steam across the country, and of course now,
through ONDCP and CSAP, there are I don\'t know how many coalitions, but
there\'s a lot of them funded, as well as those that do their own.

In the early 1990s, I had the pleasure of meeting Marilyn Culp who came
to Miami from Oregon or Washington ‑‑ I\'m not absolutely sure ‑‑ and
took over the job for the Miami Coalition, which was funded by
businessmen. When I first met her, I was working for the Florida Alcohol
and Drug Abuse Association, and I walked away and said there\'s no one
that I know of who could possibly organize or get all of the Miami
providers to even talk to each other.

Through the years, Marilyn Culp was probably one of the only people who
I knew that somehow could bring people together and get things done and
yet not alienate folks. She was a remarkable woman and battled cancer
for the last six or seven years until she passed in early June, I
believe it was.

Just to let you know, her husband happened to be the trainer for the
Miami Heat and she was at the Miami Heat game when they beat ‑‑ I\'m
sorry, anybody from Michigan ‑‑ Detroit and got themselves into the
national championship and won the national championship.

On a lighthearted note, Marilyn, of course, knew that she was going to
die, and she left her husband a note. All around the house, she left him
notes, and she left him one note that said to open on, I believe it was,
June 20th. It said congratulations, and it was the day that the Miami
Heat took the national championship.

She was a great asset to our country, to our world, and to the
coalitions, both treatment and prevention. So I wanted to mention her.
Thank you.

DR. CLARK: And thanks for taking the time to acknowledge the passing of
a contributor to the field. I think that\'s very important.

Anybody else?

(No response.)

DR. CLARK: We at SAMHSA did lose a staff person in the crash of the
Lexington, Kentucky airplane crash at CSAP. Steve MacElray, who worked
for CSAP, was coming home from the NPN meeting there and had taken that
flight. So we do lose people. What we did here for Steve was have an
in-house ceremony and discussion. Staff people were, obviously, affected
by that.

The point is that we need to take time to acknowledge the contribution
and the passing of people who are laboring in the trenches.
Unfortunately, death occurs at all ages for our members, but while we
soldier on, we can pause to reflect on their contributions so that we
can remain energized. So thank you.

Any other issues for council? You can discuss any issue that you wish to
pursue, whether related to today\'s presentations or other matters of
interest. Any questions? Val?

MS. JACKSON: I just wanted to mention I was fortunate enough, Melody and
I and Matt had lunch with Jack today. He was very exuberant and actually
opened doors for us to say, well, I\'d really like to hear your thoughts
on discretionary grant funding. He probably got the two people in the
country who have a whole lot to say about discretionary grant funding.

MS. HEAPS: (Inaudible.)

MS. JACKSON: Well, yes, true.

But we focused on that one and gave him a number of thoughts. Among
those ‑‑ and you may have some insight on this ‑‑ the thought occurred
to me that perhaps in the future one of the things that we need to do is
to tear apart that big red circle that you have that shows that 95 or 94
percent, whatever it is, of those people who don\'t seem to access
treatment. And we kind of know. We expect that they\'re probably some
trauma people and some disabled people and there are some folks like
that. But perhaps we need to start looking at what targets are in there
that might be folks that we can reach if we target particular
populations that you could discover through, as Jack said, mining.

I appreciate his getting input and I hope that you continue to ask for
input across the country. I think not only Melody and I but many people
across the country have great insight as to some of the populations that
need to be treated. We support the discretionary grants, believe that
they\'re very innovative, and I just wanted to make that comment to
reinforce my belief, strong belief, in the need for discretionary
grants.

DR. CLARK: Thank you.

Any other comments? Dave?

MR. DONALDSON: I\'m still trying to get my arms around the ATR and
exactly what happened. But I have always tried to follow the course that
you hope for the best, you do your best, but also prepare for the worst.
So I think my question would be is there a contingency plan. If the ATR
goes away, how do we preserve this vision? It\'s the right vision. This
big tent approach to recovery management services is right.

I know in the faith community, this has been a wonderful entry point.
It\'s a way that affirms the value of the faith community. It shows us
where we can serve in this continuum of care, and I\'d hate to see that
go away. I think we\'ve got great momentum. How do we build upon that?
How do we continue to preserve the voucher approach which I think
certainly affirms a person\'s dignity? Also, it protects faith-based
groups that are concerned about their identity and methodology being
stripped away. So how do we keep that going?

But I think the other is that the next time you present a national plan
and if this one is DOA ‑‑ and I hope and pray that\'s not the case ‑‑
then it is much harder to launch something new because people will be
predisposed to thinking how long is this going to last and they\'re only
going to get one leg on the bus. So what is our plan? What is our
strategy moving forward?

DR. CLARK: Well, I think the administration is stepping back to consider
what it needs to do to inform the Congress of the utility of ATR and
that process will probably intensify over the next month or so. Our data
demonstrates that we\'re doing okay with ATR.

It\'s not just the faith community who has benefitted from this. That\'s
another point that we need to make. It\'s community-based organizations
and it\'s this notion of empowerment. I\'m glad you highlighted that. It
makes it clear that the person who has the problem plays a role in the
solution and that it\'s not a matter of professional paternalism, if you
will. So the administration will continue to stress that and then we\'ll
see what happens.

We do have an ancillary program in terms of recovery community support
programs. It does not have the voucher element. It is subject to
charitable choice. So it is not an ideal substitute for ATR, but we\'ll
just have to work with the wishes of Congress and the will of the
people. The President\'s agents will be trying to communicate the
administration\'s position on this matter over the next month or so.

Melody?

MS. HEAPS: I just want to completely echo David\'s response about ATR
and its importance.

But I would like you to just inform us with regard to the funding
proposal for ATR that the administration has put forth and how the block
grant was brought into that. I\'m not sure we were completely clear.
What is the budget proposal with regard to ATR this year from the
administration\'s standpoint?

DR. CLARK: Oh, we discussed this at our last meeting. Basically the
proposal was to incentivize jurisdictions to use a portion of their
block grant in order to be eligible to be competitive for ATR funds.
That is, shall we say, one of the sticking points for some members of
Congress who have made their concerns known through the proposals in the
House and the Senate. That\'s an issue that is on the table being
discussed.

Anything else?

(No response.)

DR. CLARK: All right. We\'ve had a full day. I thank you for your
undivided attention and attendance. Can I have a motion to adjourn?

DR. SKIPPER: So moved.

DR. McCORRY: Second.

DR. CLARK: It has been moved and seconded that we adjourn. All those in
favor?

(Chorus of ayes.)

DR. CLARK: Anybody opposed?

(No response.)

DR. CLARK: All right. Have a safe trip and your comments and questions
and concerns have been duly noted and will be addressed. Thank you.

(Whereupon, at 4:23 p.m., the meeting was adjourned.)