SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Thursday,

January 27, 2005

Sugarloaf, Seneca, and Rock Creek Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

P.O. Box 360833

Strongsville, Ohio 44149

Kenneth A. DeCerchio, M.S.W.

Director

Florida Department of Children and Families

Substance Abuse Program

1317 Winewood Boulevard

Tallahassee, Florida 32311

David P. Donaldson, M.A.

CEO

We Care America

10 G Street, N.E., Suite 502

Washington, D.C. 20002

Bettye Ward Fletcher, Ph.D.

Professor

Jackson State University

1120 Andrew Chapel Road

Brandon, Mississippi 39047

IN ATTENDANCE:

Melody M. Heaps, M.A.

President

Treatment Alternatives for Safe Communities (TASC)

1500 North Halsted Street

Chicago, Illinois 60622

Valera Jackson, M.S.

CEO

Village South/West Care Foundation, Inc.

3180 Biscayne Boulevard

Miami, Florida 33137

Chilo L. Madrid, Ph.D.

CEO

Aliviane NO-AD, Inc.

7722 North Loop Road

El Paso, Texas 79915

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 349

Crandon, Wisconsin 54520

[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 5

SAMHSA\'s Disaster Readiness and Response Activities

Daniel Dodgen, Ph.D.

Emergency Coordinator

Office of the Administrator, SAMHSA 5

Sheila M. Harmison, D.S.W.

Special Assistant to the Director

Office of the Director, CSAT 21

Overview of the Drug Enforcement Administration\'s

(DEA) Supply and Demand Reduction Efforts

Michele Leonhart

Deputy Administrator, DEA 34

Discussion 50

Discussion with Disaster Presenters 60

E-Therapy Update

Sheila M. Harmison, D.S.W. 76

Discussion 90

Council Roundtable 100

[P R O C E E D I N G S]{.underline} (10:38 a.m.)

DR. CLARK: Can we come to order? Our first presentation in the open
session will be a discussion of SAMHSA\'s disaster readiness and
response activities. The presenters will include Dan Dodgen, Sheila
Harmison, and Carol, are you saying anything?

MS. COLEY: I\'ll say good morning.

DR. CLARK: Well, the key issue with that aside is that we\'ve got a
focus on disaster readiness and response, both at the SAMHSA and at the
center level.

Dan is going to give his presentation. He leads up our effort, but his
effort is buttressed by the contributions of all of the staff who are
working with him.

Dan Dodgen?

DR. DODGEN: Good morning. I\'m Dan Dodgen. Thank you for the nice
introduction, Dr. Clark.

It is really a pleasure to be here and to meet with the folks here at
CSAT. As you probably already know from just having been around folks
for awhile, you really have some great people. I certainly want to
acknowledge both Sheila Harmison and Carol Coley, who were on the matrix
advisory group for the disaster readiness response matrix. They are just
invaluable contributors to that group. Of course there are many other
staff at CSAT, too many to mention, who have also really done a
tremendous job to support us.

What I\'m going to do today is talk briefly about an overview of
SAMHSA-wide activities, and try to give you a thumbnail sketch of how we
approach disaster issues at the agency. Then I\'m going to hone in a
little bit on things happening recently, particularly the tsunami
response, and then of course all the hurricanes in the fall to give you
a sense of how these different activities play out in a particular
incident.

I just want to start by making sure that we\'re all on the same page.
There are lots of different definitions for the kinds of things that
we\'re going to talk about this morning, and I just want to make sure
that we\'re at least thinking about the same things when we talk. So
disasters, as it says, are natural or manmade events with an
identifiable beginning and end in which the impact exceeds the capacity
of the local community to respond.

Now, obviously there are disasters in local communities that don\'t
exceed their capacity. I don\'t in any way want to minimize that. Those
are very, very important events that merit some kind of response. But
I\'m talking about from a federal perspective, for something to really
invoke a federal response, this is what we\'re talking about in terms of
definitions.

A public health emergency occurs when a natural or manmade event creates
a need for health services that exceeds the response capacity of the
local health care service delivery system. Obviously SARS in Canada was
a very, very good example of that. I think many of us are watching very,
very closely with the avian flu and waiting to see what is going to
happen with that. That probably will be our next big international
public health emergency. But again, something that we follow very
closely and fall also under this matrix area.

Then of course the third, terrorism, is an action undertaken to achieve
a political, ideological, or theological goal through a threat or action
that creates terror or horror. Of course these are the headlines from
the Madrid bombings on March 11th.

So what are the SAMHSA activities? These are the basic four areas that
we\'re going to talk about this morning. I\'m going to move through
relatively quickly. But please, if at any moment you have a question,
comment, or something isn\'t clear, feel free to interrupt me. There\'s
no sense in going so quickly and having it still be confusing when
we\'re done. So feel free to interrupt.

I just want to talk about a few key examples of science to services. As
you know, that\'s an important area agency-wide for us. We are really
trying. I think many of us that work in this area are aware that the
research base is really just starting to develop, both in mental health
and in substance abuse. It is not something that we have traditionally
focused on, those in the research community, for behavioral health. So
we\'re really in the process of beginning to develop consensus documents
and trying to get information out there, trying to get seed money out
that will help us to develop even ideas of where we need research, not
to mention of course developing the research base that has begun.

One of the things that we have done is worked with the National Research
Council and the National Academy of Sciences\' Institute of Medicine to
put together a report on psychological consequences of terrorism that
actually proposed a public health model for responding and preparing.
That is available on the Internet. If anybody is interested, I can get
you the link, or we can make sure that someone sends that to you. I
might have a few hard copies in my office if you\'re really interested,
we\'ll see if we can dig some out.

Actually, let me talk about a couple of these others. We also have been
doing some expert panels cofunded with NIH really looking at issues
around assessment in particular, because as we know, one of the things
that is really important in a disaster event is just figuring out what
is going on in the population. What do people need? What kinds of
presenting problems are they having?

If you go back to our definition of exceeding the local capacity to
respond, then obviously assessment is really going to be an important
part of that because we need to understand what the needs are if we\'re
going to be able to merit how the response needs to be gauged, and
whether or not there is a significant federal role in that response.

The National Child Traumatic Stress Network, some of you may be familiar
with that CMHS initiative that has really grown tremendously in the last
couple of years. It started at \$10 million a year, and it is now \$30
million. They don\'t just focus on disasters and terrorism, they focus
on other aspects of child trauma, including exposure to violence and
maltreatment. But they have developed a significant interest in disaster
and terrorism response. In fact, we\'ll see in a minute that have been
very helpful in preparing materials for the tsunami response.

Templates for Response, Recovery, and Resiliency, there are a number of
different initiatives that you may have been exposed to over the last
couple of years as they have evolved. SAMHSA did to an all hazards
planning guidance, and I know we are in the process of thinking about
developing an appendix for that specific to substance abuse. I think
Sheila was probably going to say a little bit more about that, so I
won\'t.

We also have developed a cultural competence guideline specific to
disaster response for behavioral health, which is really a very unique
effort. We are so, I don\'t want to say primitive, because I think that
has a negative connotation, but we are so early really in the whole
learning curve. This is work that has basically been going on at SAMHSA
for about 30 years since we signed an agreement with FEMA back in \'74.
Before actually SAMHSA existed, but nevertheless, that agreement dates
to \'74.

So really when you think about the overall picture of disaster response,
we are still very much in our childhood of learning about these things.
So these guidances in many ways represent a first in the field.

Another document that you may be familiar with is our risk
communications guidance. For any of you who might ever be put in a
position of having to speak to the public about a disaster event, even
if it is just a small, local event, I strongly encourage you to take a
look at this booklet. If you have not had copies given to you before at
this meeting, I can make sure to get some that can be mailed to you, and
we can also give you a link.

It is an incredible document. It just talks about how to deal with the
media, and how to deal with the press in these kinds of situations. How
to not get caught into sort of battles about definitions, but really to
make sure you keep your focus, and how to explain the nature of these
kinds of events to the press in a way that helps them to understand the
consequences. It is a very good document that I have distributed
everywhere from the Greek officials at the Olympics to local public
health officials here, and they love it. It is, I think, a very good
example of how SAMHSA is helping to create templates that have an impact
not just on the behavioral health community, but really on the larger
public health and emergency management community.

Some of our infrastructure that we\'re beginning to put in place, and
again have come a long way, there are a number of different things here.
The \"All Hazards\" Emergency Capacity Development Grant Program many of
you are probably familiar with. We have given grants to 35 different
states for them to develop a substance abuse and mental health disaster
response plan.

Really corollary to that initiative, we have established the SAMHSA
Disaster Technical Assistance Center. Are you going to talk a little bit
about that more, Sheila? Okay. I think what you need to know about that
is it is a new TA center established in 2002, and their job is really to
provide guidance and assistance to the state, not just in applying for
grants, but also in sort of learning about the knowledge base, pulling
information together, what research exists. It is an excellent resource.
I will get to our website in a minute, and I\'ll show you how you can
link into some of these resources.

The final two things, the regional meetings and the June 18th meeting
were national meetings. That was June 18, 2003 by the way, I need to get
that added in there. That was really the kickoff for the state planning
grants. We have since had six regional training meetings where we have
met with officials from states to help them develop their plans.

We\'ve met everywhere from Washington, D.C. to Guam. I think Sheila has
been at every single one of those meetings, so she may want to comment
on them as well. But I think, again, it is an example of SAMHSA\'s
commitment to helping states build infrastructure and learn how to do
this, and learn from each other. Because of course in regional meetings,
every state is doing something a little bit different, and they get to
work together in thinking about these things.

Then of course finally what you probably are most likely if you see
anything about SAMHSA\'s activities in the news, what you are most
likely to see would be the ones on this page, which is our disaster and
terrorism response activities. The FEMA Crisis Counseling Assistance and
Training Program, you probably have heard about. That is run through our
Center for Mental Health Services. This is a collaborative agreement
between FEMA, which is now part of the Department of Homeland Security,
and SAMHSA.

When there is a federal declaration of disaster from the President that
authorizes individual assistance, then SAMHSA immediately can enact this
program with funding from FEMA. It is a huge program that although it
primarily focuses on mental health, there are substance abuse related
activities that are eligible, and we\'re certainly working to help
states figure out better how they can combine both mental health and
substance abuse within the parameters of this program.

On occasion we get supplemental assistance from Congress. I think Sheila
is going to talk a little bit about some of our post-9/11 activities
that were administered through the Center for Substance Abuse Treatment.
We also recently, I\'ll be talking about in a minute, we received a
similar supplemental from Congress for Florida for the hurricanes.

I want to talk a little bit more about the hurricanes, just to give you
a sense of how some of these activities work in practice. If you look at
this map here, this was in anticipation of Hurricane Ivan. Some of our
colleagues from the Center for Substance Abuse Prevention have the
capacity to do GIS mapping for us, and have really done I think a
wonderful job in helping us plan how we can reach out to our grantees
even before a hurricane makes landfall.

As you\'ll see, the three different colors, blue, red, and yellow
represent the three SAMHSA centers. You can see as we were anticipating
landfall, where we had SAMHSA centers that might have been impacted.
Again, this just is a little bit more closely looking at this. Of course
as everybody remembers, Ivan followed a very strange path in that it
ended up sort of veering back to the east and affecting the Panhandle
more than we anticipated when we first had these slides done. This is
just looking at the same information in different ways.

So what did we really do with all of this? Well, first off, we updated
our website. We activated our Disaster Technical Assistance Center to go
to extended hours. I\'m talking about all the activities as the
hurricanes were getting ready to make landfall. Staff from all three of
the SAMHSA centers began calling grantees. Some of you who are grantees
in the state probably received some of those calls.

We updated our service locator on the website so that people from those
states if they were having some kind of behavioral health consequence as
a result of the stress and everything related to the disaster, could
access services if they wanted through our website, as well as providing
information for applying for grants.

So this is what this famous website looks like. I\'m sure all of you
have spent many, many hours on the SAMHSA website. I know every time you
are on a conference call or something, you just can\'t help but be
compelled to go over and check out that www.samhsa.gov. The next time
you do that, if you look in the very middle of that opening screen, it
will say disaster readiness and response matrix. I paid a lot of money
to have them put our matrix area right in the middle of the screen. I\'m
kidding, of course. But nevertheless, it is there, so it is really easy
to find. If you just click on that, it will immediately bring you go
this next page.

What you\'ll find here are links to a number of the different things
that we\'ve been talking about today. The 2004 hurricane season, we put
a link up there, and I\'ll show you in minute what that takes you to.
The action plan describes our overall activities and current funding
opportunities. This is something that we\'ll need to update. If you go
there right now, of course there aren\'t a lot of current funding
activities, but if you follow through some of these others, you\'ll see
some of the ongoing grants. So what I\'m saying is we don\'t necessarily
have new grants, we have some ongoing response grants like the crisis
counseling that I mentioned a minute ago, and also the SAMHSA emergency
response grants that are funded within SAMHSA for situations where there
is not a presidential declaration of disaster, but there is still a
significant reason for SAMHSA to have a response.

This was the description that went up shortly after the hurricane
season. You can see a little bit more about some of the things that we
said there, as well as all of the links on the right-hand side. It is, I
think, a very, very nice website.

Some of the other things that we did during the hurricane season was we
had daily and often twice daily calls. ESF 8, are people sort of vaguely
familiar with the National Response Plan and all its activities? Well,
ESF stands for Emergency Support Function, and 8 is public health and
medical. That is where SAMHSA\'s primary involvement is.

Through that, we are able to collaborate not only with all of our
different colleagues at HHS, including CDC, HRSA, and FDA, but also
folks like Department of Defense, Veterans Affairs, and Department of
Agriculture. I think what is important there is just to know that there
is a behavioral health person on all of those calls, which even a year
or two ago was not the case. We now are part of all those calls. So as
we are sitting there on these calls talking about all of the different
activities and planning for them, there is someone there representing
the kinds of issues that we\'re most concerned about.

Then as I mentioned a minute ago, part of the response also can involve
additional supplemental appropriations from Congress. Following the
hurricanes, as our colleague here from Florida can attest, Congress
appropriated money of which \$11 million will be for SAMHSA to assist
those in need of substance abuse and mental health services.

Let me just talk very briefly about the tsunami response, because I know
there has been so much in the news lately, and I\'m sure you all have
been dying to know what, if anything, is SAMHSA doing about that. I
actually can report to you that we are, again, for the first time ever,
being involved in this kind of international response.

CDC, of course the Centers for Disease Control, has been very, very
involved in this response, because as you know, there has been wide
fears of public health outbreaks because of the poor sanitation and the
other conditions there in Southern Asia. CDC has actually reached out
and requested that SAMHSA participate with them in their response. They
want to have behavioral health be a key part of their response. This
again is new. CDC has never reached out to us before and said we want
you to be a partner with us in this kind of response. Again, I think it
represents a fact that incrementally we are getting our issues more and
more at the table. People are thinking about them more clearly at CDC.

In addition, the National Child Traumatic Stress Network that I
mentioned a minute ago has been very, very active in developing some
information sheets for us specifically for dealing with issues of how
children might be affected, as well as how people who are working in
areas where children have been affected, how they might deal with some
of those issues.

I think probably most of you know that one of the most traumatizing
aspects of disaster response is dealing with the trauma where children
are victims, either because they are homeless, or even because they have
been killed. That tends to have the highest impact on the first
responders, the public health workers, and other people that go in, if
there are child victims. So we have got these folks in there working
with us, because as you know, part of the recovery effort is
disproportionately women and children that were impacted in the tsunami.

And then in addition to that, we have developed in the last couple of
years some very strong and formal collaborations, as well as formal with
the Department of State, and as you know, the U.S. Agency for
International Development, USAID, is the lead agency. The person who is
in charge of the psychosocial aspects of the response happens to be a
close friend and colleague of mine, so we have been able to also
informally comment on their plan and provide input as well. I\'ll check
how that looks in a minute before they go out.

Some of the current activities - am I way over, Sheila? I\'m wrapping
it up. Current activities. The in-service we held for all SAMHSA staff
in December. It was very well attended and I think really created an
opportunity again to inform the folks here in the building about this
work.

Sheila is going to talk to you about the

post-9/11 grantees report. The concept of operations is something that
we\'re working on right now which will be a protocol that will guide
SAMHSA\'s overall response in disaster and terrorism events that I\'m
very happy about. We\'ve got so many smart people, we have been doing
this a long time in this building, and in previous buildings, but we
haven\'t got it written down. Now it is being written down, and I think
it is going to really enable us to respond much more quickly and
efficiently in the future.

We also held a tabletop regional meeting for the first time ever, an
exercise here in the National Capital Region involving three states.
Again, all three SAMHSA centers as well as several other federal
agencies were involved in this, and it was a public health behavioral
health tabletop drill. It has never been done before anywhere in the
U.S. on a multijurisdictional scale.

And then TOPOFF 3, some of you may have heard of. It is every two years
the federal government does a top officials terrorism planning exercise.
You will be seeing, and I can\'t tell you many details, but you will be
seeing a lot about it in the news in a couple of months. SAMHSA has been
able to be significantly involved in this in helping to develop the
scenarios. Again, that\'s a first and I think something that we should
be very proud of.

Have you had your building tour yet? That was yesterday afternoon,
right? You probably saw that we have an operations center now with all
those cool screens and everything and the videoconferencing ability.
That will be our operations center in a disaster, up on the 8th floor.
We actually are in the process of putting in some very significant
electronic equipment that will enable us to keep that place functional
even in the event of a partial shutdown of the rest of the building, or
pieces of the government. I think it is going to really make it easier
for us to contact grantees, have everybody in the same room, and really
develop a coordinated SAMHSA response.

So a lot of very, very good things happening. When I talk about
disasters, I always like to end with a warm fuzzy slide. So being a
\"Calvin and Hobbes\" fan, I just want you to think warm thoughts, both
because of the terrible cold outside, as well as just to remind you that
we are working to make things safer and develop a better behavioral
response.

(Applause.)

DR. DODGEN: If people, by the way, are interested in hearing more about
the tabletop exercise that I mentioned to you, I do have copies of the
final report. I\'ll have them with me on CD-ROM if people would just
like to see what the lessons learned were.

DR. HARMISON: Good morning. It is a pleasure being with you here today
to talk to you about the substance abuse treatment field and disasters.

Thank you, Dan, very much for your presentation on the overview of what
we are doing here at SAMHSA. I have to say that it has been a pleasure
working with you, Dan, this past year and a half I believe it has been
that you have come on and taken on this particular role. Thank you so
much.

To give you a background of course as to what we are doing in SAMHSA at
CSAT, let\'s look at what the definition of trauma is. Trauma is an
event that involves an actual or threatened death, serious injury, or
threat to one\'s physical integrity. It is directly experienced,
witnessed, or learned about.

What does that mean exactly? What would that be? Directly of course are
natural or manmade disasters, military combat, sexual assault or
physical assault. We have heard of many of our Iraqi soldiers coming
back and having problems with PTSD now, so we are dealing with that very
heavily within our Veterans Administration hospitals.

Sexual assault is a problem that we have to be aware of of course with
our clientele, women in particular who suffer from this in the past and
often come with this kind of a problem when they are dealing with PTSD.

Witnessed events are seeing an accident, a violent assault or disaster,
or learned about family or friends having a personal assault, injury, or
death. Trauma develops into PTSD, post-traumatic stress disorder, and we
can look at it according to event and personal events.

The kind of event that we would have here would be the kind of trauma,
the kind of disaster, the kind of situation that will be affecting this
person. It doesn\'t have to be a major disaster for someone to get PTSD.
But you do have to look at the duration, the proximity, and the severity
of the event. You also have to look at where that person is within
themselves. What are the supports they have, and what is their internal
motivation to get better?

All of these pieces can be summed up with looking at their preexisting
mental disorders, their family history, their personality, their
childhood experiences, and their social supports.

Clinical symptoms of trauma of course are a sense of numbing, sense of
detachment, being in a daze, derealization, recurrent images, thoughts,
and dreams. These sound significant, they sound like a lot of symptoms.
But I have to tell you, I have done these types of talks for years now
on the disaster after 9/11, and I have had people come up to me after
certain events and say thank you very much for discussing PTSD because I
suffer from it, and people don\'t believe me. I have lost my job, I have
difficulties, and it is for real. I have had people talk to me for hours
about this.

Also there is marked avoidance of stimuli that arise with recollections
of the trauma. There are marked symptoms of anxiety or increased
arousal, having again difficulty sleeping, irritability, poor
concentration, and exaggerated emotions.

Where does the substance abuse treatment system come in in all of this?
Where is it that we can make our interventions? Well, there are many,
many places. Of course there is prevention in the beginning to try to
help folks. But for treatment itself, you have your trauma that occurs,
and I\'m just going to quickly go through this.

You have your stress symptoms, and right before the stress symptoms, we
can do some work. so after a disaster, right after a disaster, we can be
there in the field helping out. If we don\'t get to the client at that
time, often what you\'ll see are acute or delayed PTSD developing. Well,
we can work with them right before that happens, too.

If we have a client coming in at another point, we can deal with it
after those pieces. Chronic PTSD of course is something that we see a
lot with our clientele that we deal with. We have to have our therapists
and our clinicians trained and ready to deal with this issue whenever
those folks come in.

Excessive use of alcohol or drugs in response to trauma does occur.
There is an increased demand for services often from people with
lifetime histories of substance related disorders, and there is an
increased demand for services from people with current substance relate
disorders. So therefore, you have three different populations you always
have to think about whenever there is a major disaster or a trauma that
is occurring.

First off are those folks who are just trying to cope with the disaster
by using substances. The second are those who are in recovery that
realize that they are going to have to deal with having those urges
again because of the disaster. Then the third population are those folks
who have never been in recovery but have suffered from substance use
disorders not realized it, but have that sudden revelation with all the
extra pressures.

So again, we have to look at the nature, duration, and proximity of that
traumatic event, and we have to look at where is our staff. Are they
prepared to deal with these problems? We have to train them so that they
understand PTSD, and we have to have our systems ready so that they can
deal with a disaster in a crisis.

So what that means is not only having your staff ready, but having your
administration of that program ready. We have administrators who are in
the process at this time of developing plans for their programs so that
their staff can handle the clients that come in once there is a
disaster, but also so that their staff can deal with those disasters
properly.

As you know, in our field we have many recovering folks that are there
doing the counseling, so we have to be prepared for their issues also,
and the fact that they may be separated from their family should there
be a traumatic event.

The key is that you have to have the treatment delivery staff able to
recognize the symptoms of stress within the staff themselves and among
patients.

There has been a lot of confusion about substance use being a problem
once there is a disaster. I have been out in the field a lot talking
about this issue. I have heard many folks say there is no substance
abuse problem after a disaster. Well, now we do have much research to
support the fact that yes, there are, and I\'ll talk a little bit about
that too a little later on in this presentation, but yes, there can be
significant substance abuse issues after a disaster.

Some people are unclear, though, of this question. The key difference of
course is in the classification schemes defining substance use disorders
versus an increase in substance use. Remember, as I have said before, an
increase in substance use will occur, but that doesn\'t mean that those
folks necessarily have a substance use disorder. We still though have to
deal with the public health and safety problems that come about with
that.

Let\'s just take a look at the DSM-IV definitions. For substance
dependence, it is \"A maladaptive pattern of substance use leading to
clinically significant impairment or distress as manifested by three or
more of the following occurring at anytime in the same 12-month
period,\" and that would be tolerance, withdrawal, the substance taken
for longer amounts of time over a longer period than was intended, and
there is a persistent desire or unsuccessful effort to cut down on this.

There is a great deal of time spent in activities necessary to obtain
the substance. Important social, occupational, or recreational
activities are given up or reduced because of that substance use, and
the substance use is continued despite knowledge of having a persistent
or recurrent physical or psychological problem likely caused or
exacerbated by the substance.

That\'s different from our substance abuse, in that this is the same
definition, except that it is one or more of these following items. It
is within the same

12-month period. That is recurrent substance use resulting in a failure
to fulfill major role obligations at work, school, or home. After 9/11,
we found that there were many children that were going to school and
saying my mom and dad are drinking a lot and they are not functioning
well. I don\'t know what to do. They were not coping well, and that had
to be dealt with at various treatment centers, and at the schools.

There is also recurrent substance use in situations in which it is
physically hazardous. Of course driving and working in dangerous jobs.
There is current substance-related legal problems such as DUIs from
that, driving while intoxicated.

There is continued substance use despite having persistent or recurrent
social or interpersonal problems caused or exacerbated by the effects of
the substance. Remember, these symptoms though do not meet the criteria
for substance dependence, but they are important to understand.

In the American Journal of Epidemiology in 2002, Vlahov, et al., looked
at the 9/11 disaster and said, I\'m going to look at the impact of
cigarette use, alcohol use, and marijuana in the Manhattan, New York
residents. With that, what we did is he measured what happened the week
after 9/11 and compared it with the week before. He did many other
studies on this, too, but this is the one I felt was significant for us
to look at today.

Vlahov reported that 3.3 percent of the respondents started using
cigarettes in the week after 9/11, but they did not use the week before.
Similarly, 19.3 started drinking alcohol the week after, but did not use
the week before, and 2.5 percent began using marijuana the week after,
but not the week before.

Smith, et al., stated and found with his research that alcohol
consumption often increases following a disaster. After Hurricane Hugo,
beer consumption went up 25 percent. After the Oklahoma City bombing,
alcohol consumption in the year after that increased two times greater
than in a controlled community whenever there was a comparison done.
This is after the Oklahoma City bombing.

Cottler, at al., in 2002 looks at substance abuse and disasters within
the current drug users themselves. Of an N of 166, 36 percent of these
people experienced a traumatic event. People that were exposed to these
traumatic events were more likely to meet the criteria for antisocial
personality disorder, affective disorder, schizophrenia, and generalized
anxiety disorder. Eighteen percent of the sample had PTSD.

Zatzick, et al., found in their study in 2004 that 58 percent of 269
randomly selected injury survivors hospitalized at a level one trauma
center had high levels of immediate post-traumatic distress or alcohol
abuse and dependence. So the take away message from this particular
study is early mental health screening and intervention procedures that
target both PTSD and alcohol use should be developed for acute care
settings. This is critical in that we\'re always looking at screening
devices and ways that we can go into these situations and evaluate what
is happening.

In 2004, Adams, et al., reported on a sample of 1,762 Connecticut
adults. They reported an increase in substance abuse, alcohol or
tobacco, after 9/11 also. So perhaps we should screen people for
increases in tobacco use, alcohol consumption, and sleep problems as a
better way of identifying folks who need the formula help that we have
in the wake of a disaster, rather than asking questions of whether they
are experiencing mental or behavioral problems.

If we don\'t ask them, obviously they\'re not going to tell us. It is
important for substance abuse treatment providers to recognize that
these events leave their imprints on patients. Disasters, terrorist
attacks, and other generalized traumatic events may activate preexisting
PTSD or compound the effects of previous trauma.

If you don\'t ask about it, they\'re not going to tell you. Again, the
program should be set up so that there is a disaster plan. The
administrators should have an idea of how to maintain the setting and
operations, as well as how to reach out to the localities and the state
to get the resources they need.

The treatment programs should offer therapeutic experiences designed
specifically to folks on the histories of trauma and of PTSD, and those
programs should be prepared to address disasters and terrorist attacks
within and outside of their agencies.

The public health system response to trauma thus is that we have to look
at the administrative as well as the clinical piece of these systems
going from the programs up to the state level, and federal, of course.
In the short term and in the long term, what type of research and
training are we going to need?

CSAT at this point has done quite a few things after 9/11, and with
Dan\'s help also, I just wanted to share with you some of the products
that we have developed. At your place setting where you are at, I\'ve
had Carol hand out these CDs. These were developed by the Division of
State and Community Assistance and are compiled of many of the materials
that we discussed today already, in that you have the substance abuse
treatment state \"All Hazards\" plan document that has been developed by
Jean Summers-Miller, and the other expert panel members that we have at
CSAT. That includes Ivan Watt, who is a medical doctor and was involved
in the 9/11 D.C. anthrax response, as well as Henry Bartlett, who is the
President of COMPA, which is an organization of methadone directors in
New York City.

So look through this document, if you will, and let me know if you have
any feedback, because we\'re anxious to see if it is going to be
helpful.

We also do oversight of opioid treatment program accreditation standards
for emergency and disaster planning. That is on here where you have one
document that is a programmatic document. It has got a big X on it, it
is for methadone programs. It is a template for methadone programs to
use whenever they need to start developing their own programs in
addressing disasters.

We also have the 9/11 CSAT supplemental grant report that is on here. I
think all of you received this earlier, this one document. It is on the
nine states that we funded. We have also at this point put in some
funding support to DTAC, and we\'re happy to say that we have further
research sources in the future now to use and to help us develop more
products.

Before I end, I just want to thank Carol Coley, who has been my partner
in crime, if you will, at the Disaster Response and Readiness Workgroup.
She is our program lead. I have been the policy lead. We have Steve
Shapiro, Terry Schomburg, and our new members on that workgroup are
Arlene Stanton and Jocelyn Whitfield.

Thank you very much.

(Applause.)

DR. CLARK: You got a lot of information in a short period of time. I
think because our presenter from the DEA is here, Michele Leonhart, we
will have her present, and then we can have discussion subsequently if
that is okay with council members.

Ms. Leonhart was unanimously confirmed as the Deputy Administrator of
the Drug Enforcement Administration by the U.S. Senate in March, 2004,
following her nomination by President Bush. She is a Special Agent. She
graduated from college in Minnesota with a B.S. in criminal justice. She
has pursued her career goal to be a police officer, joining the
Baltimore Police Department.

Special Agent Leonhart graduated from the Baltimore Police Academy and
performed patrol functions in the northwest district of Baltimore. Her
career interest in law enforcement led her to the DEA. She was hired as
a DEA Special Agent in late 1980. She selected Minneapolis as her first
duty station. So the weather here should be a piece of cake for you. She
has arrested a number of drug traffickers, varying from millionaires to
street-level dealers.

She has moved around the country a little. She went to St. Louis,
Minnesota, and she is now in Arlington, Virginia. In 1993, she
transferred to the DEA Headquarters as an Internal Affairs Inspector and
was again promoted and served on DEA\'s career board until her
assignment of Assistant Special Agent in Charge of the Los Angeles Field
Division.

In 1996, she was promoted through the ranks to Senior Executive Service,
and was assigned to oversee a DEA special agent recruitment program at
DEA Headquarters. In \'97, she was made Special Agent in Charge of the
DEA San Francisco Field Division, where she served until her appointment
in September of 1998 as the SAC of DEA\'s L.A. Division.

So she has been around the country, she has seen a lot, and she is here
to talk to us.

MS. LEONHART: Thank you. Thank you very much, Dr. Clark, and George,
thank you for the invitation.

When we received the letter, it was addressed to DEA Administrator Karen
Tandy. She is in Phoenix today addressing the U.S. attorneys who put our
drug traffickers in jail, so she couldn\'t be here, but she asked if I
had an interest in it. I said I definitely do.

Over the last two years, the Deputy Administrator has had the great
privilege to meet some of you around the country and at DEA
Headquarters, and I believe in what you do. I think it is real important
for you to hear from me, a career drug agent, a narc, truly a narc, what
you and your profession and the treatment professionals really mean to
us.

If you watch the movies, if you read the papers, it always looks like
enforcement, prevention, and treatment, we\'ve got the boxing gloves on,
and they\'re always boxing. It always cracks me up. Even at Christmas, I
have six other brothers and sisters, and we get into all these debates.
We talk about all this, and I said, you don\'t understand. We have
probably never been this organized with the three prongs, which are
really enforcement, prevention, and treatment. So it is a great honor,
and I thank you for the invitation to be here today.

In the letter, it said will you please come and discuss supply efforts
on DEA\'s behalf and some demand reduction efforts. I looked at it when
I saw that it also wanted trends. I have got to tell you, after being an
agent now for 24 years, about 12 of it which was truly on the street, my
first buy I ever made was from a podiatrist who gave me Dilaudid for a
stubbed toe.

I really have to tell you, there are two professions that have taught me
about drug abuse, and have made it easier, especially in those first 12
years on the job, and now working in policy, I am so thankful that I
have that background and that I have had those great relationships with
many in your profession. Two sets of people really tell DEA agents what
is gong on, setting aside the informants and set aside those that we
lock up and put in jail.

It is the treatment professionals. I learned that very early on in
Minneapolis. I went to South Minneapolis as a new agent, and really
wanted to know. We had a group of people that moved into Minneapolis
into one neighborhood, and they dealt cocaine. We had never seen cocaine
at the high purity level that was starting to be distributed in the
early \'80s.

We asked around, we asked the street cops, what is going on? Has
somebody new moved into the neighborhood? Why all of a sudden have I
been alerted by my treatment friends that they have seen a spike? Why
has this happened? So I was a grade seven, what they call a narcling, a
baby agent.

(Laughter.)

MS. LEONHART: I realized if I really want to know what is going on, I go
to the treatment people. They were able to show me the correlation
between availability of cocaine on the street.

In one particular neighborhood, in fact, all my buys were out of a bar
called Joe\'s Bar in the men\'s bathroom. They were the ones that were
able to say, okay, this is why. This group from Cuba and South Florida
has moved into the area and has brought with them the most high potent
cocaine that the area has ever seen. People couldn\'t handle it. So you
started seeing them.

The other profession that has helped me out my whole career is my
sister, who I love dearly. Here I am a cop, I\'m a narc, and she is a
teacher, and I respect that profession so much. I have got to tell you,
she is in L.A. Unified in a school that has every kind of drug problem
mentionable, and when we get together and go out to dinner, she\'ll ask
me, what about this and what about that?

I often find myself taking out a pen and writing it down, because I have
no clue as to what it is, and here I am 24 years in the Drug Enforcement
Administration. With my sister, the treatment professionals that helped
me in the early days really taught me about cocaine use and abuse, and
really helped me in San Diego understand methamphetamine.

It was a treatment professional in San Francisco that met with DEA and
told us, \"Look, what I\'m hearing is methamphetamine is now abuse. It
is spreading across the nation. It\'s no longer a problem in the West.\"
As a treatment professional, that flipped the switch for us, and we have
been fighting the nationwide meth problem ever since.

So teachers and treatment professionals. So that is why I\'m very, very
happy to be here today.

Let me add two other people that I understand are on your board that
have helped. It is very interesting. We recently heard about all these
successes in Chicago, and I want to tell you about some of the
successes, because not every major city can say this.

I believe the answer is combined enforcement, prevention, treatment, and
community attack.

In Chicago, the overall crime rate is down 4 percent, homicides are down
25 percent, and non-fatal shootings are down 39 percent. The police
commissioner and superintendent went out and announced this. We know it
is because in Chicago, and I appeared at a heroin symposium last summer,
we know that Chicago has gotten their act together. We see that we\'re
not going to arrest our way out of the problem, it is not all about
prevention, because what do you do after someone starts taking drugs,
and treatment is on the back end. So it is a combined effort.

I wanted to mention Melody, because I know it is her efforts in that
area that have helped Chicago.

Another person, I understand he\'s not here, but I have to actually add
a third profession that has really helped DEA.

Now, I was a SAC in San Francisco, Special Agent in Charge, and I was a
Special Agent in Charge in Los Angeles. The best person dealing with
medical marijuana issues and legalization and all that for the last
seven or eight years, it was a doctor who has got a nice science
background that was probably the best person I ever heard talk about the
effects of marijuana. He belongs to this board, and it is Dr. Voth. I
was really, really hoping to see him here. I have met him. He spoke at a
class I attended in Monterey about five years ago. Absolutely
outstanding.

You asked for what are some of the successes that DEA has seen, so let
me talk about some of that, but with a caveat. When I talk about these
successes, it is not just DEA. Every time I talk about it, it is really
about the three of us, the three-prong approach.

Much of our DEA resources are devoted to pursuing major illegal drug
trafficking organizations, cartels, and like in Chicago, the violent
traffickers. More often than not, these organizations are complex and
frequently have multinational and/or international links. We seek to
destroy these groups by not simply seizing the drugs and getting the
criminals locked up, but to seize their assets and destroy their
financial base.

We have put a lot of effort into intelligence gathering, coordination,
and cooperation with other federal agencies, both state, local, and our
foreign counterparts, which are key, in order to build the best and hard
hitting cases.

One persistent tenacious problem that you very early have been helping
us with is methamphetamine. When I talked about it a little bit earlier,
I saw people shaking their heads. Methamphetamine. We saw this drug
initially in the western region of the U.S., but today it exists
nationwide, largely in rural areas. I\'m certain most of you, if not all
of you, have seen the devastating effects in your communities with
methamphetamine addiction, and the effects they have on their families
and their communities.

Most recently our greatest impediment to doing something about the meth
problem has been the fact that the primary ingredient, if you think
about it as a recipe, the primary ingredient you need is a nasal
decongestant, which I need right now, called pseudoephedrine. It has
widespread legitimate use and availability.

Unlike other illicit drugs that require some knowledge of chemistry to
produce it clandestinely, meth is easily made with household equipment
and materials purchased at major chain store retailers, or even truck
stops. Instructions are easily found on the Internet, and we have
children attempting to make methamphetamine.

DEA and our law enforcement partners have been aggressively targeting
the meth superlabs that were responsible for producing and distributing
all over the country about 80 percent of the meth found in the country.

Through enforcement operations, we have been able to see a shift in the
pseudo availability. The traffickers in the west set up these big labs,
mass production labs, and were shipping to L.A., they were going to
Iowa, they were going to Illinois, they were going to Minnesota, they
were going to Nebraska. I have been gone a year, I was back at Christmas
and got briefed on a couple of cases, now they are going to Atlanta,
South Carolina, and the east coast.

We know that the key is cutting off the access to the main chemicals
needed to produce methamphetamine. Those are pseudoephedrine and
ephedrine. We have made great success. When we got together with our
state and local partners, we realized the major superlabs were not going
into the Walgreens and getting their pseudoephedrine. They were getting
it in bulk coming across the border in Canada.

At the time when we started the operation, a lot of the brokers were
middle eastern traffickers, and this is right after September 11th. So
we set our sights on trying to find out what the connection was, and we
were very concerned about terrorist financing and the proceeds from
selling this product that you and I can go and get in a drug store, but
in bulk, that is our problem.

Today we may finally be on the cusp of realizing the serious impact of
this drug problem. A number of states have enacted legislation to
restrict availability of pseudo, which goes beyond the limits imposed
federally. I was reading yesterday that Senator Feinstein, and I believe
12 other Senators, have just rolled out proposed legislation similar to
other legislation in states, very aggressive legislation that will help
the control of pseudoephedrine.

Why? Because the superlabs that used to produce for the whole entire
country, we have basically shut down. They are dropping at dramatic
rates. So it is these small toxic labs we call \"Beavis and Butt-Head\"
labs out in your communities, the ones that blow up, the ones that cause
all the environmental damage, and are right in the middle of your nice
neighborhoods. That is our threat right now.

Legislation, state legislation, is really moving quickly, and it is the
right thing to do. Now we see a rollout of federal legislation.

I\'m happy to tell you that we realize a significant number of successes
each year by actually targeting the right criminals and putting them out
of business.

The example is LSD. You remember LSD back in the \'70s. What is it? Tune
in, tune out, whatever. Dr. Leary. You remember that. It was a major
problem in the \'70s. Then it went away. But it has popped up, the same
with Ecstasy, and has been a very popular drug for young adults, and
especially in connection with rave parties.

Well, we targeted the right person. Although it took us 30 years to get
there, it was as simple as identifying and realizing when we came upon
him that there were two individuals in Northern California that probably
produced the world\'s supply of LSD.

There were only three LSD labs seized in DEA history. The fourth one was
seized in 2001 as a result of this great focused enforcement approach
with our state and local partners.

They were operating this major lab out of a missile silo in, if I get
this right, Winteka, Kansas. The middle of nowhere. They were producing
the world\'s LSD there.

Well, guess what? Great investigators go out there, arrest them, arrest
their product. For the first time, you can see since that happened,
every year there is this decline, decline, decline of LSD. You probably
see it.

You cannot find LSD right now. Over a 60 percent reduction, 60 percent
reduction. So here is a DEA operation just focusing on the right person
that wipes out LSD. But that is not always going to work with some of
these other drugs, and that\'s why it is so important for us to work
together.

We had Ecstasy kind of drop on top of us, and all of a sudden kids were
going to rave parties, young adults, we had deaths, and it became a
national problem. You saw it. It was the whole community. Law
enforcement, enforcement, and treatment that did something about it. You
have all been out there talking about it, spreading the word, and doing
community education on it.

It is a good time for me to introduce, I brought Catherine Harnett with
me. She is our Chief of the Demand Reduction Section in headquarters.
She thinks the world of this group. I had a chat with her this morning.
We would like to be invited. If you want us to give you the latest
trends and you can give us five minutes, we\'ll come and do it. If you
want to see us here for an hour, we\'ll do it. Catherine is the one to
coordinate with.

There are outstanding things being done by our demand reduction
coordinators in the field. If you haven\'t met one, there is one in all
21 field divisions, and some of them have two. I would suggest that is
the greatest resource for you is they are DEA special agents, but they
have an interest and they have the desire and the drive to do something
about abuse.

I talked about this Ecstacy case. It was called \"Candybox.\" Again, it
is focused enforcement, we picked an operation and little did we know
when we started it a few years back, that it would wipe out 15 percent
of the country\'s MDMA, or Ecstasy, supply. So if you are seeing fewer
people coming in, fewer people with abuse of Ecstasy, they are having a
harder time finding it.

We implemented an impact study basically to try to find out, that\'s our
biggest challenge, how do we, and it is probably one of yours, too, how
do we really show that we are making a difference? By looking at that
one operation, we were able to show a 15 percent reduction in
availability.

We were able to show in the cities where we had enforcement operations,
in the cities where we did combined treatment, prevention, education of
the public, the price went up, and the availability is down. It has been
sustained over a six-month period. So we are proud of that.

There is more major successes, and I\'ll just mention a few, because I
know you guys probably want to go to lunch. But I mention them, I just
told you about two enforcement operations. But these successes are huge.
They are because of your efforts and our combined partnership.

Since 2001, 600,000 fewer teenagers are using drugs. Could you ever
imagine that? I know I couldn\'t. Current marijuana use by teens has
dropped, and marijuana was our biggest. We have been worried about
marijuana because we saw that use go up. Well, since 2001 it continues
to drop. It dropped 11 percent last year, and now I think Catherine
we\'re up around 17 percent. It is unbelievable.

Cocaine. So many of you handle cocaine problems. Well, the entire South
American cocoa harvest is at its lowest level in nearly 20 years. The
cultivation of coca has been slashed 21 percent in Colombia. You
haven\'t felt that yet, but we have people that are charting this out,
and they think for the first time by summer we may see indications of
availability problems with cocaine.

We indicted 89 percent of the leaders of the most wanted international
drug organizations responsible for supplying drugs to the United States
streets. I told you about meth superlabs. Cocaine use has plummeted over
70 percent during the past 15 years, with almost 3.5 million fewer
Americans using cocaine today than two decades ago. Phenomenal.

DEA has almost doubled the seizure of drug proceeds from these
traffickers in the past year. We see this as a success. Over \$5 billion
in drug controlled funding was allocated for treatment, prevention, and
research in 2004. Communities in 42 states are the recipients of over
\$18 million in \'04 to establish or continue drug courts.

So those are great successes that we all share in, but we also share in
the challenges. The biggest challenge for us is to get out the message,
what is the effect of drug use on the non-user? Our administrator likes
to call it the secondhand smoke message. How do you convince someone
that says look, I don\'t use drugs, my kids don\'t use drugs, so it
doesn\'t bother me. I don\'t care if this saves the country money, I
don\'t care, fewer people going to jail, I don\'t care because it is not
going to affect my family.

What we do is we try to send the message that in 2002, 11 million
Americans age 12 and above, and I always wondered how you could be a
12-year-old driver, but 12 and above admitted that they drove under the
influence of illegal drugs in the past year. An innocent driver may not
have abused drugs, but the innocent driver is the victim on the road
when someone has taken drugs and decides to drive.

Just like the dangers of secondhand smoke, the drug use kills 21,000
Americans each year. Nearly half of the people stopped for reckless
driving who weren\'t drunk tested positive for marijuana. Three-quarters
of illegal drug users are employed in the workplace, which means
employers have the problem, and then we pass on the health care
problems.

Illegal drug use leads to crime. Two-thirds of men arrested for crime in
36 cities nationwide tested positive for illegal drugs. One-third of all
AIDS cases are drug related. Who is the biggest victim here? It is
children.

Last year alone, 9,000 children were abused by parents involved in
methamphetamine in Iowa. That abuse and neglect strains our social
services, and we all pay the price. I could go on and on and on. I hope
what you got from what I said today was how this is really a
partnership, and we all, if we can find a way all staying in our lanes,
doing our individual what we are supposed to be doing, but doing it
together, we can make a difference.

DEA is committed to it, and I don\'t want to leave you without telling
you, you asked for trends, I get trends from you, but hopefully I can
give you a new trend. You saw what happened with OxyContin. Huge abuse
all over the country, hit a lot of people by surprise, but I\'ll bet you
saw it first.

Well, there is a new type of OxyContin that was released in January. It
is called Paladone. Four times more potent than OxyContin, eight times
more potent than morphine. Released in January. How long until it starts
being diverted and hits our streets?

So if there is any one trend, I felt I can\'t leave, you can give me the
hook and take me off. I needed to tell you about that, because that is
going to cause all of us a major problem. The pharmaceutical problem is
growing and growing, and for the first time, you heard the President
talk about it, it is in his National Drug Control Strategy, you heard
the drug czar John Walters talk about it, you\'ve heard former ‑‑ I
guess almost today, tomorrow ‑‑ former Attorney General John Ashcroft
talk about it, and you are going to hear DEA talk about it.

We\'ve got to do something about the prescription drug problem. Why
can\'t we just use our regular techniques on our side, because now it is
available over the Internet. We see these spikes in pharmaceutical drugs
caused by the Internet. So we\'re working on it. We\'re putting
strategies together, we\'re working with you

Our demand reduction agents out in the field would love to be invited to
your meetings and give your folks updates on drug trends. We have been
wanting to do that for years. So again, I just want to thank you so much
for the invite to come today and to share that.

I know they wanted a little question and answer period, so I\'ve got
Catherine here to help on demand reduction questions. I\'ve got my
assistant, Joel Fries, in the back who has got 30-plus years as a
diversion investigator working the prescription side. What can we help
you with?

DR. CLARK: Melody?

MS. HEAPS: The Afghan heroin specter, where are we? Have we seen it? It
is hard in Illinois, in Chicago, because we tend to be a heroin capital.
We are seeing some increase, but we\'re not sure yet.

MS. LEONHART: Right. Let me say this. A lot of people are asking DEA,
why are you even interested in Afghanistan heroin? Because you don\'t
find it very often in the United States. It has flooded Europe, they
should be worried about it. But they say, why should DEA be worried
about it in the states? Well, we are very worried about it.

It was just years back when Afghan heroin supplied three-quarters of all
the heroin in our country. So we have to learn from history. We can\'t
let up. As we are attacking and doing all these things in Colombia and
Mexico, you had better believe that with the right traffickers having
the right access to domestic traffickers, you are going to see Afghan
heroin cheaper than the other heroin, more potent than the other heroin,
we suspect, if nobody is doing anything about it.

So I didn\'t put it up as a trend, because it really isn\'t showing up
yet, but it is another thing, like Paladone. Let me throw it out to you.
Thanks, Melody, for bringing it up.

Let me throw it out to you to watch. If that gets out of control, we\'re
in trouble. There are no jails in Afghanistan. We have 12 agents over
there trying to do drug work. There is no counterparts. We are just
training a police force. There is no prisons, there is no judges. There
is no prevention, there is no treatment.

So the United States takes on that responsibility to do something about
it. We have got something in place, and we are hoping, it is called
Operation Containment, to contain it, contain it there in the region,
not let it out of the region, and not let it affect the U.S. drug
market.

Thanks for that question.

DR. CLARK: Dave?

MR. DONALDSON: Two questions for you. First, I was talking with Richard
yesterday about the national survey that we received on drug use.
Speaking of geographic trends, we were curious about the drop in the
rural area, which according to this, was very significant. More than
half. He said he didn\'t believe it, especially with the spread of meth.

MS. LEONHART: Right.

MR. DONALDSON: Is this correct? And if so, why?

MS. LEONHART: Well, I\'ll ask Catherine if she knows about that study. I
haven\'t read that, but there are a couple of people that have said has
there been a change? Can we actually say there has been a change in drug
use in rural areas?

I find it very hard to believe, but I haven\'t seen the study, and I
don\'t know, was it specific drugs? I don\'t know who they looked at.
But I will say this. If it was regarding methamphetamine, I believe that
is the residual of all those efforts on your behalf and the efforts on
the enforcement to shut down that pseudo supply out of Canada. It is
just a matter of time.

We have already seen a slight rise in these \"Beavis and Butt-Head\"
labs in rural areas, and moving east. So that does surprise me.

Catherine, are you aware of this?

MS. HARNETT: Which survey is it? The report that was out last December?

MR. DONALDSON: Correct.

DR. CLARK: It is the Household Survey.

MR. DONALDSON: Yes.

MS. HARNETT: I know that the meth numbers, at least some of the
prevention people that we talked to, there is some concern that they are
not capturing everything we need to capture. I think also with the
arrest data not available anymore in the form that it was, we may be
missing some rural users.

But really I\'d like to look at it more carefully and talk to some more
people, but it does show either meth declining or steady I think in a
number of areas. But I\'d like to check more into it. As you know, it is
easier to measure in some of the urban areas than it is in the rural
areas.

MR. DONALDSON: Yes.

MS. HARNETT: In terms of both prevention and statistics, that\'s an area
that we really need to do a lot of work in.

MR. DONALDSON: Yes. According to our networks, in the rural areas it is
just spreading out of control. I was shocked to see that. I hope that\'s
correct.

MS. HARNETT: And I think the Monitoring the Future also shows similar
reductions in meth, or no increases from last year.

MS. LEONHART: We\'ll remember that. We can now go back and look. I was
surprised, the huffing or the inhalants, I grew up in rural Minnesota,
and that was big back in the \'70s. Rural drug use seems to be a lot
different than big city drug use. But I am very interested in your
question, and we\'ll definitely take a look at it.

MS. HARNETT: And our demand reduction people across the country that
serve in rural areas continue to say that meth is an enormous problem.

MR. DONALDSON: The other question is you mentioned different
institutions that you are partnering with to help you. What about the
faith community? How are you partnering with the faith community, and
how can we better help you?

MS. LEONHART: Well, I can tell you Catherine is our go-to person on
that. She has briefed me and the administrator, and I know that there
are some good projects coming up down the pipeline.

Catherine?

MS. HARNETT: Particularly in Missouri, we have a very strong
relationship with the Addiction Academy, I think it is called, in
Missouri. Our DRCs, some of them across the country are working very
closely with the faith community both in prevention and in addiction
treatment.

It varies from place to place depending on what kind of programs are in
place. But we do as best as we can where the communities are set up in
the vein to work with them. That is one of our priorities, working with
the faith community.

We do, I think, in Baltimore have some programs, and Missouri, the St.
Louis area, I think is our strongest faith-based programs. But it is
something that we consider a top priority where it does have an impact
on the community.

MS. LEONHART: Anyone else? Sure.

DR. McCORRY: Could you say a little bit more about DEA\'s plans with
prescription misuse?

MS. LEONHART: Sure.

DR. McCORRY: Or their version of prescription drugs, and what is the
kind of game plan for addressing that?

MS. LEONHART: Well, to stand up and talk about pharmaceuticals and what
we are doing, we have our hands on so many different things that we have
never done before, so I\'ll throw out a few and you\'ll see.

One is through Catherine and our very talented diversion folks. They
have come up with what we call the Medical Examiners Database. The
administrator when she came on board a year ago said, we wait for DAWN
data, that\'s too late for policymakers and for all of us to really be
able to react quickly to changing trends.

So it is just in the pilot right now, but I believe we have got people
working on it and we were able to bring it to medical examiners, and is
it seven or nine?

MS. HARNETT: Nine.

MS. LEONHART: We have nine medical examiners, some rural, some big city,
state, some are city or county coroners, and others are for the state.
Now for the first time we have given them the tool to talk to each
other. This is going to become very important when we see what happens
here with Paladone being released. All of a sudden we see this spike.
And are the medical examiners able to pick it up?

And I think the dream would be if all of us working in the area could
have some method to talk to each other on a regular basis and to post,
here we are seeing a spike and you need to know it might not be
anything, but here law enforcement, you need to do what you can on it,
here treatment and prevention, you guys need to know about this, it
could be headed your way. That is one of them.

Our Internet strategy, I\'ve got to tell you, we are back at Internet
101. There is one thing the agents aren\'t real good at, and that\'s the
Internet. They\'re out making drug cases. The bulk of our agent
workforce is not from the techie age. So we are at 101, and we\'re
learning about the Internet.

We have this new technology we call the Webcrawler, which is going to
these Internet pharmacies. There could be one organization or one person
behind it, and they could have 100 pharmacies. There was no way to
connect the dots to be able to show, okay, that one person, here we are
focused on this one Internet pharmacy, but that person is controlling
all of these.

Our Webcrawler technology is in there. Think of it as a huge Google. It
crawls in there, finds the connections, and then it makes a snapshot for
us. We\'re going to be able to use that in prosecution and in focusing
on resources.

Another very interesting thing, and I never can say it right, I want to
say phenylephrine. We are hoping, there is a manufacturer that just
released a new nasal decongestant that they claim cannot be used in meth
labs. If that proves to be correct, you are definitely going to see an
impact on methamphetamine use. People are not going to be able to get
it. That goes back to the controlling the pseudoephedrine.

There is legislation in \'05, and we are just waiting to sit down with
the FDA, which actually puts DEA on a panel to review new drugs coming
out with the potential for abuse, and lets DEA look at it and give
comment. With Paladone, we suggested, but it wasn\'t taken. We were
almost powerless there that it really be marketed for severe pain. I
mean, four times OxyContin, eight times morphine. But we run this
balance and we also realize that these are very, very sick patients.
They need this kind of medication. So we walk this tightrope. We are
very, very happy to see more interaction now in DEA. We are hoping to,
so we don\'t have an Oxy problem jump up on us, put things in place that
can give us the red flag and say look at this.

If there was some way we could develop that with this group, that would
be the best of all worlds. I\'m going to go back and talk to Catherine
about it. If it works with the ME database, could we do something else?
They are talking to each other. They are posting warnings. Fentanyl
lollipops. They are the first people that told us this stuff was
happening. So that\'s just a few things.

DR. CLARK: One last question, Melody.

MS. HEAPS: The ADAM program. There was word that it was going to be
resurrected and put in a different place outside of Justice, and we
haven\'t heard anything about it. It was a fabulous tool for many
reasons.

MS. LEONHART: Right. First of all, all of us use ADAM, we use DAWN, and
we needed QUICK. When we heard about ADAM going away, we were very
concerned, because we depend on it. It tells us what they are using, and
the last I heard, and I\'m going to let Catherine speak if it is wrong,
but the last I heard, they were looking at possibly ONDCP picking up the
funding and carrying the ball so that we don\'t lose.

I\'m worried about losing one year\'s worth of data. So we stand with
you. We definitely stand with you concerned about ADAM. We are hoping
for some of these other things like the ME database and just
prescription monitoring programs in the individual states.

It was great. We did testimony on the Hill and we could show in the 22
states I think it is that have prescription monitoring programs and that
have gotten grants to set these up, they have the lowest abuse of
OxyContin numbers. I mean, they are the lowest. So there is definitely a
correlation there. Then you look at the states that have done nothing on
prescription monitoring, and they are high. Good question.

Well, thank you very much. Really, we offer to come and give you drug
trend information. I had a PowerPoint I was going to give you, but I
really think I needed other things to tell you rather than how cocoa in
Colombia is produced and all that.

Thank you.

(Applause.)

DR. CLARK: We still have our disaster people here for questions.

Frank?

DR. McCORRY: Just a quick question around critical incident debriefing,
which we kind of use a lot in New York and has been used a lot. But then
I understood that it was not viewed as favorably as a post-disaster kind
of intervention. Is there anything on that?

DR. DODGEN: This is actually a somewhat complicated issue. What makes it
complicated is that, as I said earlier, the research base is just not
very sophisticated in this area, particularly when we are talking about
intervention.

For those of you who don\'t know, critical incident stress debriefing is
a popular model used by many law enforcement, DEA actually uses it, as
do many branches of the military in many of their units as a way of
addressing potential stress problems with people who are first
responders to some of these different kinds of events.

The reason it has become controversial is that there is some research
that suggests that if the intervention is done in certain ways, there is
actually a potential for harm. Not just for having no benefit at all. It
appears to be that in particular when people use a model that is really
designed for group processing, but they do it with individuals, for
people who use sort of their multiple steps that are part of the
intervention and don\'t necessarily follow all those steps, for example,
verifying that you have a heterogeneous or a homogeneous group, which is
what it is designed for, people who already know each other, already
work together, already have sort of shared experiences and you do this
process with them, it has benign effects, and in some cases, very
positive. Versus if you just sort of pull a bunch of people who were
called into an emergency situation and don\'t know each other and in
many cases compel them to go through a group processing of experience,
that is where you get some of the harmful effects.

So the research, again, is very, very early on this. I\'m not going to
say that we\'ve got definitive research on this, but what I\'m seeing so
far suggests to me that if the model is adhered to pretty strictly,
there is little potential for harm, and significant potential for
positive benefit. If the model is not adhered to strictly, there is in
fact potential for harm for people.

As we know, for some people you can retraumatize them by having them
sort of go through the experience again verbally. If you have either
unskilled clinicians doing that or people just not following the model,
I think there is potential for harm, and it is something we need to be
very cognizant of.

MR. DONALDSON: Well, I want to thank you for your presentation. It was
very good. This is an area of service of great interest and great
concern. I was involved in the national summit that you mentioned in New
York helping to facilitate the faith-based side.

I just wanted to follow up on some of the items that were discussed then
to see where we are at. First was the collection of the needs assessment
data. You might want to write down a few of these. Two, the delineation
of roles and duties. I know for a fact that there is still confusion on
the grounds. It is like adding disaster to the disaster.

I think there were some good things that happened in Florida, the team
that has been comprised there. But where are we at with the plan for the
continuation of services? So do we have guidelines for handling the
stockpile of medications, for example? What about food?

DR. DODGEN: Let me talk about this in a couple of different levels. At a
level particularly of SAMHSA in terms of what we\'re doing, the expert
panels that I mentioned to you a minute ago, some of the issues that are
brought up in that consensus document from the meaning that you\'re
referring to, we\'ve actually had multiple expert panels. I mentioned
assessment as one, but also outreach, intervention, a number of
different issues.

All of those if you go to the report from that 9/11 meeting -

MR. DONALDSON: But I\'m not referring to information gathering. I\'m
referring to implementation. We have been talking about this going on
four years.

DR. DODGEN: Right. If you\'ll allow me to continue. What I was going to
say, because I think your point is exactly right on the money. What we
need to do first is really find out what we already know and get the
experts together. That has actually been done. That is what I was
talking about.

Now what we\'re going to as the next phase, which is exactly what you
pointed out, the implementation phase, and part of that of course is our
Disaster Technical Assistance Center, it is some of the other activities
that you\'re referring to where we need to get the people who are now
providing the technical assistance up to speed on what is happening. In
fact, that is what we\'re doing right now, that is part of why we
created the Technical Assistance Center.

It is so that when people who are developing plans call into us and say,
hey, what are we supposed to do, then we actually have some answers for
them. The reason that I caution is because I\'m not going to tell you
that we have all the answers and all this, we don\'t. But we are
developing, and we are getting the information that we have out there.

I think your other question is really a big picture HHS question in
terms of the Strategic National Stockpile and in terms of some of the
other things. The Strategic National Stockpile, as you probably know,
has been a very, very tricky issue because in the legislation that
created the Department of Homeland Security, that was actually moved
from the Department of Health and Human Services over to the Department
of Homeland Security.

That was probably not an appropriate thing to have happen, because they
really didn\'t have the expertise over there. It has now moved back,
although sort of the authority to deploy it and the authority to
administer it are now housed in two different places. That is a long way
of saying that as a consequence, it is both a political and a policy
issue in terms of what happens with the Strategic National Stockpile.

Having said that, though, I will say that there are people now looking
at the contents of the stockpile in ways that they weren\'t a couple of
years ago in terms of what are some of the other kinds of medications
that need to be in there beyond sort of just the initial kind of
vaccination and sort of emergency medical response medications that were
initially part of it, some of the Mark IIs, the anti-agent things that
were in there. So I think that we\'re actually seeing progress in where
that\'s at.

But again, in terms of the list of what\'s in there, I can\'t really
talk about that in a public forum, but I know that people are talking
about some of the issues. Does that help? Does that address that
question?

MR. DONALDSON: Not really.

DR. DODGEN: Okay.

MR. DONALDSON: To be honest with you, you are working on it, and I know
that we\'re working on it as well. But this is very important.

If I can just follow up on a question I brought up the last time we met.
You weren\'t here at that time. It pertains to the use of volunteers.
Relating to substance abuse, we know what happened on 9/11. Many clergy
and chaplains were turned away. In fact, one study said over 700,
because there was no certification process in place.

Bobby Polito, he was there in the counseling center. He reported back to
the Secretary that people were looking for their pastor, priest, or
rabbi to talk to, but all that we had there were psychiatrists. Many of
the psychiatrists were in a back room playing cards because nobody
wanted to meet with them.

In part of your discussions, is there any kind of certification process
that would allow those that have been laboring around those disaster
sites for decades, again, clergy, chaplains, that would have that kind
of organized and approved access?

DR. DODGEN: Yes. I think actually there are a couple of different
answers to your question. I think it is a very good one. I know I
actually am myself a Red Cross disaster mental health worker, and have
been doing that for about 12 years, 13 years now.

I agree with you. I think many people are more comfortable talking with
clergy than they are talking with people that are identified as mental
health professionals or substance abuse professionals. I think that
there are a couple of different ways that that question has to be
answered.

First off, of course in the volunteer organizations, I\'m sure you\'re
familiar with the Red Cross, it actually has a chaplain core that is
integral to them, and it has its own certification process. Anytime the
Red Cross deploys, they are deploying clergy as well. The little
green-vested people if you think in your disaster site, and of course
there is the whole aviation incident response which also has a spiritual
care unit.

So I think on the volunteer side, they actually have been looking at
these issues for a long time and already have mechanisms in place for
addressing it. I think on the federal side, of course you know the
Department of Defense which was very involved in the Pentagon, less so
in the response in New York City, also has significant chaplains. Those
folks, all of the Department of Defense\'s response teams include clergy
as well as perhaps social workers, mental health, as well as nurse or
physical health care.

So I think there are a number of places where that is already
incorporated. At the end of the day, is the Department of Health and
Human Services going to develop an initiative that includes clergy?
Probably not. The department is actually trying to avoid sort of
bleeding over beyond our public health response, so it is unlikely that
they would develop actually a certification process.

As you know, certification and credentialing is an incredibly
complicated and very controversial issue, period. I don\'t care if
we\'re talking about mental health or substance abuse, or if we\'re
talking about nurses, physicians, or whatever. We actually have to be
really, really careful to not get into issues that historically have
been the guilds\' responsibilities in terms of sort of who is
credentialed and who is qualified.

So I don\'t anticipate the department trying to come up with some sort
of procedure for doing credentialing or certification for clergy, or
really for anybody else in a disaster setting. That is actually
something that I don\'t think at the federal level we want to get into.

MR. DONALDSON: That\'s unfortunate, because I feel like this is one of
the greatest entry points for us to help professionalize many of the
clergy and chaplains that we have out there.

DR. DODGEN: Well, I appreciate that comment. And I can actually convey
that up. I won\'t tell you it is not going to happen, because as you
know in the last couple of years, many different things have happened
that we didn\'t think were going to happen.

I\'ll be happy to actually pass that forward. It would be interesting to
see if that generated discussion department wide. It would just be hard
to know where that would go, but I can pass that forward.

MR. DONALDSON: Thank you very much.

DR. CLARK: Ken, and then Anita.

MR. DeCERCHIO: Let me speak to some of your comments. What we found is
we learned from Andrew in Florida, just to give you the scope, we had
four hurricanes in five weeks. The first hurricane, Charlie, 24 counties
out of 67 were a disaster. Frances, 42 counties were declared disaster
out of 67. Ivan, an additional 16, and 16 more with Jean. At any one
point in Florida, all but about 13 counties were declared a disaster
area.

Dave, on your point, a couple of things. We ended up networking this
time that we didn\'t do with Andrew with the Florida Interfaith Network.
Jody came to me a couple of years ago and said look, we didn\'t connect
in Andrew, and there is an opportunity here. We don\'t have to certify
them. I mean, they have a process by which they engage, they engage
ministers and ministries.

Our role was to just make them a part of our team in a coordinative way
and let them not get in their way, and then tap into the tremendous
resource, support, coordination, that they do, so that it was, well, for
obvious reasons. So I guess I\'m suggesting in that respect there is a
lot of activity, and maybe a role to identify those types of
organizations.

We trained people to go out in these disasters on basic crisis
counseling that were accountants. So the idea that a clergy would have
to be certified as opposed to get the basics in terms of the crisis
response, I think we\'re overdoing it in terms of a certification
process as opposed to people with compassion and clergy skills in terms
of here are some core things, depending on where in the disaster you are
connecting, that I think could turn lose a tremendous cadre of what your
intent is.

That is just from our experience. We did a better job of coordinating
with Lutheran Disaster Response, and let them work it. The scope was
kind of phenomenal. I have to say that I really appreciate Sheila\'s
work and SAMHSA\'s work on this from a recipient, from someone that was
in the middle. I wasn\'t in the middle. I was kind of in a coordinative
role for people in the field. But early on I asked for a coordinator
response from SAMHSA with FEMA so that we weren\'t having a quarrel with
Centers for Substance Abuse Treatment and the Center for Mental Health
Services.

Our responses were coordinating with mental health through part of the
mental health team, so we weren\'t just communicating with the field in
substance abuse in one path in mental health and one path in
communicating up. I found that to be very extremely critical. It
required access to crisis services and crisis response grants that was
inclusive of substance abuse. One of the largest responses in the state
for crisis counseling was managed by primarily a substance abuse
provider network that had mental health agencies. They handled the
response in all of Southwest Florida in terms of the immediate crisis
services grant.

I won\'t go on and on. I have to say I really appreciate SAMHSA\'s
response to that and coordination with other federal partners. The
tendency for us in the state is to reach out to the community and say
what do you need, and start deploying. The tendency for the feds is to
call us and say, what do you need? There are times when the responses
all have to be measured.

We found that waiting when an area is hit and letting the area assess
and determine their needs and then having people prepare to move in was
pretty critical. Communication. You can\'t over-communicate in these
situations all over the place. I just can\'t say enough about the level
of communication that is required, both with our federal partners and
across the state with the state emergency disaster response and with
communities.

We were having two calls a day with each of the areas that were
affected. A lot of our role was coordinating with FEMA and the big state
disaster response. You really have to respect what communities are going
through and not want to have a bunch of folks reaching down doing things
across purposes that at the local level seems like chaos.

You can think about the chaos created by the disaster, and then folks
reaching down trying to do things all over. They want a coordinated
response. A lot of what we do as managers was facilitating that.

I won\'t go on beyond that. The idea of opioid preparedness was a big
one. Thankfully we only really had one situation where a patient had to
call us and said I can\'t get access. The providers were tremendous and
we gave a lot of flexibility in providing and letting them access and
create all kinds of opportunities for doing guess dosing and access to
centers, because we had a fair amount of impact, large areas that you
can imagine were impacted.

So if you are not prepared, get prepared. There is nothing like going
through it for the lessons learned. I just really have to say that I
appreciate all the support in helping us put together the crisis
counseling grants, the crisis response grants, and the supplemental,
which is in process. Pretty critical, pretty critical.

The takeaway, there is a lot of focus in the first 30 days and the first
60 days, but the trauma is for a couple of years. So we are really
trying to put together a plan that extends out over a period of time,
and that creates some enhanced treatment capacity that typically is not
available through traditional crisis services grants. So I really
appreciate everything that everybody did, frankly.

DR. CLARK: Anita?

MS. BERTRAND: Good morning. I thought the presentation was very
informative. I have a question. You all may know this, but I\'m the new
kid on the block, so I want to ask.

I was thinking that perhaps as we talk about workforce development, that
there is ways that we can intertwine curriculum to support, I want to
say the vulnerable population. There is a large percentage of the people
that are abusing substances that when disaster strikes, and you talked
about this in your presentation, that will cross that line.

I was wondering also if the other departments are working in conjunction
with CSAT. I know we are on the back end to put supports in place for
the vulnerable populations who are, I want to say abusing. I think that
that\'s critical.

DR. DODGEN: Yes. I think, again, that\'s a very, very good question. You
have a really good council here. You guys have some great questions.

I think that increasingly we are beginning to look at issues of all
kinds of special populations that even a few years ago we probably
weren\'t looking at, including the homeless, including people who are

HIV-positive, including people who are just not ambulatory for whatever
reason. They may be seniors, they may be in nursing homes, they may be
in some other kind of inpatient facility.

I think the situation in Florida that Ken was just talking about
actually really illustrated that very well, because they actually had to
set up some special needs shelters in Florida just for some of these
groups that really couldn\'t just get in their cars and leave, and
weren\'t going to be able to respond to some of the typical evacuation
procedures for a number of different reasons.

So I think that there is an increasing awareness of this. There are in
the plans that are being developed, some of which have been released,
like the National Response Plan, where there are now sections about
special populations, now your question is about two things, though.

One is are we thinking about it, and I think it sort of gets back to
your question, are we thinking about it, and are we doing anything about
it. As you know, that is a multistage process. So I think the answer is
I don\'t think a few years ago people were even really talking very much
about special populations, particularly people with chronic mental
illness and substance abuse, but a number of other special populations
as well.

I think people are now talking about those. Those are now being written
into plans. I think that you probably know that, for example, CDC and
HRSA both have their big billion dollar state plans for bioterrorism
preparedness. They are now being asked to look at special populations.

The reality is the quality of what is in many of these plans as it
addresses these special populations is still not very good. So we have,
again, to go back to the implementation question, we have to do a better
job I think of pulling the information that we already have together to
give assistance to states, and then we have to hold people\'s feet to
the fire a little bit to make sure that they do it.

They are getting federal dollars in some cases for development of these
plans, and I think we need to do a better job of making sure that the
plans really reflect what the guidance says they have to. So we are
starting to talk about it, we are starting to ask people to do it, but
when you actually look at what is written into the plans, we still have
a ways to go before we really can say that we are successfully
addressing these issues.

DR. CLARK: Thank you, Dan. I appreciate your presentation, and your
presentation, Sheila, and the support that you both have, Carol and
others, Ruby, and Jocelyn. Thank you very much.

Why don\'t we just move to the last presentation of the day instead of
taking a break, and then you can decide whether you want to linger on or
not. The last presentation is on e-therapy. We are going to dial in Val
Jackson.

Sheila, do you want to come forward?

DR. HARMISON: Hi, Val. This is Sheila.

MS. JACKSON: Hi, Sheila.

DR. HARMISON: I\'d like to begin with telling you a bit about where we
are at with e-therapy. But before we do that, let\'s take a look at what
the President had said in his State of the Union address on January 28,
2003, supporting the work that we\'re doing here.

\"Addiction crowds out friendship, ambition, moral conviction, and
reduces all the richness of life to a single destructive desire. Let us
bring to all Americans who struggle with drug addiction this message of
hope: the miracle of recovery is possible, and it could happen to you.\"

This support has been invaluable to us, as we have been working towards
increasing our understanding of how our populations have specific needs
for substance abuse treatment and the kinds of interventions that we can
use for that.

SAMHSA\'s seven performance outcome domain should always be thought of
when we are considering a different type of intervention, or a different
vehicle for an intervention. That includes social support of recovery,
abstinence from drug and alcohol use, family and living conditions,
employment and education, crime and criminal justice, access or
capacity, and retention in treatment. We call that the SAFECAR, that\'s
why that little car is there. This is Dr. Clark\'s invention.

As such, you can look at these particular outcome domains and always
have them in the back of your mind when it comes to how we are going to
put out this particular kind of initiative and think about it in terms
of the substance abuse field.

We have been working very hard in SAMHSA and CSAT of course to look at
the changes and make some kinds of different interventions within these
various new things that are occurring in SAMHSA. One of course is the
involvement of new providers such as the faith community, the emphasis
on recovery and associated services, the use of treatment vouchers,
changing the service milieu, which is primary care settings, drug
courts, reentry, and

co-occurring disorders. The requirement to employ best/proven practices,
science-to-services, new drug treatments, an emphasis on program
performance and outcomes reporting, and telemedicine.

What is information technology? It includes all of these and more. It is
telemedicine, it is telehealth, e-health, e-therapy, e-counseling,
online counseling, and e-records. I can\'t tell you the debate that
I\'ve had with other federal agencies on is this

e-therapy, e-health, is this e-counseling? What is it?

Well, actually there is no real definition of what

e-therapy or e-health is at this point. So we are in the process of
development.

Information technology is a vehicle for delivering counseling and
treatment services. This can include text messaging, chat groups,
e-mail, instant messaging, and audio and video-teleconferencing through
the Internet. Those of you who have children understand instant
messaging. I have to tell you, when I\'m on the computer, I\'m always
turning off that instant messaging. They\'re getting constant
discussions with their friends, even when they\'re not there.

Many underserved patients are vulnerable to the stigma within our field,
and can really benefit from this. There is not only stigma that they
have to deal with, but sometimes disabilities, as well as the location
that they\'re at. Rural clients of course are our main focus at CSAT
when it comes to these kinds of initiatives. Within that, you have the
Native American community, you have communities also that are
impoverished, you have prescription drug abusers, juveniles, gay,
lesbian, bisexual and transgender, and the elderly population.

Again, as I said, e-therapy is well suited as stigma often discourages
individuals to take access of service.

Let\'s look at some of the challenges to

e-therapy. There are restricted reimbursement codes, you have licensing
for in-state treatment only, there is no generally accepted minimum
standards of care, there is limited measurements of effectiveness, and
you have privacy issues. Currently there are numerous sites on the
Internet though that offer e-therapy as such. In fact, there are
thousands of them.

Some sites offer prescreened therapists who interact with the clients
online, one on one. The cost, we have been involved in this project for
years, and two years ago the costs were just about the same, they
haven\'t gone up too much, but they are high. That is \$1.60 a minute to
\$90 per hour for a chat session, or \$30 per

e-mail exchange.

Our history has been, as I say, over a long period of time, beginning in
April of 2002 when CSAT held an interagency federal government
conference on e-therapy held at the direction of HHS Secretary Thompson.
Representatives from NIMH, NIDA, NIAAA, HRSA, and the Veterans Affair
attended, and the topics were those of course that we\'re all invested
in at this time still on outcome research, the e-therapist\'s roles,
quality of care, ethical and legal guidelines,
licensure/standards/regulation, and confidentiality.

In the spring of 2003, SAMHSA with all of its various centers, NIDA,
NIMH, and NIAAA, met with the Secretary\'s Interagency Workgroup on
E-Therapy to discuss the feasibility of e-therapy. A conference was
beginning to be planned, but somehow it didn\'t occur at that time. So
in March of 2004, CSAT invited other federal agencies in to talk about
where they wanted to go with e-therapy. What is it they think that they
can do with it?

We did discuss then a conference, and sure enough in December, we did
our conference entitled \"E-Therapy, Telehealth, Telepsychiatry, and
Beyond.\" I\'m not certain how many of you have received that notebook.
We sent it out to everyone. Speaking to Val, I know that she had just
got it yesterday, so it may not have been delivered to your door yet,
but please do glance through it.

We had 32 speakers there, so I\'m not going to list them all. That takes
up six slides. But the topics there were the same as before, but
expanded. We looked at the definitions and the clinical applications of
e-therapy, and we looked at the technology of it. We had Comcast,
Verizon, and a company that does Internet through antennas, and that
company is called Comspeed. They are through Arizona. Some of you may
have heard of them.

We talked about financing issues and had representatives from CMS there.
We talked about practitioner organizations and what it was they could
do, and they demonstrated. We had probably five different demonstrations
of the kind of work that is going on there now with substance abuse
treatment, prevention, and mental health.

Remember, this was a conference for all three areas, not just substance
abuse. But we wanted to get an idea of what the scope was in the field
and where we might go. It was an exploratory conference, if you will.
They dealt with rural populations, ethical and legal issues, medical
applications, and the dark side of the Internet.

The dark side of the Internet was cyber suicidology, and it is one thing
that most people don\'t think about, but it does occur.

We in our explorations of the Internet have come across some very
interesting e-therapist advertisements, and wanted to share those with
you as to what has been occurring out there and that you might want to
just look at.

This is Melodie. Melodie is rated at five stars. They don\'t say who
rated her at five stars, but she is rated at five stars. Her degrees are
in dual diagnosis, certified relationship counselor, and she is a social
worker. Her fees are comparable to the others, in that you are talking
about a tarot reading, or a mini, one question, five or six paragraphs
for \$45. It is about the same that we had before. Comprehensive, three
questions, 12 to 15 paragraphs, \$75. She is an expert in addiction and
substance abuse. That is how she touts herself.

Let\'s look at another one. This is AbbieGrrl. These are on the
Internet. You have to be aware that they are there, and these folks are
doing business.

AbbieGrrl is an \"expert in addiction and substance abuse.\" She is a
\"Bona-Fide practicer \[sic\] of 12 steps, recovering for over a
decade.\" She wants to share her experiences with you. Her degrees are
\"I came, Came to, and Came to Believe. The 1st step is the only one you
have to work perfectly each day.\"

She has experiences and qualifications of I think basically being a
recovering person herself and wanting to share that with others. She
wants to remember, \"The fear, the shame, the big black hole of
loneliness in her gut.\"

I\'ll leave it up to you to evaluate these kinds of business ventures on
the Internet.

There are numerous types of online communication. Synchronous and
asynchronous. Synchronous I like to think of as a circuit. As such, when
you make a request, you get a reply back. That would be your instant
messaging. It is an immediate reply back. There are chat rooms where you
can talk to someone, and these are real time, that you can hear back
from them. Or webcast.

Asynchronous are those that you make a request or you put out a response
to somebody. It is going to sit there for awhile. It is not an immediate
real time piece. That would be email, listservers, or message boards.

Health care ad pharmaceutical wireless applications are numerous at this
point. We did discuss some of these within our conference. We have
patient care, which is remote patient monitoring and visiting nurse
services. They do use e-therapy, they use this kind of technology.

Hospital environments. You have patient trackers, patient bar coding,
wireless medical glossary, notification and alert. With practitioners,
you do have e-prescriptions, billing, chargebacks, electronic patient
medical records, clinical results, and CPOE. We\'ll go over that one a
little later also in this presentation. This is Computerized Physician
Order Entry.

Pharmaceutical. We have customer relationship management, call
reporting, sample tracking, library, physicians desk reference,
diagnostics, specimen tracking, and you can think of that also when it
comes to doing drug testing, computer aided dispatch, and messaging.
These applications are numerous, and they can be used within the
substance abuse treatment field also. It is just a matter of what the
limitation innovations are at this point.

The available network technologies for telepsychiatry are traditional
integrated services, digital networks, plain old telephone system,
broadband fiber, satellite, wireless, ADSL, and asymmetric digital
subscriber lines. These were some of the presentations that we had, and
they talked about these various applications within those 32 speakers
that we had at our conference.

Let me talk to you about the ones that relate directly to our field,
Join Together. They have what is called AlcoholScreening.org. This is
one of a couple that they have. This is a screening and brief
intervention model that targets all drinkers who are dependent. It
refers likely dependent drinkers, and it advises risky, non-dependent
drinkers to cut back on their use.

It does not label, and it educates all visitors about moderate drinking.
What they use is an instrument called AUDIT. That AUDIT instrument has
numerous questions that they answer, and from that, they get a score.

Twenty-one percent of the users with possible alcohol use or dependance
click through to the \"Learn More\" or \"Get Help\" area at the end of
that AUDIT piece. There is no interaction with a therapist, it is just
your test. But they can go and get more help from Join Together if they
want to learn more or get help.

Then 15.8 percent of the users drinking hazardous amounts or binge
drinkers click through to the \"Learn More\" or \"Get Help\" and 9.4
percent of the non-hazardous drinkers click through to \"Learn More\" or
\"Get Help.\" So that is significant when you take a look at the entire
population that came in and took those tests.

Another presentation talked about HealthSim, Inc. It is research with
computer-based interventions. These are educational components for
prevention. They are science-based substance abuse prevention multimedia
programs that have been developed for middle school-aged children, as
well as elementary school-aged children. You have HIV prevention for
adult injection drug users, customizable HIV, STD, and hepatitis
prevention programs for young drug users, and computer-based therapeutic
education systems for substance-abusing adults.

eGetgoing. I know we have all heard of eGetgoing. eGetgoing is a
provider of live, real time online substance abuse treatment delivered
in a group setting via the Internet. It is the first and only online
provider to receive CARF and JCAHO accreditations for its adult and
adolescent services.

How does it work? It uses a distance-learning platform for groups of up
to 10 clients to come in and log into group sessions. That is all they
do are group sessions. They are facilitated by a professional counselor
who is video-streamed into the session. Clients can see the counselor on
their computer, but the counselor cannot see the clients.

The clients cannot see each other, so you do still have that anonymity
that\'s present, though there is a person that the client can talk to,
and that person is on the screen.

Through voiceover IP, clients can speak spontaneously to each other and
the counselor. The counselor has a wide range of interactive tools and a
large library of multimedia to engage the client. This includes slides,
videos, and surveys.

There is also a personalized home page that provides each client with
their own space to journal and to do homework assignments, and to also
relate directly to their counselor if they want to.

What is the impact of the Information Age when it comes to the federal
government? Well, there is a federal response in general, and there is a
Department of Health and Human Services response specifically. The
report to the President, \"Revolutionizing Health Care Through
Information Technology,\" talks about specific frameworks for health
care information infrastructure, in that they would want to see
electronic health records for all Americans that provide every patient
and his or her caregivers all necessary information required for optimal
care while reducing costs and administrative overhead.

This is a focus that CMHS is taking also, and they are looking very
closely at electronic health records and doing computer assisted
clinical decision support in some fashion possibly with that. But
e-health is what Kathryn Power spoke about whenever she spoke at the
conference. I invite you to take a look at her slides.

Again, computer assisted clinical decision support has been written up
as a part of this framework also to increase the availability of health
care providers to take advantage of state of the art medical knowledge
as they make treatment decisions, enabling the practice of
evidence-based medicine.

The PITAC, or proposed framework, that is just a little pseudonym for
them, for a health care information infrastructure by stating also that
they would have a computerized provider order entry. CPOE, remember we
spoke about that earlier, just a few minutes ago, such as for tests,
medicines, and procedures both for outpatient care, and within the
hospital environment. They also advocate for a secure, private,
interoperable electronic health information exchange, including both
highly specific standards for capturing new data and tools, and for
capture of non-standards-compliant electronic information from legacy
systems.

DHHS itself also has a plan they have just put out in July of 2004.
Their strategic framework stated as delivering consumer-centric and
information-rich health care. This framework talks about informing
clinical practice, interconnecting clinicians, personalizing care, and
improving population health.

The vision for consumer-centric and information-rich health care is you
have fewer medical errors, less variation in care, consumer-centric
care, medical information moving consumers, and care that\'s delivered
electronically as well as in person. This is where we could fit in
medical records being protected from unauthorized access, your privacy
issue again, and clinicians spending more time on patient care.

What are the critical issues at this time to consider? Well, we have to
define terms in relation to

e-therapy. We do have to look at the conceptual framework for this. We
have to define what is required for licensing, credentialing, and
regulations, and the limitations of them. We have to look at the
controls on the technologies, such as the secure sites. Some are not so
secure. And we have to protect clients from

non-credentialed counselors.

We also have to train counselors in the use of this technology, we have
to consider the confidentiality, we have to do information security,
look at cultural issues, and the cost.

What is next and when? Are we really ready to consider e-therapy now as
a viable therapeutic intervention? I think we are. I have to say that
the evaluations that came back from the conference were really very
supportive of this, in that it is now time to begin to look at this.
This is a cheap way of doing therapy, and it is not appropriate in all
aspects, but is it something that we want to consider?

At this time, we at CSAT are developing and pulling together an expert
panel which Val Jackson is going to be the chair of ‑‑ that\'s why she
is here with us today ‑‑ to start looking at these various issues and to
start really considering do we have the wherewithal to ask our field to
do this, and is it something we would want to support.

Thank you.

(Applause.)

DR. HARMISON: Any questions? Yes?

DR. FLETCHER: Thank you very much for a very interesting discussion. I
promise you I\'m on information overload at this time, as well as
congestion overload, but this caught my attention.

I\'d like to ask you a couple of questions. In terms of your
explorations and developments in this area, do you have preliminary data
that speaks to the efficacy of e-therapy as a modality of treatment, and
also have you taken into consideration and deliberation the implications
of e-therapy, particularly for indigenous communities and groups that
are not literate in technology? Would that be a factor that might
further limit their access to treatment?

DR. HARMISON: Well, in taking your first question, yes, we do have
research data that was presented, and I encourage you to glance through
the materials that we sent that show that this type of therapy done
online is as effective as seeing someone face to face.

You do have to watch for the factors that you have to have some kind of
support available close to that client should there be an emergency, and
that you have to be really comfortable with the technology to be able
to, if you are viewing that client, to be able to understand body
language. You\'re only going to be seeing a part of that body language.

Dr. Clark?

DR. CLARK: Yes, I think, again, we are still in the preliminary stages,
but it is quite clear. I presented from George Mason, whose in fact
target population were communities of color and low income individuals.
There are issues in terms of access to the technology, but broadband is
remarkably cheaper. The hardware, you don\'t need elaborate computers,
you can get Internet-accessible devices that are fairly inexpensive.

As we were pointing out, especially in low population or low-resource
dense areas, one of the things is it is easy for people to say well,
this isn\'t as good as a face to face. But then you say well, there is
no face for somebody to face. So essentially you are saying but for
something that may not be as good, if we don\'t do it, then the person
is left with nothing.

So the question is is nothing better than something? If we don\'t
stimulate the dialogue, then we don\'t have the discussion. This is also
useful for online assessments. Join Together is doing it, oddly enough,
our Household Survey is a face to face online computer assessment,
computer assisted assessment. So we spend \$50 million collecting
information upon which we rely that is driven by technology.

So not a panacea, not for every person in every situation, but it allows
many individuals to deal with issues. Dave raised the issues of a faith
community. It allows people of specific faiths to congregate together
online to pursue matters from their perspective. There are any number of
facets, if you will, that this offers. The key issues is, as was pointed
out, we need to tease out some of these variables. But I don\'t see the
issue of limited access based on economics or culture imperative to be
an overwhelming barrier.

These are things that we need to address, but they are also the same
things that are applicable to our traditional delivery system. We saw
the presentation on the workforce that has been raised, and it is
turning out as Chilo pointed out, look at our workforce. So from a
cultural competence point of view, we have some of these same barriers.
We need people like you raising these questions. But we should also
forge ahead, I believe.

Kids use it, predators are using the technology, and they are able to do
it very effectively. Yet, we have some problems saying well, it doesn\'t
work, it doesn\'t do this, it doesn\'t do that. We just heard Ms.
Leonhart from the DEA saying drug dealers are using it. Everybody is
using the technology, but the traditional providers who are really
interested in preserving the integrity of the system and the welfare of
individual, we shouldn\'t shy away from the technology which we can use
to provide ethical care, carefully crafted care, and we can tie in with
the NIH, which is one of the things we had Dr. Pickle from Arkansas
present some of this data associated with buprenorphine. They are using
it fairly effectively.

Again, not a panacea. One size does not fit all. It won\'t work for
every person, but this is something that we should seriously consider.
If not just assessments, if not for specialty issues, not for
augmentation, then some other form of intervention that we are
comfortable with.

MS. JACKSON: Dr. Clark?

DR. CLARK: Yes, Val?

MS. JACKSON: Yes, thank you. I really appreciated being included on this
conversation. I am also very excited about being able to help led the
workgroup to explore and tease out some of those things that you were
just talking about.

I did want to say that at The Village, we actually did not end up
running an e-therapy group, but we had one all set up as a
demonstration, and we were working with eGetgoing when they were
starting out.

One of the things that we did is to decide at that time that what we
would do is to start the group, the Internet therapy group. We were
going to do it with adolescents, and we were going to do it while our
adolescents were still in residential treatment with us. That way they
would get comfortable with it. Then we were working either with a school
or a library if they didn\'t have the technology at home, so that when
they moved into aftercare and their continuing care, they would have
access set up at school, and the time frame set up at school so that
they could continue the therapy there.

While we didn\'t actually carry out that study that we had set up, I
thought that it was a really interesting approach in terms of being able
to actually access kids once they get out of their primary treatment. I
think it probably has places for primary treatment, but I see a lot in
terms of an adjunct for treatment also, and a continuation of the
recovery.

I think that that is definitely a possibility for this. In that case,
the kids that we had, some of them came from foster care or from homes
where they really didn\'t have technology in their household.

DR. CLARK: And that\'s an important point, recovery management services
as a component. So after you finish formal care, what about recovery
management services as an element using technology to facilitate that,
the notion of using boys and girls clubs, libraries, schools, and other
sites for places to access the hardware.

The George Mason study, they just gave the hardware to the clients and
they reported the hardware didn\'t disappear, and the hardware wasn\'t
hard to find subsequently. It turns out that people actually used it and
made good use of it, and they didn\'t have any problems with it.

So at some point from a larger systems perspective, depending upon the
complexity of the person\'s problems, it may be cheaper just to provide
the stripped down hardware that functions as an Internet access tool
than to worry about the price. So there are all these issues that we
need to sort out. I think with Val\'s leadership, we\'ll be able to
pursue some of these questions.

Frank?

DR. McCORRY: This is more on a related issue that I heard, and Sheila,
you mentioned in your presentation.

I understand CMHS is doing a fair amount of work on decision support, I
guess computer decision support for treatment planning and level of care
assessment. I wasn\'t sure what CSAT is doing around those kinds of
issues. I understand it to be computerized decision support is the term
that is used for this kind of technology that supports clinical
decisionmaking in some way.

I might be overinterpreting what CMHS is doing, but I understand they
are looking at different software packages. Perhaps it is another area
for us to explore somewhere in the future.

DR. CLARK: That\'s a good point.

Judge?

JUDGE WHITE-FISH: Having a background prior to being a judge, I guess I
just want to go on record, some flags come up for me.

Looking at ethnic minorities, I know my community, even though the money
is available with my tribal members, I can go into a household and I
know I cannot find a computer. They have no use to run computers. It is
not in our society. It is just the way it is.

Being a small community, everything is done by word. A lot of verbal,
but that is our tradition. There are a lot of traditions in the native
culture.

Being a therapist before I was a judge, being a counselor, I mean, I
have to say right away it is like what? Wait a minute here. But as time
goes on and if the numbers are there, I mean, it is up to me to have an
open mind being a recovering person myself to have that open mind.

However, as I heard in the training that I received, my greatest concern
would be the licensing. I know I have had extensive training in AODA,
and I have spoken nationally on it. On licensing, I have always said,
and I will always say it, counselors are a dime a dozen. A darn good
therapist is hard to find.

Now, what are we going to attract by using the machines? That\'s the
question. Again, when they wanted to make counselors be certified in a
degree with all the others, I said match me, because I\'m a recovering
person, against somebody with a degree, a counselor with a degree, and I
bet you I will beat them.

First of all, looking at an individual, the body language, looking at
their eyes, as I do as a judge to the people that stand before me. A lot
of attorneys want to appear telephonically in front of me. I decline. I
say no, if it is important, your client\'s case is important enough, you
will appear in person in front of me. Well, Your Honor, I have to go 600
miles. Well, sorry. That is not my problem. If you want to really defend
your client, then you appear before me. I leave it there. Needless to
say, they do.

Again, here. The appearance is a great deal. I can easily tell you no
over the telephone. Appear before me, and I might listen to you. I mean,
that\'s personal, and that is exactly what client-oriented therapy is
about. Maybe we\'re inventing a new one called telephonic-oriented
therapy. Maybe I\'m an old counselor from way back.

But I know in my teachings, they told me, even a blind dog can find a
bone.

DR. CLARK: That\'s a good metaphor, even a blind dog can find a bone.
The question is what is the bone. So again, we\'re not suggesting that
technology is a substitute for the one on one therapy. What we are
pointing out is that we need to leverage our resources, technology has a
way of reducing the cost of services, and the question on the table has
to be what are the appropriate uses of technology.

If we don\'t examine, if we don\'t think about it, if we don\'t
contribute to the dialogue, then we are overshadowed by events where the
technology is elevated anyway. The kids are using the technology. There
are a lot of people who are now much more comfortable with technology.

Banking is now technology driven. So the question is what is the
appropriate place, and that is what we are pursuing here.

Bettye?

DR. FLETCHER: I certainly support that idea, because technology
permeates all areas of our lives at this juncture. However, my concern
would be as we continue on this council, to have a continuing dialogue
regarding how this technology is impacting subpopulation groups, and
whether or not we are seeing variations in terms of the efficacy of this
approach with different populations.

DR. CLARK: Indeed, and again, that\'s one of the reasons why we now have
a subcommittee. We have a council member who is concerned about this
matter, and of course we will have your input, and if you\'re interested
in working with the subcommittee, I\'m sure Val would welcome your
contribution.

Anita?

MS. JACKSON: Yes, I absolutely would love it.

MS. BERTRAND: Just a quick comment. The recovery community uses the
technology tool for support in a lot of ways. When we are away places
like this, we can go online and log in and talk to other people in
recovery. Just sometimes that two lines of information.

Weight Watchers uses the technology. But I understand the point about
being careful and the difference between therapists, counselors,
professionals, or

non-professionals. I support various levels of care, and think that even
the community-based level, faith-based level that we need to look at
some out of the box types of ways of reaching people. I want to say
since I have been in the profession for 13 years, things are changing.
So we have to continue to look at new ways of reaching very difficult to
reach populations.

DR. CLARK: Thank you. Thank you, Sheila.

DR. HARMISON: Thank you.

DR. CLARK: With that, the question on the table is do we have any
further items to discuss? This is the roundtable for council. Or are you
worn down sufficiently?

(Laughter.)

DR. CLARK: As Dr. Fletcher said, I got so much information.

Chilo?

DR. MADRID: I want to personally thank certainly Dr. Clark for such a
very stimulating meeting. There was a lot of information given to us, a
lot of views were articulated both ways.

And certainly George Gilbert for planning this and for giving us a lot
of support as a council, and certainly a big round of applause to
Cynthia for being there for us.

(Applause.)

DR. MADRID: My last statement is for the next meeting, I\'d like to
perhaps get the workforce people from the Partners for Recovery to come
in and talk to us about some of their studies, some of their
deliberations, some of the direction that they\'re thinking about
taking, and then affording us the opportunity to give them some feedback
in that area.

DR. CLARK: All right. That is a topic for the next council meeting.

Dr. Fletcher?

DR. FLETCHER: Yes, if it is appropriate, I know that gender transcends
all areas of the work of CSAT. Might it be appropriate at some point in
time to be able to be briefed or have some information on treatment as
it relates to women as much as they bring some unique issues to the
table?

DR. CLARK: Not a problem. It is part of our matrix, and we\'ll work out
with Cynthia whether it is this meeting or the next meeting. We have a
lot of activity in the area of women\'s issues, women and children\'s
issues, and family issues, which would include women and children, as
well as men. So we can look at the issue from a number of perspectives.
We have documents completed and documents in the works also.

Judge?

JUDGE WHITE-FISH: To follow up on the ethnic, I would be more than
willing to be involved in that, because I have a great concern. That
concern being, again, if you were to look at the 12 core functions that
I had learned, those 12 core function are ethnic-oriented. They are from
white class, or middle range income white class, are where those 12 core
functions came from. They are not kind of related to the ethnic
population. You wonder how come the counselors, the number that you see
in our communities and in the Native communities, and I would guess even
in the African American communities and in the Asian American
communities, I would guess your counselors are not Asian American or
African American. I know they definitely are not Native American in my
community. They are other than Native American.

So you have the 12 core functions that don\'t really work. It works, and
I\'ll use my analogy again, even a blind dog can find a bone. But it
doesn\'t work to the proportions that I see culturally relevant and
culturally specific treatment work. I would like to, if I can assist
with some of that information, I\'ll gladly do that.

It scares me to see those numbers. I have always know that, though, that
the numbers on counselors, I have always known that. Like I said, I have
been a judge for over 10 years. It was the same problem I think 12 years
ago when I was in the chemical dependency field, and I just moved here
to a different level and I say wait a minute, we\'re still facing that
same problem. So hopefully I can be somewhat of a solution to that
problem.

DR. CLARK: All right. We will put you with Chilo and anybody else who is
interested in this issue.

Any other topics? Dave?

MR. DONALDSON: Just we may want to consider allocating some of the time
for the subcommittees to meet. After chastising Dan about
implementation, I want to make sure that we\'re putting adequate time
into not just talking, but what do we do with all this information.

DR. CLARK: Good point.

DR. McCORRY: I\'d like to see the issue of like a data presentation or
the performance measures and that whole thing, just put it in the queue
where it belongs.

DR. CLARK: Again, another issue of great concern. You heard that from
Mr. Curie\'s comments. So it sounds like the things that this council
are concerned about are the things that SAMHSA and CSAT specifically
want for this council. So we are all in alignment with the same
discussions. The topics aren\'t easy, but discussing the topics is going
to be easy, because we are very anxious to get your input on those
topics.

Anything else?

(No response.)

DR. CLARK: If there is nothing else, I\'ll entertain a motion to adjourn
this meeting of the council.

DR. MADRID: So moved.

DR. FLETCHER: Second.

DR. CLARK: All those in favor?

(Chorus of ayes.)

DR. CLARK: Then our next council meeting is tentatively what, Cynthia?

MS. GRAHAM: May 18-19.

DR. CLARK: May 18th and 19th. I look forward to seeing you then. Thank
you.

(Whereupon, at 1:05 p.m., the meeting was adjourned.)