SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

CENTER FOR SUBSTANCE ABUSE TREATMENT

NATIONAL ADVISORY COUNCIL

Wednesday,

March 21, 2007

Salons D & E

Hilton Washington DC North/Gaithersburg

620 Perry Parkway

Gaithersburg, Maryland

IN ATTENDANCE:

[Chair]{.underline}

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

Director

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1015

Rockville, Maryland 20857

[Executive Secretary]{.underline}

Cynthia A. Graham, M.S.

Public Health Analyst

Center for Substance Abuse Treatment

1 Choke Cherry Road, Room 5-1036

Rockville, Maryland 20857

[Members]{.underline}

Anita B. Bertrand, M.S.W.

Executive Director

Northern Ohio Recovery Association

3746 Prospect Avenue

Cleveland, Ohio 44115

David P. Donaldson, M.A.

CEO

We Care America

44180 Riverside Parkway, Suite 201

Lansdowne, Virginia 20176

Bettye Ward Fletcher, Ph.D.

President and CEO

Professional Associates, Inc.

P.O. Box 5711

Brandon, Mississippi 39047

Valera Jackson, M.S.

CEO

New Century Institute (NCI) Systems, Inc.

4500 Island Road

Miami, Florida 33137

IN ATTENDANCE:

Francis A. McCorry, Ph.D.

Director

Clinical Services Unit

Division of Health and Planning Services

New York State Office of Alcoholism

and Substance Abuse Services

501 7th Street

New York, New York 10018

Gregory E. Skipper, M.D., FASAM

Medical Director

Alabama Physician Health Program and

Alabama Veterinary Professionals Wellness Program

19 South Jackson Street

Montgomery, Alabama 36104

Judge Eugene White-Fish

Tribal Judge

Forest County Potawatomi Tribal Court

P.O. Box 340

Crandon, Wisconsin 54520

[Ex Officio Members]{.underline}

Terry L. Cline, Ph.D.

Administrator

Substance Abuse and Mental Health

Services Administration

1 Choke Cherry Road, 8th Floor

Rockville, Maryland 20857

[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

Chair, CSAT National Advisory Council 7

Member Introductions and Activity Updates 7

SAMHSA Update

Terry L. Cline, Ph.D.

Administrator, SAMHSA 12

Discussion 23

Director\'s Report

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM 33

Discussion 51

Legislative Update

Joseph D. Faha, M.Ed., M.P.A.

Director of Legislation, SAMHSA 63

Discussion 83

Consideration of September 20, 2006

Council Minutes 84

Substance Abuse Treatment Services for

Individuals with Disabilities Update

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

Public Health Advisor

Office of the Director, CSAT 85

Discussion 93

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

PAGE

Council Roundtable 96

Follow-Up Discussion on the Budget 117

Access to Recovery (ATR) and Recovery

Support Services Update

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

Director

Division of State and Community Assistance, CSAT 134

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

Director

Division of Services Improvement, CSAT 141

Discussion 151

National Registry of Effective Programs and

Practices (NREPP) Update

Kevin Hennessey, Ph.D.

Science to Service Coordinator

Office of Policy, Planning, and Budget, SAMHSA 156

Frances Cotter, M.A.

Public Health Advisor

Division of Services Improvement, CSAT 178

Discussion 182

1993-2003 National Expenditures for Substance

Abuse Treatment

Rita Vandivort, Ph.D.

Acting Branch Chief

Organization and Financing Branch

Division of Services Improvement, CSAT 185

Discussion 195

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

PAGE

E-Therapy Update

Valera Jackson, M.S.

NAC Member 210

Stella Jones, M.S.W., L.I.C.S.W., B.C.D.

Senior Program Management Officer

and Project Lead, E-Therapy Initiative

Division of Services Improvement, CSAT 211

Discussion 215

Council Roundtable 216

[P R O C E E D I N G S]{.underline} (8:50 a.m.)

DR. CLARK: I\'d like to call the session to order. I\'m delighted to
welcome each of you to the 49th meeting of the CSAT National Advisory
Council. I hope you find the discussions and presentations enlightening.
We have much to discuss today. Since we last met, CSAT has laid the
groundwork for some substantive changes that are important to assist the
Center in accomplishing its immediate and long‑term goals, and we want
to bring you up to date on that.

We have Dr. Terry Cline, SAMHSA\'s Administrator, and he will be
speaking shortly. He has a very tight schedule, so we will start off
with comments by him. So we\'re glad to have him present since he just
recently started.

Before we further the meeting, I want to invite the members of council
to introduce themselves and briefly let us know some of the activities
they\'ve been involved in, and then we\'ll defer to Dr. Cline.

Why don\'t we start with Dave?

MR. DONALDSON: Good morning. Dave Donaldson with Convoy of Hope, living
part of the time in Africa. We\'re actually building a compound there
and distribution center in Nairobi, Kenya, and doing a lot of relief and
development in the Mathare Valley, one of the largest slums in the
world. In addition, we\'re doing a lot of relief and disaster response
here in the States. I wasn\'t expected to be here today, but it was
great to get the call that those dates were changes. It\'s a great
pleasure. Thank you.

DR. FLETCHER: Good morning. I\'m Bettye Ward Fletcher from Jackson,
Mississippi. I serve currently as the president and CEO of Professional
Associates, Inc., which is a research and evaluation firm in Jackson
which works with primarily indigenous communities around issues of
evaluation, particularly outcomes evaluation and participatory community
evaluation. In my prior life I served 30 years in higher education as a
professor and administrator.

DR. McCORRY: Good morning, Dr. Cline. Good morning, everyone. I\'m Frank
McCorry. I\'m with the New York State Office of Alcoholism and Substance
Abuse Services. In my capacity there, I work on quality and performance
improvement and co‑occurring disorders. I\'m also a chair of the
Washington Circle Group, a national organization supported by SAMHSA to
develop performance measures, and co‑chair of the National Quality
Forum, which will be issuing a report very shortly on evidence‑based
practices, from screening through continuing care, which we hope will
spur some movement towards adoption of these practices, including things
like pharmacotherapy and the development of some performance measures
that can drive some accountability.

MS. JACKSON: Good morning. I\'m Valera Jackson. When I started on the
council I was the CEO of The Village in Miami, Florida. I live and work
in Miami, Florida. I\'m currently the executive director of NCI Systems,
which is a collaboration of six of the largest agencies in Florida, many
that I know that Dr. Clark has been to and recognized. We are dedicated
to developing Centers for Excellence. We\'re kind of at the beginning of
looking at opportunities to do innovative work not only in Florida but
across the country with the experience and know‑how that we have
developed in our own agencies and organizations.

I also just wanted to mention that I am the chair of an organization,
South Florida Provider Coalition, that is a managing entity and manages
all of South Florida\'s substance abuse block grant funds and money, and
we are looking now at all of Florida to develop a managing entity
privatization of the funds and funding, going through the legislature
this year and endorsed now by DCF and hopefully by the legislature soon.

DR. CLARK: Greg?

DR. SKIPPER: Good morning. I\'m Greg Skipper. I\'m on the faculty at the
University of Alabama School of Medicine, and I run the Physician Health
Program in Alabama, and I\'m engaged in some national research projects.
Thanks.

MS. BERTRAND: Good morning. My name is Anita Bertrand and I\'m from the
Cleveland, Ohio area, and I manage the Recovery Community Services
Program and organize individuals in recovery and from the churches to
support the largest system, and I am a product of your system, with 16
years of recovery, and I\'m proud to be on the council.

JUDGE WHITE‑FISH: Good morning, everyone. I\'m Eugene White‑Fish. I\'m a
judge for the Potawatomi Tribe in Crandon, Wisconsin, as well as the
president of the National American Indian Court Judges Association. That
has judges throughout the United States, including Alaska.

One of the things that I\'m glad to see as I was talking to Dr. Clark, I
said that I see SAMHSA involved in a lot of things in Indian Country
since I sat on this board. A young lady that\'s sitting in the audience,
I\'ve seen her a number of times in Indian Country. I can\'t speak for
all Native Americans across the country because they\'re each sovereign
nations, but I\'m glad to see that SAMHSA has become more involved. NIDA
is pulling all the leaders of all the national organizations together,
along with the National Congress of American Indians.

One of the things that we\'re definitely looking at is meth, and I look
at SAMHSA also as being one of the leaders in that, addressing the
issues across the nation and not forgetting Native and Indian Country
across the nation, including Alaska. So that\'s a good thing. I know the
president of NCAI. He and I have both said that\'s a problem in Indian
Country across the United States. So that\'s definitely on our table,
and we\'re going to be meeting in June in Alaska. Thank goodness we did
not choose to meet in Alaska in December or January.

(Laughter.)

JUDGE WHITE‑FISH: I also hear there\'s no daylight up there at that
time.

But thank you, and it\'s a pleasure meeting you, Dr. Cline.

DR. CLARK: Before we go any further, I would like the record to show
that Dr. Chilo Madrid, a very faithful member of the council, underwent
a quadruple bypass about three weeks ago. He spoke with Cynthia last
week and informed her that he expects to be back in his office next
week. So a comment to Chilo is to hang in there and we wish him a
continued speedy recovery.

Now I would like Dr. Cline to have his comments. We\'re delighted that
he\'s able to join us today. Prior to his appointment as the SAMHSA
Administrator, Dr. Cline served as Oklahoma\'s Secretary of Health, a
position he was appointed to by Governor Brad Henry in 2004. He served
concurrently as Oklahoma\'s commissioner of the Department of Mental
Health and Substance Abuse Services, a position that he had since
January of 2001. The important part is that we have a psychologist for
mental health and substance abuse becoming the Secretary of Health, and
talk about integrated services, a one‑man integration team. Throughout
his career he has championed the principle of mental health and freedom
from substance use disorders as fundamental to overall health and
well‑being and that mental and substance use disorders should be treated
with the same urgency as any other health condition.

I won\'t read his entire bio given his tight schedule, but I encourage
you to pick up a copy of his bio on the document table outside the
doors, as well as bios of the members.

Dr. Cline?

DR. CLINE: Thank you, Dr. Clark.

It\'s a great pleasure to be here and to meet all of the members of the
advisory council, and I would like to thank you for your service and
your volunteer time and your commitment to improving systems across the
country, and also advising Dr. Clark and CSAT in the important work they
have to do.

I would also like to My purpose in being here today, one is to introduce
myself and to get to know you a little bit better, although as Dr. Clark
mentioned, I will be rushing out the door immediately afterward this
morning, and also to provide you with some updates from SAMHSA in terms
of some developments, some new information that\'s come to light that
has just recently been released, and also to talk briefly about the
budget, all that in about 15 minutes. I don\'t talk quite as fast as Dr.
Clark because I\'m from Oklahoma, but I\'ll do my best to keep the pace
moving along there.

Part of that experience that Dr. Clark referenced in Oklahoma was very
important for me. Being able to oversee the Medicaid agency as well as
the Department of Health, as well as the tobacco endowment settlement
trust, all of those were in the health cabinet and the Department of
Mental Health and Substance Abuse Services. So it was really a unique
opportunity to have someone with the behavioral health background at the
helm of this health cabinet. It was the first time that had happened in
the history of Oklahoma. I don\'t know if that\'s happened in other
places as well, but I think it speaks to the importance of our issues in
the overall health picture, and I would like to commend Governor Henry
for the courage to do that. I\'m not a physician, and the majority of
health cabinet secretaries had been physicians, and I didn\'t come from
the Department of Health or one of the other more traditional
organizations. So that was a dramatic departure.

Part of what took me down this path ‑‑ I\'ll spend one minute on this ‑‑
is my very first professional job was providing home‑based family
therapy in the housing developments in Cambridge and Somerville,
Massachusetts. Most people don\'t realize that this was an area where
there was incredible poverty. Most people think of all the ivy league
schools and MIT and Harvard and all those places, but there is a great
deal of poverty and many, many struggles. Providing that home‑based
family therapy took me right into people\'s living rooms, into their
kitchens, and having all of the discussions about the struggles that
they were facing every day, and I can tell you that my training as a
clinical psychologist had not prepared me for that work at all.

One of the things that was most apparent in almost every situation was a
struggle with substance abuse and addictions. That may not have been the
identified issue, but it actually resulted in a referral. It may have
been a child who was acting out in school, it may have been somebody who
was falling behind who was getting in fights with their peers. But when
you spent time with the family, you learned very quickly that that was
usually a leading contributor to some of the struggles within the
family.

Now, SAMHSA has been engaged in one of the key responsibilities at
SAMHSA, and one of the things I\'ve enjoyed a great deal in my two and a
half months on the job has been the great wealth of information that
comes through SAMHSA and goes across the country. One of our primary
missions is helping to spread information, evidence‑based practices. You
have on your agenda for later today some presentation around NREPP, and
hopefully all of you are familiar with the clearinghouse and all the
information that\'s available with that.

As the advisory council, I would like to highlight just a couple of
issues for you because these are reflective of some of the trends that
we\'re seeing most recently in the United States with the data that we
have. One of these trends and one piece of data is coming from our
National Survey on Drug Use and Health, which is the kind of extension
‑‑ many of you I think are familiar with the old Household Survey. So
this is the extension of that survey. One piece of information from that
is actually looking at inhalant use among young people, and there\'s
good news and bad news in this picture. The bad news is that there are
about 1.1 million adolescents between the ages of 12 and 17 who report
using inhalants in the last year, 12‑ to 17‑year‑olds who report using
inhalants. That\'s the bad news, over 1 million young people.

The good news within that picture is that there\'s been between 2004 and
2005 the use among those young males is relatively stable. It\'s about
4.2 percent, and it stayed around that level over that period of time.
The bad news in that ‑‑ I\'m doing the good news/bad news here ‑‑ is
that we\'ve seen a significant increase for girls. So young females
between 12 and 17, the percentage rose from 4.1 percent to almost 5
percent. That\'s a statistically significant increase in the number of
adolescent girls who report using inhalants. So that\'s very disturbing
to see that kind of stablity with young males and then to see a
significant increase with young females. It\'s something for you to be
aware of.

Another piece of interesting information came from the Drug Abuse
Warning Network which looks at emergency room visits and those visits
that are drug related. In that report, which was just released a couple
of weeks ago, there is again good news/bad news results here. The good
news is that there\'s been relatively no change for drug‑related
emergency room visits from 2004 to 2005, but when you look within that
data and look at the types of visits that are taking place, there is a
significant increase. So here you have overall stability in the overall
number of visits, but the types of visits, we see some significant
changes, and one of those changes has been a 21 percent increase in the
visits that are attributable to non‑therapeutic use of pharmaceuticals,
non‑medical use of pharmaceuticals, including prescription and
over‑the‑counter drugs.

So again, as you\'re looking at trends, if you\'re looking at systems
and the responsiveness that\'s needed for systems, this is an important
change that we\'re seeing, people who are ending up in emergency rooms
who are in need of services and having some sense of what is driving
them to those emergency rooms. So we\'re seeing some changes over time.

One of the programs I think you may be familiar with that Dr. Clark has
been very active in organizing is the Screening, Brief Intervention and
Treatment Program, which is an incredible program which allows us to
have that kind of early touch with somebody who is accessing services in
what might not be the most desirable course because they\'re showing up
in the emergency room. But if they\'re there, we have a window of
opportunity to reach those individuals to do those screenings and to
assess the need for either a brief intervention or treatment, and then
to work to make sure that connection takes places. So that\'s a
significant program that has great results, I think is available now
through grants in 34 states across the country, five tribal entities and
three territories.

Is that right? I don\'t think that\'s right. No, that\'s the SBIRT.
What\'s the number for that? Do you remember?

DR. CLARK: SBIRT. Reed, help me. What states are we in?

PARTICIPANT: We\'ve got 12 states. We\'ve got 16 colleges.

DR. CLINE: Sixteen what?

PARTICIPANT: Sixteen colleges.

DR. CLINE: Okay, 16 colleges. So what this program allows us to do is to
have that broader continuum of care in addressing these needs for
individuals, and that\'s significant. Again, if people are coming to our
attention, we\'re aware that they\'re struggling with these issues
because they\'re showing up in the emergency room, what can we do to
help make those connections?

Also, in looking at those populations where we\'re trying to get ahead
of the curve, what can you do in terms of having those services
available in student health clinics, universities and colleges across
the country? So that\'s very exciting work, and again it\'s an attempt
to get ahead of the curve, to make sure that we\'re intervening as early
as possible when we know that people are struggling with these issues.

The last issue that I wanted to highlight was the release on March 6 by
the U.S. Surgeon General, who released his report on the prevention and
reduction of underage drinking in the United States. This is a report
that the Surgeon General had worked very, very closely, and Dr. Clark
and his staff worked very, very closely, as well as individuals at NIAAA
through the institutes, to really help the Surgeon General collect all
the latest research and science and findings that are related to
underage drinking in the United States. This is another issue that\'s a
good news/bad news picture.

While we have seen some stability and actually some declines in tobacco
use and some other drugs, underage drinking is one of those areas where
we have not seen that decline, so that\'s a concern for us. If we\'re
thinking about how can we get ahead of the curve, I think everyone is
aware that our service systems are working at full capacity, that there
are not enough resources at that end of the continuum and we\'re not
able to keep up with the need. So what can we do to intervene as early
as possible, and if we can actually prevent young people from beginning
to drink, then we may be able to avert some of those struggles that they
experience later in life.

There are about 11 million underage drinkers. When you start to think
about the numbers, they\'re big numbers. We\'re not talking about small
numbers of people, and nearly 7.2 million of those 11 million are
considered binge drinkers. So when you think about the risk associated
with the behavior in the immediate in terms of driving and risky
behavior, sexual behavior, other behaviors, and this is something that
could have a huge ripple effect if we\'re able to impact this, and the
Surgeon General\'s call to action is really to increase awareness and to
make the country, make the nation aware of the significance of this
problem and the challenges associated with that.

So there\'s a lot of other data which I\'m going to skip over. I would
encourage you to take advantage of that information that is available,
and certainly as council members I know that you\'re probably much more
aware of the information and data than most people, so hopefully you\'ll
spread that word as you go back to your respective locations as well.

I\'ll talk just a little bit about the budget. I saw that Joe Faha, our
legislative director, will be on the agenda later today, so you\'ll be
able to ask him additional questions in addition to any questions that
you may have for me. But he can talk some about the process, too. We
have the President\'s budget which gets rolled out, and then we have the
response from Congress, who actually appropriate the money and the funds
for that. Some of those decisions from Congress will be in alignment
with the President\'s budget, and some of those decisions will not be in
alignment. But they are basically the funders, and President Bush has
provided the guidelines through his proposed budget. I am going to talk
to you briefly about his proposal.

He\'s proposing \$3.2 billion for SAMHSA in fiscal year \'08, and there
are several areas where we will see continued investment of available
dollars for services that include children\'s mental health, HIV and
AIDS, screening and brief interventions ‑‑ you heard me talk about that
earlier ‑‑ suicide, school violence prevention, criminal and juvenile
justice, which actually has a significant increase proposed for drug
courts, Access to Recovery. Have there been discussions about that
program here?

DR. CLARK: Yes.

DR. CLINE: It\'s a very innovative program that provides recovery
support services for individuals, as well as substance abuse prevention
and mental health transformation.

The budget more specifically, when you\'re looking at substance abuse
treatment and prevention, provides about \$2.3 billion for substance
abuse prevention and treatment activities. Of that, \$1.8 billion is
requested for the substance abuse prevention and treatment block grant,
which is the same level that we saw in fiscal year 2007. I think all of
you are aware that \$1.8 billion is really the cornerstone of funding
for prevention and treatment activities across the country. So it\'s
important that that is firmly in place in this President\'s proposed
budget.

You should also know that this is a budget that has several reductions
that are identified, and some programs that are actually proposed for
elimination. The overall message behind this budget was that we are
working towards a balanced budget by 2012, and to do that we had to make
some very, very difficult decisions. Other areas that had full support
in this budget were the Access to Recovery program, which is about \$98
million. That\'s significant. There will be a new RFA that will be
coming out in the near future on that, again a very innovative program.

I think I\'m going to go ahead and close at this point. I would like to
again thank you for your contribution to the National Advisory Council
for CSAT. I know that Dr. Clark appreciates your advice and your
guidance and the leadership that you\'ve demonstrated by volunteering to
participate in this process, and I would also like to join him in
thanking you for that contribution.

With that, I\'ll close, and if you have any questions, I\'ll be happy to
do my best to address those questions, or if there are any comments or
concerns, I\'ll turn it back over to Dr. Clark.

DR. CLARK: We still have a few minutes of Dr. Cline\'s time, so this
will be an opportunity for council members to raise any questions they
might have. The floor is open for that.

MS. JACKSON: Well, I\'ll just raise a concern. You just discussed the
budget, and certainly I understand the need to balance the budget in
this country. However, I really am concerned about the discretionary
funding that has been a cornerstone of SAMHSA, all of the SAMHSA
agencies\' funding. I think that it has been probably the innovation of
so many new treatments. Dr. Clark has heard me talk about this many
times because I was in the beginning of the Women with Children and the
family treatment initiative back in 1992. We were one of the first 10
agencies there.

You know, if it weren\'t for that having happened and that money being
appropriated by Congress, and then CSAT and SAMHSA subsequently being
able to spread that across the country to make it into all of the
states, we today wouldn\'t have the attention that\'s going to families.
Of course, it kind of wanes. It goes up, and then it goes down, and now
I believe it\'s being proposed to go down again. I mean, that\'s just
one example, because I think the discretionary funding just is something
that cannot be done without if we\'re going to move forward in the whole
services to science. We in the field ‑‑ you\'re there. I guess I\'m
preaching to the choir, but I\'m just saying how do we help to get that
message across? We know we can go talk to Congress, and I think that we
do. Maybe we need to get more of that going.

Are there other suggestions that you have, particularly about the
discretionary funds? I know there are many issues, but I\'ll ask about
that.

DR. CLINE: Well, thank you for the point, and it\'s taken to heart. I
agree about the importance and the role of these targeted funds to
actually make improvements across the country, and certainly the example
you gave is an excellent one of services where we can actually get ahead
of the curve by making sure that there are babies that are delivered
drug‑free, and we can break part of that cycle. There are fiscal cases
as well as human cases to be made about the importance and the need to
do that.

Part of the dilemma, I think, that we find ourselves in, just to address
this, and it\'s not specific to any one program, the discretionary
programs are more vulnerable in some ways because they have not had as
much of the data and the longstanding data to demonstrate the outcomes
of these programs. When Congress and the President are in the position
of making decisions about, again, where will we reduce programs to help
move toward that balanced budget, any program that does not have strong
data on outcomes is vulnerable. There has been such great work in just
these last few years, and the National Outcome Measures are an example
of that, where SAMHSA has worked collaboratively with the states to
develop these measures that can be applied and are focused on recovery
for individuals, and you can make the case for recovery for entire
communities in the impact. But we do not have several years of a track
record for many of these programs, and that makes them vulnerable at a
time like this.

So in terms of what you can do, I think certainly to have those informed
discussions, as you referenced, with your congressional members is
something you have done and certainly can continue to do, because they
may not be as aware of the importance of those programs. I think as
advisory council members to have that ear to the ground and to hold
these discussions that address issues of accountability, and when you
hear discussions about data ‑‑ and again, I\'ve been on the other side
of those grants and I know how burdensome they can feel at times, and
especially if I don\'t have a good sense of their applicability. It\'s
that void where the data just goes, and it\'s like what\'s being done
with that?

So part of what we need to do is to educate people who are providing the
data about the importance of that. The National Outcome Measures are
important for multiple audiences. One audience is the audience of
Congress. How can we demonstrate that these programs are effective?
You\'ve got one dollar to spend. It can be on an ineffective program or
one that has a demonstrated track record. If I\'m making that decision,
whether I\'m a program manager in Oklahoma or anywhere else, I\'m going
to go with the one that\'s most effective because I can\'t afford not
to.

So make sure that those discussions are happening here. If Dr. Clark is
not doing that, then you may want to ask him about that. But my guess is
that he\'s been a champion of that. Thank you for the question.

DR. CLARK: Frank?

DR. McCORRY: Just a quick comment and concern, I guess. My concern is
really that whatever the particular projects, that often budgets are
driven by projects, even if the data might be very good or it\'s a
strong investment by whoever the executive is in a particular project,
and whether it\'s ATR or SBI, what typically happens in my view is that
there\'s an investment because of the value in it, and some programs in
some states benefit.

But even within the state, most programs don\'t benefit. Even what we
learn gets exposed or some programs benefit, but the ability to take
what we know and apply it systemically rather than a project‑driven
approach to areas that are important ‑‑ so you might, if you\'re an ATR
person, you might feel good that this budget is kind to ATR, or an SBI
person at a project level. But at a state and a system level, whether
New York or some other state benefits, it\'s wonderful to benefit from
it, but it doesn\'t really answer the basic, fundamental question of how
do we improve quality systemically, not on a project basis but within a
systemic structure.

Secondly are issues of readiness and performance measures and those
kinds of issues that will drive quality, adoption of evidence‑based
practices. My concern is that budgets that don\'t have those kinds of
capacities built into them in which what we know gets prioritized to be
implemented across the particular programs or states that are in the
project itself to me fails. It doesn\'t fail. It\'s quite successful,
but it doesn\'t necessarily change the actual service delivery system,
whether it\'s within a state or within a country.

Even NOMs as an outcome measure, measurement without some strong
capacity to help programs to improve and a structural capacity that puts
states on the dime and other kinds of entities on the dime to not simply
measure but to have a capacity to work with programs to improve based on
those measurements, those kinds of elements to me are key, even if the
budget was up 20 percent. We might be celebrating, and that\'s wonderful
stuff, but we fail to be able to take that learning and apply it
systemically. I was just wondering what your thoughts were on something
like that.

DR. CLINE: Thank you for the question. You\'re asking a question and
raising some points that address multiple levels, and it really ties
back in with the earlier question as well. Part of that gets back to the
use of data, the use of outcomes information, and the utility of that. I
mean, it doesn\'t do any good if it doesn\'t get used in some capacity.

There are implications across the entire spectrum of services and
management of those services, and there\'s a great deal of discussion
about the use of a public health model in actually moving the needle
within the states on a population basis. This is an area that you\'ll
see in the Screening, Brief Intervention and Treatment approach if
you\'ve heard about the Strategic Prevention Framework. These are really
using public health approaches to improve the quality of life for people
across, whether it\'s a community again or a state or the country.

We have had many challenges in the past about gathering data to have a
good baseline with that. You heard some of those things with the
National Survey which have given us a lot of that information, which has
been helpful. How would we know if we were making improvements if we
don\'t have a good sense of the baseline with that?

So being able to instill this performance or process improvement culture
I think is critical. Again, if you have one dollar, if you\'re 58
percent effective or efficient with that, then you\'re wasting half of
that resource. That doesn\'t mean that we don\'t have individuals who
are well intentioned, who are working hard, but they may not have the
tools they need to be as successful as they need to be. I think SAMHSA
has a demonstrated track record of being concerned about that and
concerned about being able to spread that. But I agree with you
wholeheartedly that, again, especially with limited resources, but at
any time we need to be very cognizant of the process and the performance
piece of what we\'re doing, are we hitting the mark as well as we could
be.

DR. CLARK: Dave?

MR. DONALDSON: Thank you very much, Dr. Cline. I really appreciate what
you said about dealing with some of the root causes, and that is
alarming for young ladies to see that kind of increase. I\'m the parent
of two adolescents, so that especially hits home.

Our society is just being bombarded with images through television,
Internet, and it\'s saying to these young ladies that if you don\'t look
this way, you\'re not measuring up. If you\'re not an \"American Idol,\"
you\'re a failure. Consequently, it\'s leading these young ladies to
have a grudge against themselves, against others, perhaps their parents,
and it\'s leading to these aberrant lifestyles.

What do you see as a priority in response to the media and combating
these images and putting forth at least a balance to what they\'re
digesting?

DR. CLINE: Let me talk about just a couple of examples of the types of
things that SAMHSA is involved with. One is working with the industry
around what\'s called the PRISM Awards, which is recognition of those
areas of the entertainment industry that are addressing issues of
substance use and are starting to address issues of mental illness
within their television, whether it\'s shows or movies, and making sure
that there are actual accurate depictions so that substance use does not
become glamorized, as you were mentioning it often is in advertising.

We know that huge amounts of time are spent by our young people watching
television, and there are leaders within the industry that are beginning
to take note that they have a responsibility and an ability to influence
people across this country by their depictions of substance use and
recovery. I don\'t know if you\'ve seen that in some of the television
shows. I mean, some people who are actually struggling with recovery,
are firmly in their recovery is being talked about in those shows. So
there\'s a great ability to reach those individuals as well, and we want
to make sure those individuals get recognized for that. We don\'t want
them to do all that work and then it\'s like, so what? It really hasn\'t
made any difference, and not being able to have some recognition from
their peers as well.

There also have been great collaborations with the Ad Council, and I
don\'t know if you all have seen any of the ads from the Ad Council.
Have those been shown here? If they haven\'t been, I would encourage you
at some point to see those. They are very powerful. I mean, I can\'t
watch one of those without being close to tears. I mean, they are
incredible. That again is the kind of partnership I think that can help
counteract some of what we see. But we\'re swimming against the tide, so
we need to do everything we can in our power to address that.

Just before Dr. Clark cuts me off here, one of the things I\'d like to
clarify, when I was encouraging you to continue in your role as you\'ve
done before in terms of talking with Congress, there\'s a qualifier that
as advisory council members, the role really in that capacity is to
advise Dr. Clark and CSAT, and you\'re not able to lobby or to have
those conversations with Congress in that capacity. So I just needed to
clarify that. I know that many of you have been engaged in those
conversations long before you were on the advisory council. So I just
wanted to clarify that.

DR. CLARK: Thank you, Dr. Cline. I really appreciate your taking time to
come here. You are, of course, always welcome. I would speak for the
council to say that. We hope you\'ll be able to join us again in the
future. When you have more time to interact with the members, I\'m sure
they\'ll be happy to hear from you.

I want to thank Rich Kopanda, my deputy ‑‑ he has played a critical role
in helping to manage CSAT ‑‑ and Cynthia Graham for her role in
organizing this meeting.

We have a number of staff people in the audience who are here to hear
from you also. So when council provides input, it\'s not just to Rich
and myself. It\'s to the number of staff who come to this meeting so
that they can hear your opinions, and it influences how they think about
what it is that we do.

You will see a printed copy of the Director\'s Report in your materials.
Dr. Cline mentioned that the budget process has continued. You heard him
talk about the budget. I want to present some slides that review that so
you can see it, so I\'m going to move up here.

As you know, SAMHSA is one of the 11 grant‑making agencies of HHS. Our
vision is a life in the community for everyone, and our mission is
building resilience and facilitating recovery. The goals are
accountability, capacity and effectiveness. The issue of accountability
remains. You heard Dr. Cline talk about the importance of the issue of
accountability, and our data focus is a critical part of that.

For CSAT, our mission is to improve the health of the nation by bringing
effective alcohol and drug treatment to every community. The matrix is
still our guiding principle at SAMHSA. Has anybody here not seen the
matrix? I know some of you probably have your walls painted with the
matrix and you\'ve got pictures of it, but it continues to be our list
of priorities, so I won\'t go over that because we\'ve discussed it in
the past.

As Dr. Cline pointed out, our proposed budget for \'08 is \$3.1 billion,
\$3.168. The 2007 continuing resolution, the budget is \$3.3 billion. So
as you can see, there is a reduction proposed between 2007 and 2008.

When you look at a comparative analysis in terms of discretionary
funding by major activity, Health and Human Services will experience a
0.29 percent increase in budget relative to other departments. If you
look at Labor, it\'s a 9.4 percent reduction in their budget. The EPA
budget is a 4 percent reduction. A number of departments like Education
have no change, and there are modest increases in others.

If you look at SAMHSA relative to other operating divisions within HHS,
HRSA has got a 5.61 percent decrease. CDC is a 0.86 percent decrease in
the \'08 proposed budget. SAMHSA would have a 5 percent decrease. ACF
would have a 3.9 percent decrease.

This balanced budget strategy is requiring people to make some changes.
For \'08, the proposed decrease for CMHS is 29 percent. For CSAP, the
proposed decrease is 19 percent. For CSAT, the proposed decrease is 12
percent. Again, relative to other entities, we\'re suffering decreases.
There are some increases in some places and some decreases in others.

The guiding principle, as Dr. Cline pointed out, is a balanced budget by
2012, and there\'s an emphasis on direct services. For the proposed \'08
budget, the assertion is that hard choices were required, and therefore
hard choices were being proposed. Several factors have been considered
in making program reductions and eliminations. One‑time expenditures
that don\'t need to be replicated, completed functions and commitments
within grants, and the scrutiny of automatic renewals ‑‑ indeed, the
assertion is that programs should not continue in perpetuity. Programs
with purposes that are addressed in other places, the notion is if
there\'s redundancy in the federal government, that redundancy needs to
be eliminated. So if we don\'t eliminate that redundancy, then we\'re
spending too much money.

Underperforming programs and programs without solid performance
measures, another statement that Dr. Cline made. If you don\'t have
data, you cannot defend your programs. If you have inadequate data, you
can\'t defend your programs. Proposed reductions in the past that were
not enacted.

So these were guiding principles that were made for the \'08 budget, a
key issue for us as we shift toward a more performance oriented
environment.

The SAMHSA decline is about 5 percent or \$159 million. The budget funds
presidential initiatives like ATR and other priority areas such as our
block grant, criminal justice portfolio, SBIRT, and our Minority AIDS
Initiative, while making targeted reductions in areas where grant
periods were ending, activities can be supported through other funding
streams, or efficiencies can be realized.

The block grant, as you can see, from 2005, the proposed block grant is
actually a reduction from 2005. The 2008 proposal is a reduction from
2005. Our Programs of Regional and National Significance have two
components, capacity, with a reduction from 2005 at \$385 million, \$386
million, to the proposed 2008 at \$339 million. Of particular note, our
science to service line item in 2005 that we had was \$36.7 million; for
2008 that is reduced to \$13.1 million. So if you look at CSAT\'s budget
in total from 2005 to 2008, it would go from \$2.198 billion to \$2.11
billion.

The President\'s budget includes \$98 million for Access to Recovery,
and also has \$25 million targeted for methamphetamine treatment. The
\$22 million available to more than triple the number of grants for drug
treatment courts, that spectrum of courts that deals with the legal
system and substance abuse and juvenile justice, et cetera. An
additional \$12 million is to support Screening and Brief Interventions
in general medical and community settings. I\'m calling this \"Back to
the Future,\" the reintegration of substance abuse treatment into the
primary health care delivery system. \$25 million is available to fund
three new grants to states, 18 new campus grants, 8 new grants to
medical schools, and 12 new grants to school districts and community
health clinics serving Native Americans. Early identification of
substance abuse decreases total health care costs by preventing
progression toward addiction.

As we\'ve discussed before, particularly for SBIRT, some of you have
seen what I refer to as the big red slice, 73 percent of the people who
meet criteria for abuse and dependence of illicit drugs, and 86 percent
of the people who meet criteria for abuse and dependence of alcohol do
not perceive a need for treatment, and so they\'re not knocking on the
doors of the substance abuse treatment programs.

So we have to find people where they are. They\'re not knocking on the
substance abuse treatment program doors. We believe that you have to go
to community health centers, student health services, emergency rooms,
and SBIRT is allowing us to screen a large number of individuals and
identify and refer people to treatment.

When we look at the \'08 budget, we should also look at the programs
that we\'ll have to eliminate. The proposed budget would eliminate a
number of programs in CMHS, not the children\'s block grant, which is
not being eliminated, but other children\'s programs will be eliminated.
Mental Health Transformation activities would be eliminated. Older adult
activities would be eliminated. Adolescents at risk would be eliminated.
Consumer and support TA would be eliminated. Disaster response and some
of their homeless activity would be eliminated.

If we look at CSAP, their evidence‑based practices activity would be
eliminated. Their Center for the Advancement of Prevention Technologies,
their CAP programs, would be eliminated. Dissemination training would be
eliminated, and best practice program coordination would be eliminated.

When you look at CSAT, our Strengthening Treatment and Access to
Retention, the STAR program, would be eliminated. Our special
initiatives outreach would be eliminated. Our state service improvement
activities would be eliminated. Information dissemination would be
eliminated. Program coordination and evaluation, some of our technical
assistance, and our contribution to the Minority Fellowship Program will
be eliminated.

These are the specific STAR activities that would be eliminated in the
proposed budget. When you look at our special initiatives outreach, some
of our TAPS would be eliminated, our HBCU and the Lonnie Mitchell
conference would be eliminated, our planning and special initiatives out
of my office would be eliminated, the performance measurement contract
in DSI would be eliminated, analysis of the AHRQ\'s health care costs
would be eliminated, and our scientific, technical and logistical
support would be eliminated. Our HIV/AIDS cross‑training would be
eliminated, and our confidentiality training would be eliminated. Our
Partners for Recovery activity would be eliminated, and our consumer
affairs and education activity, including Recovery Month, would be
eliminated. Then our CAP contract would be eliminated. Our printing
would be eliminated, and our clinical and technical assistance would be
eliminated.

We would experience decreases in the following areas. Our COSIG grants
would decrease between \'07 and \'08; opioid treatment programs would
suffer a decrease; TCE general would suffer a decrease; PPW would suffer
a decrease; RCSP would suffer a decrease; children and adolescent
activity would suffer a decrease; treatment systems for the homeless
would suffer a decrease; and our program coordination and evaluation
activity would suffer a decrease.

So the \'08 budget is a very tight budget, and we will operate within
that budget, making whatever adjustments that we need to make. The
President has a goal of balancing the budget, and we also have a war
budget. So we need to make critical decisions in order to support that
budget.

We will begin planning for the FY \'09 budget shortly. The Administrator
is interested in getting input from a wide variety of stakeholders, and
I\'d like to solicit your ideas in this process. We don\'t know the
amount of money SAMHSA will be given in \'09. I expect we will do what
we\'ve done in the past, and that\'s to plan for several potential
funding scenarios using the \'08 budget as the base. These possible
scenarios include a straight or flatline request ‑‑ i.e., no change from
the \'08 budget ‑‑ and a reduction from or an increase to the
President\'s 2008 budget at different levels, say plus or minus 2
percent, or plus or minus 4 percent.

Later this morning, during the time reserved for council roundtable,
I\'ll be asking you for your thoughts on what CSAT\'s priorities should
be as we look ahead to FY \'09 based on your expert knowledge of trends,
developments, needs in the field, where should we begin allocating our
resources, where can we make the most impact and get the biggest bang
for our bucks. Should we focus on expanding the availability of
treatment services or improving treatment quality through the
dissemination of evidence‑based treatment practices?

Frank, you raised that issue. What good is the information if it stays
in Sam Smith\'s back pocket? Excellent Program X, located in State Y,
but never diffuses to anybody else except Excellent Program X located in
State Y. It\'s a great program, but what about everybody else in the
game? So we don\'t really change the dynamic for everybody else, and
therefore in the aggregate nothing changes. It\'s a drop in the bucket.
It\'s a drop of ink in an ocean. Indeed, this becomes an issue. Should
we focus on how we disseminate information? If we have an increase, what
are the priority areas that we should address first? Are there new
programs or activities that we should be focusing on, or should we
expand current efforts such as ATR or SBIRT? If we\'re faced with
additional cuts, how would you recommend that we reduce, eliminate or
refocus our current programs? Your suggestions will help me in advising
the Administrator where SAMHSA should be headed and developing budget
proposals for 2009 and planning for the future of the agency.

I would also like to stress that this is very important because, indeed,
we also don\'t know what the Congress is going to do in the \'08 budget.
We know what they did for the continuing resolution. You have that
information. But for the \'08 budget they may or may not agree with the
President, and then we would have a one‑year budget, if you will, if
they don\'t agree with the President. So we need to figure out how to
operate in that context. We did have an appropriation hearing. Some
members of Congress would support the President\'s budget. Others have
raised questions about it, and since we don\'t lobby, we don\'t know
what position they will take. We support the President\'s budget and we
will operate within that budget. But if we have other resources, of
course, because there\'s a difference of opinion, then we will operate
within the appropriated budget.

But because you heard the Administrator focus on performance, and
because the money is tight and the whole notion of if we\'re going to
save, if you will, the activity that we do, if we\'re going to
demonstrate our utility, we need data, you heard the Administrator make
reference to data from the Household Survey with regard to inhalants,
you heard him make reference to our DAWN data with regard to
prescription drug abuse, he\'s also interested in our TEDS data, we are
interested in taking the large data sets that we have and integrating
them into how we function.

As a result of that, we have a proposal that we\'ve gotten approved by
the Administrator that will affect two of our divisions, the Division of
Service Improvement and the Division of State Community Assistance. We
propose to restructure our activities so that we can consolidate our
data activities currently spread across those two divisions into a new
performance measurement branch that will be located in DSCA. This new
branch will be responsible for coordinating all of our program
performance activity and analysis of national data sets employed by the
center so that we can be much more aggressive in using these data. Not
only are we dealing with performance in the expectation of the funders,
we\'re dealing with performance in the expectation of the Office of
Management and Budget. They want to know how is this program doing and
what is your evidence, and where did you get your data. So as you heard
reference to the National Outcome Measures, we\'ve got our GPRA data,
but we also spend a lot of money collecting other data, and we need to
integrate all of that in our RFAs and our TA and our assessment.

With the consolidation of the performance measurement activities in the
new branch, the plan also affords the opportunity to restructure three
DSI branches. But before we go into detail, we believe that
restructuring is needed and will improve our ability to accomplish our
mission. This culture of performance, a new performance‑based
environment in which we are expected to manage for performance and
demonstrate solid outcomes and results, is a critical environment. We
can\'t ignore it. We can\'t say, well, the status quo is the most
important thing in which we can engage. We didn\'t do it yesterday; why
should we do it tomorrow? We believe that behavioral health needs to be
as adaptable as primary care and other systems. If we fail to do that,
then we continue to take the hits.

I mentioned GPRA in part, and you heard Dr. Cline mention this. With our
2008 budget deliberations, all emphasis will be on documenting our
performance. As we talk about 2009, we have some time, and part of what
we want to be able to do is to document the utility of the various
programs that we have so that there\'s no debate about how important
these programs are or how useful they are. If programs are not
performing, we should be the ones to say this isn\'t working, let us
shift gears. If we don\'t do that, then obviously it\'s done for us. If
we don\'t establish that we have the administrative and managerial
sensitivity to performance, then when that is imposed on us it may not
be as, shall we say, delicately done as we would do for ourselves.

I appreciate our staff\'s willingness to rise to the challenge. CSAT\'s
service accountability improvement system embodies almost the ultimate
in performance reporting. These are challenges that we face, and I think
we will rise to this challenge.

SAMHSA is also being asked by OMB to have a SAMHSA‑wide data strategy to
consider the agency\'s need in a broader context. Another challenge is
the need to examine consolidated versus individual program results so as
not to put the latter at risk. We need to anticipate a flood of block
grant NOMs data from states when they are reporting next year. They
start reporting in October their National Outcome Measures, and we need
to be prepared to analyze and understand and report that data, and
contrast that data with our TEDS data, which is basically national data.
Already with our SAIS data, we can look at the Household Survey data,
which shows you national prevalence, we can look at TEDS data, which
shows you national service system data, we can look at our GPRA data,
which shows our performance data. An example is the inhalant reference
that Dr. Cline made.

So we looked at our GPRA data and we found, in fact, that adolescent
girls do report more inhalant use than adolescent boys in the treatment
programs. So it\'s consistent across the national data, and then you
look at who is showing up for treatment and who is using inhalants. So
this was an important finding because we can show the relationship
between our national data set and our program data set. When there are
conflicts or anomalies, we of course should be able to address that. We
know that when people submit grants, what they experience at the local
level may be inconsistent with what the national data, and even the
sub‑state data, show, but that doesn\'t mean they\'re not having a
problem. It does mean that we can account for what is going on, and we
can speak to what is going on.

PART may expand and drive future budget decisions, so our data will have
to be of sufficient quality that we can survive PART reviews. The
Administrator\'s expectation regarding our use of data, including
national prevalence and trend data to guide and manage our programs,
will be a challenge, and we will work with Dr. Cline. He is actively
inviting our input. He is actively inviting your input. But the key
issue from his past is that he has used data to drive the performance of
his programs, and I think that was one of the reasons he was made
Secretary of Health in the State of Oklahoma prior to his arrival. I
Googled him and went to Oklahoma, and they checked on the performance of
all programs. You got money from the state and your performance was
evaluated and it was on the website. How many people you saw, who you
saw, how you did, that was all there. So he believes in transparency and
he believes in performance. He has been a leader in obtaining and
publicizing data on performance, and I would like to have CSAT follow
his mark.

In our case, we know that things have been scattered among divisions and
offices. We were lacking a critical mass of expertise in handling the
conceptualization, collection and analysis, and proactive reporting of
data and performance results which are critically needed for a
performance‑driven environment, and these are the things that we would
alter with our restructuring plan.

This will be, in my mind, tremendously helpful for us, particularly in a
cost‑conscious environment. So we will pursue the reorganization, and as
a result of the reorganization most staff will continue to work in the
program areas to which they are presently assigned, but some will be
realigned within the new structure. Some staff will be reassigned to new
duties, and no employee will lose their job or grade as a result of
restructuring. We presented this to the staff yesterday. We\'ve opened
the process up between the staff and the union so that we can have
ongoing discussions on the specific details, but it is clear that we
need to move in this direction. If we fail to move in this direction,
then while we are fiddling, Rome will burn, and we don\'t want that to
happen.

In conclusion, I\'d like to speak to you about our upcoming ninth annual
Lonnie Mitchell National Historically Black Colleges and Universities
Substance Abuse and Mental Health Conference. As you know, the
conference honors the work and legacy of the late Dr. Lonnie Mitchell.
Dr. Mitchell was an esteemed educator, administrator, policy adviser and
psychotherapist. He had a vision of bringing cutting‑edge substance
abuse research and policy to the public. The conference is designed to
educate students at our nation\'s HBCUs, Historically Black Colleges and
Universities, about substance use and mental health disorders, and to
bring to their attention information and strategies used in coping with
the problems of substance abuse and mental health in African American
communities. Our goal is to expose students to the many ways that we can
make a difference in their communities as advocates, providers,
policymakers, researchers, educators and in other capacities.

We\'re particularly pleased to announce this year the participation, in
addition to our Administrator, Dr. Terry Cline, Mr. John P. Walters, the
Director of the White House Office of National Drug Control Policy, will
also be there. This will be a wonderful opportunity for students
attending the conference to meet top policymakers in the field, and we
hope this will not only raise their awareness but heighten their
interest in pursuing careers that help individuals, families and
communities cope with the problems associated with substance abuse and
dependence. The conference will be held next week, March 29 and 30, at
the Grand Hyatt in Washington, D.C. We\'re looking forward to an
exciting conference this year. If you\'re going to be in town, I
encourage you to attend the conference for this singular opportunity.

We appreciate Judge White‑Fish\'s comment about SAMHSA\'s participation
with the American Indian and Alaskan Native communities. SAMHSA, in
addition to working with HBCUs, has also been active in making sure that
we outreach to the American Indian and Alaskan Native communities. CSAT
has also been actively involved in addressing the needs of Hispanics. We
have an Hispanic work group, and we\'re trying to address the needs of
each of the populations in the United States, as well as the overall
issue, going for an integrated approach without ignoring the specific
needs of each unique population.

I recently presented at an Asian American and Pacific Islander research
meeting in Los Angeles, where we reviewed some of the unique needs of
the Asian American and Pacific Islander communities. That said, we
realize there are other communities that need assistance. We work
actively with rural America, Appalachia and other communities so that we
can address unique needs. Obviously, there\'s not enough money to do
everything. We\'re stretched pretty thin. Sometimes we\'re one staff
deep. I can see some of the staff in the back acknowledging that.

We would also like to address the issue of the electronic health record
and e‑therapy, which we\'ll hear about later, but the electronic health
record we think is an important thing. As we move toward a
performance‑oriented culture, we need to make sure we get our
information uplinked to the largest systems, and the electronic health
record is going to play a major role in doing that. If we fail to keep
abreast of such changes, then again behavioral health takes a hit
because nobody knows what you do, nobody knows how important you are,
and despite the ubiquitousness of the problems, we will be unable to
demonstrate that. So we want you to know that we\'ve been actively
involved in a wide range of activities, and I want to keep you apprised
of these things so that you can give us input and you can give us
feedback, and whatever it is that you think we need to be doing, we can
include those thoughts in our planning, and hopefully working
collaboratively we can achieve a reduction in the substance use problems
that America faces. Thank you.

With that, I want to open the floor for questions or comments pertaining
to my report. Questions?

Dr. Fletcher?

DR. FLETCHER: Dr. Clark, please let me commend you on your report and
the activities of CSAT. Given the culture of performance and the results
accountability environment that we find ourselves in now, and given the
steps that you\'re taking as a part of the restructuring process, how
will that translate in your discretionary programs? Are there new
expectations? How will that get communicated in terms of discretionary
programs and the need for reinforcing the results accountability notion?

DR. CLARK: Thank you for your question. If I interpret it correctly,
what we will be doing is building on what we have been doing, and that
is making it clear through our TA to our grantees that we expect
performance. We will work with them with regard to performance. You take
the money, you\'ve got to deliver the services that you promised. If you
encounter impediments, we need to track those impediments and figure out
subsequently how to surmount those.

The key issue is that the project officers are monitoring the
performance of grantees. If somebody says I\'m going to see 10 patients,
they need to see 10 patients or explain why they\'re not seeing them.
Then we\'re going to find out what happened to those 10 patients. You
saw those 10 patients. Did they get better? Did they get worse? Did they
remain the same? Again, the whole process is you take the money, you\'ve
got to account for what you did with it, and we don\'t expect
perfection, but we don\'t expect people to say trust me, I spent it
well.

Frank?

DR. McCORRY: Thank you, Dr. Clark, for just a terrific presentation.
It\'s one of the real benefits of being on this council, to be exposed
to this information. So I really appreciate you taking the time to kind
of lead us through what\'s happening at SAMHSA and CSAT. I love the
phrase \"culture of performance\" as a kind of organizing rubric for a
discussion or for a direction.

You mentioned a couple of things. You mentioned a SAMHSA‑wide data set,
if I got that correctly, and then you also mentioned perhaps
restructuring as part of this kind of organizing around ‑‑ I wasn\'t
sure if it was organizing around the culture of performance, but trying
to put those three elements together, the culture of performance, the
SAMHSA‑wide data set, and the restructuring at CSAT. Could you just tell
me a little bit more about it?

DR. CLARK: Well, as you know, SAMHSA spends quite a bit of money
collecting data. What is happening under the PART process is that,
indeed, those data get regurgitated for us by other entities that use
the very same data that we collect. The whole thrust of performance is,
gee, what is the relationship between how you spend your money and what
you\'re getting for your money. So if a program says, well, I want to
treat people, as I mentioned, for Dr. Fletcher, then we need to know why
are we funding this program, we\'ve got to have data, what\'s the
driving problem. So now we have data, as I mentioned. Now we have
aggregate data. As you know, the Household Survey has been in existence
some four years in the current paradigm. So we can aggregate data.

We collect TEDS data, the Treatment Episode Data Set. Well, the
Treatment Episode Data Set says this is who we\'re treating, this is
what is happening. So we need to be able to reflect how we spend our
money relative to the magnitude of the problem ‑‑ i.e., the National
Household Survey ‑‑ what other problems are saying vis‑a‑vis the
Treatment Episode Data Set, and what we are seeing vis‑a‑vis our data
set, and how we reconcile the differences between them. We also need to
have better information about cost bands, how much money is it costing.
Are we choosing to spend money in the Cadillac programs versus the Ford
Taurus programs? Is there a Ford Taurus anymore? I think they got rid of
that.

(Laughter.)

DR. CLARK: Yes, the Ford Taurus program. So there is that sensitivity
there. Then there\'s the program management. You\'ve got 15 percent of
your programs that are underperforming; what did you do about it? We
can\'t say, well, gee, it\'s out of our control. When you say it\'s out
of our control, then external entities say no problem, it\'s in our
control, and since this isn\'t working so well, we\'ll give you 15
percent less money. So that\'s the issue in my mind in cultural
performance.

Rich, do you want to add something?

MR. KOPANDA: Yes. I was just going to say that from the SAMHSA point of
view, what OMB is looking for in terms of the SAMHSA data strategy is
kind of a broad picture look across the three centers, in mental health
prevention and substance abuse treatment, what data sets exist right
now, how do the national surveys, like the Household Survey, provide
data that\'s useful to our programs, how do they integrate with the data
we\'re collecting from our programs, and where are gaps, where are gaps
we need to fill. So the agency basically is looking at that overall
strategy, but it is integrated with the direct program performance,
which is going to be related to our new unit, basically.

DR. CLARK: Val?

MS. JACKSON: So taking that thought line down to the state level, I
don\'t know about all the other states, but I think that most states are
investing substantial funds of money in trying to collect data and get
information and become performance based, and a lot of that money may or
may not be used wisely depending on where you\'re at and what your
viewpoint is. That means not just that the data doesn\'t need to be
collected, but it\'s the process of trying to get it there through a
kind of cumbersome system. So it\'s a big challenge, and I\'ll speak to
Florida where the legislature has mandated a set of outcomes that have
nothing to do with the NOMs. They expect those to be met, and the ADM
folks and the state authority have to reconcile that. She\'s working
very hard to try to move this over to the NOMs and to make that the
accountable thing that matches up with you. However, I suspect that\'s
not the only state that\'s having problems with that sort of thing.

How do you connect what you\'re doing now down to the states, and then
ultimately that goes into cities, counties, districts that have to also
make decisions on how they collect data and make decisions? Are there
thoughts about how all that connects?

DR. CLARK: Well, we recognize that there\'s going to be some conflicts
in operability in terms of the expectations. We\'re trying to work with
jurisdictions on that. One of the things that we see in the electronic
health record is a potential mechanism by which we can address some of
these conflicts so that we can arrogate data without operability
conflicts. We have Rich Thorenson and Sarah Wattenberg, Rita Vandivort
and others at the CSAT level, and others in CMHS and CSAP and our Office
of Policy, Planning, and Budget focusing on that.

It\'s going to take time, but if we don\'t start, it doesn\'t happen. We
know that this is happening elsewhere in the health care delivery system
for the general health care delivery system. So we\'re going to have to
deal with the state by state conflict points in terms of differences in
operability and differences in information exchange and differences in
outcome measures. If we move toward electronic health records, Internet
data, we will be able to address that.

At the state level, they\'re going to have to deal with the NOMs because
the Congress is sending the money based on that. In fact, there is a
proposal for penalties if you don\'t do the NOMs at the state level. So
rather than focusing on the negative consequences, our objective is to
try to focus on incentivizing and working collaboratively with states
and community‑based organizations so that we can achieve this. For a
long time people said, well, gee, we can\'t do it, it costs too much, et
cetera. Well, now computers are throwaway, and the Internet is a
giveaway. It\'s like your cell phones, they\'re more interested in the
service charge than they are in the individual cell phone.

So some of the hardware issues have been addressed. We\'ve got to work
with the software issues. That\'s what we\'ve done in the past with WITS
and other platforms. This is an evolutionary thing. But you\'re right,
those things exist, but they are surmountable. They do require the
concerted efforts of all parties, and naysayers are just now welcome in
the room because the people who are writing the check don\'t really care
about the naysayers. They want to know can you deliver.

MS. JACKSON: Just a follow‑up on that. I support the NOMs, and I think
our state supports the development of the NOMs. I don\'t think that
there\'s any doubt about that. However, as I mentioned before, sometimes
the legislature doesn\'t really know what a NOM is and they don\'t
really understand that that has any importance. Obviously, putting
penalties there will get their attention, and I think that in my heart
I\'m actually for that move. However, I would ask you to please be very
cautious about making that move. It\'s not very easy at the state level
sometimes to get those folks to switch around, and we do understand that
we need to get on board, but it does take time. As you said, it takes a
little time. They\'re working hard at it.

DR. CLARK: And we recognize that. I mean, this is not so Draconian or
heavy‑handed. But as far as the Congress and OMB are concerned, they\'ve
been asking for this for a while. At some point you have to draw a line
in the sand. What we\'re trying to do is to make sure that people are
aware that the time is coming for that line to be drawn. We\'re part of
the bureaucracy, and we would be failing our state partners if we did
not acknowledge that the patience of the people who write the check is
going to be tried if we continue to say tomorrow and tomorrow and
tomorrow, we\'re waiting for Godot, while they\'re saying, well, you
know, we\'re waiting too, but in the meantime here\'s the line and here
are the penalties if you don\'t deliver.

We\'re not trying to be heavy‑handed. We\'re not trying to browbeat the
states. But even at the state level, as you pointed out, while they may
not adopt NOMs, they\'re drawing NOMs clones, NOMs‑like. So they may not
use the phrase \"NOMs,\" the acronym \"NOMs,\" but they want outcome
measures. They want accountability. So it\'s uniform.

DR. SKIPPER: Is there a provision in this laudable policy that I support
for the concept that some programs may be very important and effective
for some institutions ‑‑ for example, AA and NA, those kinds of programs
‑‑ that may be very difficult to prove their effectiveness from a data
point of view? I want to be sure we don\'t lose the idea that some
things may be hard to prove.

The other caution I wonder about is that we could spend more on trying
to prove things than actually providing services if we get too obsessed
with assessing performance, because it\'s quite expensive to assess
performance. So I just want to be sure there\'s a caution in this
laudable concept.

DR. CLARK: I appreciate that, but the beauty of the outcome measures is
it\'s less interested in your basket of interventions and more
interested in what happened as a result of your interventions. So if you
say something is working, then you need to be able to demonstrate that
it\'s working. The beauty of the outcome measures is you say I\'m
treating you for alcohol and drug use disorders; did I treat you for
alcohol and drug use disorders? If it doesn\'t work, then maybe you
should try something else, and that\'s what the beauty of the outcome
measures is. It has less to do with specific interventions.

Judge White‑Fish and I were talking about sweat lodges. A sweat lodge by
itself may not do anything, but as a part of a basket of goods it may be
terribly helpful. But at the end of the day, the question isn\'t whether
a sweat lodge was used. The question is did that person, as a result of
your basket of interventions, stop using or decrease his use of
substances? If that\'s the case, then you can do sweat lodges, you can
do motivational interviewing, you can do 12‑step programs. That\'s your
basket of interventions and you got good outcome measures, so who am I
to say that specific element or a specific thing in your basket is
unacceptable, because your outcome measures are the thing that you put
out there. As a result of taking the money to reduce substance use,
I\'ve achieved that. If I come along and say, well, the evidence base,
or this that and the other, that\'s a different matter altogether, and I
think that\'s what you\'re saying, that you can\'t prove a specific
component of the basket of goods, but the issue is your treatment
program. You treated this program; did this person get better as a
result of your treatment? If you say no and the other person down the
street says yes and they\'ve got data to prove it, then the emphasis
from a performance culture is we\'re no longer interested in what
you\'re doing because it\'s not working. The other guy down the street
is doing a good job, and the woman across the way is doing an excellent
job, so we\'re going to go that way, that\'s how the money is going to
be spent. That I think becomes the issue. It forces individual programs
to diversify or restrategize what it is they do.

Anita?

MS. BERTRAND: Dr. Clark, I just want to thank the staff of CSAT and
SAMHSA for their ongoing support for providing services and
administration across the country, and their leadership. I think that
sometimes we look at these budgets and we get caught up in what we\'re
not doing, and I think that we\'re doing a lot of good things. I\'m in
the trenches, so I know what it\'s like to be there and to struggle to
have to find dollars to provide services to individuals, but there are
people who are doing quite well, and I know that there are programs
across the country that are doing well.

I think that your comment around looking at systems and how we can
better become efficient, I know that our clients are in a multitude of
systems, and as a director I\'m constantly looking in those other
systems for ways to enhance what it is that we\'re doing.

But one of the questions I have is what is the data showing from GPRA
and the initiatives that you do have in place? What is showing in
regards to the consumers that are staying in recovery? Like what are
some of the indicators in terms of maybe there are one or two programs
that have a 60 percent rate of individuals staying in recovery over a
long period of time.

DR. CLARK: We have insufficient data for that, and that indeed is one of
the issues. One of the questions that does pop up is what does it take
for your treatment? Our hope for the recovery community services program
is that we\'ll have better data and we can do a more prolonged analysis.
We are very much interested in being able to tell that story. I\'m sure
staff appreciate your recognition of their efforts. I know I certainly
do, so I want to thank you for that. We\'ll continue to work on the
data.

At this point, I\'m sure you need to stretch your legs for a couple of
minutes. We\'ll take a 15‑minute break, and I encourage you to return
promptly so we can reconvene at 10:30. We need to remain on schedule. I
noticed Joe Faha is already here. Thank you.

(Recess.)

DR. CLARK: Joe Faha, SAMHSA\'s director of legislation, is with us today
to give us a legislative update. Prior to joining SAMHSA in 1991, Joe
was a legislative analyst with the Office of the Assistant Secretary for
Legislation at HHS. Prior to that position, he was on the staff of
Senator Bob Dole of Kansas. Needless to say, Joe keeps SAMHSA abreast of
any and everything happening on the Hill. So join me in welcoming Joe
Faha.

(Applause.)

MR. FAHA: Thank you. You know, it\'s really bad when you come to
something like this and you\'re the only one clapping for yourself.

(Laughter.)

MR. FAHA: It is a telling story. It is true that I came to ‑‑ it wasn\'t
SAMHSA at the time, it was ADAMHA, and I can remember the date. It was
January 14, 1991 that I came to ADAMHA, which makes me a senior citizen
in this organization, not just by age but longevity. The first thing I
was asked to do as director of legislation was to dismantle the
organization, to send the three institutes over to NIH. I wasn\'t all
that popular those first couple of years.

Anyway, this is a great pleasure.

Am I talking too loud? Can everybody hear me? Okay, good.

This is really a tremendous pleasure to come and talk to you. I\'m going
to give you little highlights of what my perception is of what\'s going
on on the Hill, and then I understand I have two hours of Q&As for
anybody that\'s interested.

(Laughter.)

MR. FAHA: Let\'s start with appropriations, since that seems to be the
topic du jour. As you know, we have a continuing resolution for the
entire year, through \'07, and that is at the \'06 level. So we
basically have as much money to spend for CSAT, CMHS, CSAP, SAMHSA as we
had in \'06, and there are reasonable guidelines that we need to be able
to spend it in much the same way as we did in \'06. That\'s not in every
single case, but the general rule is that you spend it in the same way
in which you spent funds in \'06.

That having been taken care of on February 15, when Congress passed and
the President signed the full year continuing resolution, we now began
the process for \'08 funding. As is always the case, the President
submitted his budget to Congress on February 5 or thereabouts, detailing
exactly what he was asking for with regard to all of the federal
agencies, and that included the Department of Health and Human Services
and SAMHSA.

Subsequent to that, SAMHSA found itself as being one of the first
agencies to testify before the House of Representatives, which we did on
March 12. This is the earliest we have ever testified before the House.
As was true for the previous two or three years, three years ‑‑ we
didn\'t testify last year. They canceled all the hearings. But in the
previous years, the two years before then, we testified along with our
sister agencies from NIH, NIAAA, NIDA and NIMH, with an attempt on the
committee\'s part to be able to get a dialogue about the relationship
between science and services. So that occurred in a very cozy
environment, for those who weren\'t there. It was (inaudible) for the
witnesses. It was one big oval table in which all the witnesses sat at
the table along with the members themselves. So at least the setting was
collegial. It felt more like you were at a meeting than you were at a
hearing. So when Dr. Cline was testifying, Congressman Ryan was sitting
right next to him instead of up on the dais. He tailored his comments as
best he could to the sense that it was a meeting.

The hearing went fine. It is the opening salvo in terms of what will be
appropriations season. We fully expect that the House will come up with
its marks for the Department of Health and Human Services and at this
point probably finish action before the July 4 recess. If not then, then
certainly before the August recess. So things are going to happen very
quickly. Hearings are happening very fast, much earlier than they had in
previous years, and so we\'re expecting it.

Now, there are many who would assume that because the Democrats are now
in charge of Congress, both the House and the Senate, that there will be
a lot more money for social programs, including substance abuse and
mental health. I\'m not so sure that the Democrats have as much leeway
as we like to be able to think that they would. They, too, are wedded to
balanced budgets. They, too, have to deal with the increased costs of
the Iraq war and the war in Afghanistan, and so they\'re under a lot of
budget constraints. So I\'m giving you an early warning that you should
not be looking forward to huge increases for substance abuse and mental
health, or actually for any social programs.

You certainly will see a redirection. There\'s going to be a lot of
areas where the Democrats will want to move. One in particular related
to substance abuse and actually mental health as well is Senator
Harkin\'s endeavor to focus on mental health promotion and the
prevention of substance abuse. He is into wellness and believes in that
concept, believes that prevention is prevention and that if we\'re going
to focus on substance abuse and mental health, we should also focus on
diabetes, obesity, all of those preventable diseases in a unified
effort. But you\'re likely to see a lot of that going on, with
additional money, but I just would warn you not to expect huge
increases.

The Senate will then pick up and work its wonders probably at the same
time but will not get their work done. I would expect that there will be
normal order, which requires that the House act first before the Senate
does on their bills. That doesn\'t mean that the subcommittees won\'t
hold their meetings and do all the deliberations. It\'s just that the
Senate itself will not consider bills, probably will not consider bills
until the House has already acted. So you\'re looking at after the
August recess, which is traditional. This is typically what happens.
They go away for the month of August, they come back, and then the
Senate picks up where the House left off. If indeed you see Senate bills
coming out before the August recess, then they are really moving fast.

Any questions about appropriations before I move off of that?

(No response.)

MR. FAHA: Good. Okay. So this is the year of what I refer to as the
perfect storm. If anybody read that book or saw the movie, you know that
it talks about a situation in which two fronts come together and they
create what is the perfect storm. Well, for a legislative analyst,
that\'s what\'s happened this year, because we not only have
appropriation going on but there is deliberations on the reauthorization
of SAMHSA. Let me spend a second just to tell you what that means.

It does not mean that SAMHSA as an organization is up for
reauthorization. That\'s not true. The organization continues. It\'s our
programs that are up for reauthorization. Technically what
reauthorization means is that if you go to any statutory provision, be
it pregnant and postpartum women or services for adolescents, services
for child welfare, whatever it may be, there is always a subsection that
says there are authorized for purposes of appropriation X number of
dollars ‑‑ this is not the exact words ‑‑ for fiscal year 2001, 2002,
2003. Well, reauthorization means that you just change those dates and
you say there are authorized to be appropriated such funds for carrying
out this section for fiscal years 2008, 2009, 2010. When that happens,
that program is considered reauthorized. That\'s all it means.

We do not need to have our programs reauthorized. We continue to receive
appropriations for our programs whether it says 2003 or 2010. It
doesn\'t make any difference. Technically, if you receive dollars for a
program, let\'s use the block grant as an example. If you go to that
statute, the last year it was authorized was for 2003. As long as you
are receiving money for a fiscal year ‑‑ so we have money, for example,
for 2007 ‑‑ that program is considered to be reauthorized for the year
for which you received funds. So it is reauthorized for \'07, but it is
reauthorized as it has always been. Then this is why it is important to
have a reauthorization process, because it is the only mechanism that
you can get changes to statutes to suit or to enable you to do things
that you want to do where the current statute limits you. That\'s the
first.

The second is that it\'s about time that we have a significant
discussion in Congress about substance abuse and mental health. There
has not been a significant discussion about these two subjects since
1999 when they last held hearings and considered our reauthorization.
The exception is certainly parity, but there really has not been a
significant discussion, and this is our way of engaging Congress in this
discussion.

Now, whenever you engage Congress, you have to be careful because you
don\'t always get what you want. You get a lot of what they want, and
sometimes that\'s not exactly what you want, and so the debate goes on.
But the benefit is usually worth it. You get the dialogue, you get the
exposure, you get the conversation, and so change occurs just because
you\'ve done that, and along the way you typically get the changes that
you are looking for in the statutes so that you can do programs.

For example, keeping with the frame of the block grant, we have
authority currently to require states to provide performance measurement
data. However, we are relying on a very nebulous provision that says
that the Secretary can require anything else he wants, or she wants.
What we want to do in this reauthorization is to make it much more clear
what it is that we\'re after and to stipulate that we do expect states
to be able to put in or to submit performance‑related data, and in our
case National Outcome Measurement data. So that\'s the purpose of
reauthorization.

Now again, it opens up Pandora\'s box, and you get a lot of conversation
that you don\'t want. So for example, even though we\'re not interested
in having ‑‑ first let me say that with regard to your discretionary
grant authority for CSAT, it\'s very generic, and CSAT has the authority
basically right now to do anything it wants to. However, Congress has
pet projects and pet issues that they want us to attend to. So I\'m
going to go through a small list of the kinds of issues that they want
to be able to bring up in this discussion.

Custody relinquishment. It\'s a mental health issue, but I\'m just
letting you know that there are situations in some states where parents,
in order to get mental health services for their kids, literally have to
give their kids over to the state so that they can go into child welfare
in order to receive the mental health services that they need. So
there\'s going to be a discussion about that.

There\'s going to be a discussion about services for older adults. I
mean, our own statistics suggest that this is something we should be
concerned about. Well, Congress is equally concerned about it, and
they\'re going to tell us exactly how they want us to do it.

Child welfare, particularly related to methamphetamine; methamphetamine
itself as a service. Despite the fact that the general numbers showed a
slight decline, meth remains a major issue for many, especially
representatives from rural districts. So there will be a lot of
discussions, though I would note that at our preappropriation hearing
there was not one question from anybody about methamphetamine.

Supportive housing and services, mental health and substance abuse
services for people living in supportive housing programs.

Workforce development, a major issue that will come up.

Accountability, which I\'ve just mentioned.

Mental health promotion and the prevention of substance abuse from
Senator Harkin.

Mental health services in schools.

Suicide prevention, and then the proverbial formula will be up for
discussion, and we will not be a part of that discussion, but I can
assure you that the winds of the formula are already blowing across the
corridors of the Senate and the House and there will be bloodletting
over the fight for some of the funds that will be appropriated for that
program.

So we will be brought into the debate on many of these issues, and
several others, as we go through reauthorization. It will start off with
a hearing which was first going to be on March 29, then it was moved to
March 23, then it was early April. As of yesterday, it looks like early
May now. So it will start in the Senate, and it will likely be a
hearing. Terry Cline will testify, and it will begin opening season. I
can assure you that right now the Senate HELP Committee are already
working on provisions to be included in that reauthorization package. So
if people are interested in contacting ‑‑ you can\'t contact on our
behalf, but if in fact you are talking to members, now is a good time to
have those conversations, largely because this is when they\'re putting
their stuff together.

Then it should not be a contentious debate. Except for the formula, I
don\'t know of any issue that\'s come up that\'s going to cause us to
have a contentious debate in the committee, in HELP Committee. For those
who recall, when we were reauthorized in 1999‑2000, the Senate did all
the work. Then when the Children\'s Health Act came up for
consideration, the House said, okay, we\'ll basically accept the Senate
bill without them ever having held a hearing or having had any
deliberations. The House just acceded to the Senate and the Senate bill,
almost word for word, was put in the Children\'s Health Act. I wouldn\'t
be surprised that the same thing would happen this year. I\'m not
suggesting or forecasting that it will, but the winds are correct, the
winds being that there\'s not a lot of controversy, and when there\'s
not a lot of controversy it makes it easier for bicameral cooperation to
go on. So I\'m looking into my crystal ball, but I wouldn\'t be
surprised if that happens.

So that\'s going to be the reauthorization process. Are there any
questions about that?

DR. SKIPPER: Who\'s on the committee?

MR. FAHA: The reauthorization committee?

DR. SKIPPER: Yes, as far as Congress goes.

MR. FAHA: You\'re testing my memory here, so let\'s see how good I am.
Senator Kennedy is the chairman, and the Democrats would include
Christopher Dodd from Connecticut, Barbara Mikulski from Maryland,
Harkin from Iowa, Jack Reed from Rhode Island, Sherrod Brown from Ohio,
Obama from Illinois, Clinton from New York, Bingaman from New Mexico. I
think that\'s all of them. On the Republican side, the ranking member is
Mr. Enzi from Wyoming, and it includes Senator Hatch from Utah, Senator
‑‑ they\'ve done a lot of changes over there, so it\'s Senator Coburn
from Oklahoma is a brand new one, Isakson, I think Sessions is still on
there. I think you\'ll find that anybody who follows the HELP Committee
that a lot of the health issues are typically Democratic issues, so many
of the Republicans just listen to their ranking member.

Pardon me if I\'m a little bit foggy on their membership. Does that give
you enough information about it?

DR. SKIPPER: I was just trying to feel out if because we\'re in a
presidential campaign, are there going to be pet issues that come up
from people who are ‑‑ you\'re saying there are no controversial issues,
so that won\'t change.

MR. FAHA: No, I don\'t know of any controversial issues, but that never
stops members from coming up with new ideas. Actually, there are two
ways of looking at that. If, in fact, they\'re generating new ideas,
because you\'ve got two presidential candidates on the subcommittee ‑‑
three, actually, Mr. Dodd, Ms. Clinton and Mr. Obama ‑‑ that if indeed
they are generating, that means our issues are in the press and are
important. So you get that, and we\'d love to see that. The other side
is we really don\'t want to see that, because that means we\'ve got to
deal with all these provisions.

However, you do bring up a point. We\'re looking forward to our first
hearing because it\'s undoubtedly that Ms. Clinton and Mr. Obama will be
at the hearing, along with Mr. Coburn, who is probably one of the more
conservative members of the Senate, and they have significantly
divergent opinions about what ought to happen. So I think it will be an
overcharged hearing.

DR. McCORRY: Could you give me an example of how these issues, any one
of them, gets translated into the reauthorization language, how you take
the wellness, the accountability, and somehow that gets traction and
it\'s going to be put into the reauthorization language that in some way
is going to shape the direction of SAMHSA in the future?

MR. FAHA: Sure. Any time we\'re being reauthorized, it\'s the process of
amending existing statutes. Now, our statutes are Title 5 and Title 19
of the Public Health Service Act and Protection and Advocacy for
Individuals with Mental Illness. Those three statutes govern everything
that we do. It\'s the language for our block grants, for discretionary
grants, et cetera, et cetera. So reauthorization is merely a process of
amending current statute.

What you\'re talking about is let\'s say that Ms. Clinton and Ms.
Collins have a provision on custody relinquishment, okay? So how it will
appear is that Title 5 of the Public Health Service Act is amended to
add the following subsection, and then it will be Section 599, Custody
Relinquishment, and that\'s in essence how it happens. It\'s no
different than you amending a speech or anything else with an add‑on. It
just gets added.

DR. McCORRY: But would it say, in custody relinquishment, that they
wanted to make that unnecessary in the future that parents have to
surrender children in order to get mental health services? So there
would be a position advocated in the language that says any child with
‑‑ I\'m just making it up, but any child with mental illness where
parents cannot afford it and must subsequently turn to public welfare to
receive services, SAMHSA should do this, that, and this about it?

MR. FAHA: No. I have a better understanding of what your question is
about. What they will amend are our statutes. What you\'re talking about
is amending welfare statutes, child welfare statutes, which in many
cases are not under their jurisdiction. So what the typical approach
would be is creating an authority for us, again an authority that we
don\'t need but they will create it, that will assist with that process,
okay?

DR. CLARK: And it may not get funded.

MR. FAHA: We have 14 authorities right now that have never been funded,
and in our reauthorization one of our proposals is to get rid of them.
It\'s not that the subject areas are not important, it\'s that they\'re
just taking up space because Congress is not putting money to them. In
addition, remember I told you that we have all the authority we need to
do anything we want to. So whether we get rid of a provision that
provides for the creation of emergency mental health centers, as an
example of one that comes to mind, Congress wanted to set up these
systems to deal with mentally ill individuals who were being picked up
by law enforcement and are being sent into law enforcement as opposed to
going into treatment, and they wanted to set up these systems so that
police could go there, get an evaluation and make a determination
whether or not treatment is appropriate, and to facilitate that
treatment. It\'s a good thing. However, no money has ever been
appropriated to it, and if we wanted to do that, we could do it under
current statute.

But you\'re bringing up a good point, and I may have mentioned this here
before. You\'ve got to keep in mind that General Motors can do anything
it wants unless statute says it can\'t, unless the statute places limits
on their flexibility, and it does so for very good reasons,
monopolization and other kinds of things. In the case of the federal
government, we can only do what the statute tells us we can do. So if it
says that you can produce red M&Ms, you can produce red M&Ms, but you
can\'t produce blue ones. But we have the authority pretty much as wide
as we can.

MR. DONALDSON: What I\'m hearing in Congress as far as a kind of growing
chorus is on the one hand the stewardship of existing resources, as Dr.
Clark put in his report, but the other is the leveraging of existing
resources. We\'re hearing this even in the speeches by the candidates,
the outreach to corporate, for example. A good example of that is the
GDA program in USAID. They appropriated \$1.1 billion through corporate
relationships, multiplied that three times ‑‑ Starbucks, Chevron, et
cetera. So I\'m wondering, with our strategy here, do we have any kind
of skunk works committee that\'s focusing on innovative ways to engage
corporate, leverage these resources? And two, with your approach to
Congress ‑‑ because I think that would be very endearing for them to
hear how we\'re multiplying these funds with these kinds of
partnerships.

MR. FAHA: You\'re presenting a wonderful situation that is a lose/lose
in many ways. You want me to go up and lobby Congress to tell them how
wonderful we\'re doing about getting money from the private sector, at
which point they immediately think in terms of, well, okay, then we can
reduce your funds. So it places us in a precarious position. I know what
you\'re saying, but there\'s a win/lose out of this thing, and believe
me, Congress is looking for ways they can not reduce services, yet at
the same time create a balanced budget. The Democrats are equally as
worried about that as the Republicans are.

Having said that, I don\'t know that we have ever ‑‑ are you going to
create an office in a university and call it a development office? I\'m
asking that facetiously.

DR. CLARK: I know.

(Laughter.)

MR. FAHA: I don\'t know. That\'s an interesting thought, though. I\'ll
bring it up for Terry\'s consideration.

Any other questions? I\'ve got a couple more things, and then I\'ll run
out of here as fast as I can.

The reentry. There was a hearing yesterday in the House Judiciary
Committee on reentry. As you know, what\'s being considered up there is
various ways of dealing with persons who have been in the judicial
system, both juveniles and adults, to provide services for them to
successfully get back into society. This bill that\'s going around
primarily gives funding and amends laws that pertain to the Department
of Justice, not to us, but we have been equally interested in this
subject largely because we have a lot of reentry programs and have been
supporting a lot of this through CSAT.

Heretofore, it\'s unfortunately not been something that we\'ve been able
to get active in largely because there\'s only so many ways I can be
divided. But I have hired somebody to help me with legislation now, and
she was at the hearing and will be thoroughly involved with the reentry
efforts, both in conjunction with our constituent groups, all of whom
seem to be supportive of the legislation that\'s going through, will
keep track of it for us. It is limited for the Department of Health and
Human Services to be really active considering that it isn\'t our
statutes being affected, but we can enter in and give technical
assistance and suggest that there be a lot more cooperation between DOJ
and DHHS. So that\'s that.

DR. McCORRY: Is there a dollar amount on this at all?

MR. FAHA: You know, I forget. There is always a dollar amount of some
sort, but I forget exactly what. My recollection is that most of it is
\"such sums.\" So that means it leaves it wide open.

The other thing that you may be participating in is parity with regard
to there being parity legislation coming out of the 110th Congress.
You\'re probably aware that the Senate committees, the HELP Committee,
passed legislation on parity some weeks ago that really was clearly just
a parity legislation. It was never intended to fix the problems that we
have with insurance companies related to substance abuse and mental
health services. It was only an attempt to create parity in the
considerations. Many substance abuse groups are very concerned about the
fact that while it does include substance abuse, in the Senate they
would like substance abuse to be much more pronounced in the
legislation. Let me be clear. The Senate bill includes substance abuse.
Whether it\'s out there in the title, whether it\'s out there in
anything, it does include substance abuse, and that\'s important to
remember.

The second issue is that it doesn\'t do anything about medical necessity
and utilization reviews that have typically caused problems for those
seeking insurance coverage for substance abuse treatment.

The third issue has to do with out‑of‑network coverage. The Senate bill
says that even if the plan covers mental health, and even if there is
out‑of‑network coverage for general and surgical benefits, that no plan
is required to have mental health/substance abuse out‑of‑network
coverage. So in essence what it would force, or at least it sets up this
situation where, yes, you get substance abuse and mental health
coverage, but it needs to be in some kind of in‑network, and if your
in‑network is not adequate and doesn\'t provide the options, then
there\'s no requirement that insurance plans create or cover those
services in an out‑of‑network facility.

The House bill is, first of all, much more pronounced than the inclusion
of substance abuse and addresses medical necessity and utilization
reviews to ensure that they aren\'t being used to reduce or to deny
coverage for mental health services, and also insists that if indeed
you\'ve got out‑of‑network coverage for surgical and general medical
procedures, that you must also have equivalent coverage for substance
abuse and mental health.

So, as you know, Congressman Patrick Kennedy and Congressman Jim Ramstad
and many other members of the House have been holding hearings
throughout the United States. We had one here in Montgomery County. Dr.
Cline went up and testified at one, and I would like to say that this is
the first time that an administration witness testified with regard to
parity, and he was selected to do that. So he is very honored in the
fact that he wants to be a spokesperson on behalf of parity. But anyway,
that happened on March 12, and there have been many efforts to promote
parity. You\'ve probably seen a lot of this stuff. If not and you
haven\'t had enough of it, then I recommend you go to Patrick Kennedy\'s
website. You\'ll get more than you need.

So that is going on. Right now, the House bill is much closer to the
Senate bill than it had been two months ago, but these issues are major
issues. Therefore, I\'m not sure as to what\'s going to happen.

Wes is giving me all kinds of signals that maybe I\'ve talked too long.
So are there any other questions that people may have?

DR. McCORRY: Not a question, but I just wanted again to say thank you.
It\'s the kind of presentation that gives me, as a member of the
council, a real kind of review or a view of the scope of work around
legislation and appropriations that\'s really helpful. So I appreciate
the presentation, and I encourage keeping you on the agenda because it
keeps us informed.

MR. FAHA: Wait a minute. Can I say something about that?

(Laughter.)

DR. CLARK: Thank you, Joe Faha. It sounds like your comments were really
appreciated, and we certainly appreciate you taking the time to be here.

MR. FAHA: Thank you for inviting me.

DR. CLARK: With that, are there members from the public who would like
to address council? If so, could you please come to the standing mike
and give us your name and the name of your organization, if you do have
one?

(No response.)

DR. CLARK: Going once, going twice, no public members. Then we can
attend to a bit of housekeeping.

Our next business on the agenda is to vote on the minutes from the
September 20, 2006 meeting. Hopefully you\'ve had an opportunity to
review the minutes. I will now entertain a motion to adopt the minutes.

DR. SKIPPER: Move that they be accepted.

MS. JACKSON: Second.

DR. CLARK: It\'s been moved and seconded to adopt the minutes.

Is there any discussion on the minutes?

(No response.)

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

(Chorus of ayes.)

DR. CLARK: Any opposed?

(No response.)

DR. CLARK: The minutes are adopted.

Obviously, as we talk about the reintegration of substance abuse into
the health care delivery system, the primary health care delivery
system, there are a number of issues that need to be addressed. One of
the topics is substance abuse treatment services for individuals with
disabilities.

Ruby Neville, CSAT\'s lead with respect to services for individuals with
disabilities, will provide us with an update on what she and her
colleagues have been doing with regard to this important initiative
since she addressed the council at its September meeting.

Ruby?

MS. NEVILLE: Thank you, Dr. Clark.

Good morning. At the last NAC meeting, of course, I presented to you
some of the needs of individuals with co‑existing disabilities. But
today, as Dr. Clark mentioned, I\'m just going to give you a real quick,
brief update, so there\'s no PowerPoint presentation to go along with
this.

One of the things that we have done since our last meeting with you is
that we have a regular monthly conference call with experts in the
field, the field of individuals with co‑existing disabilities, and some
of the things that have come out of those conversations, I\'m going to
discuss those with you now. One of the biggest issues is that of the
traumatic brain injured individuals who have substance abuse needs. This
has become a significant problem for the treatment providers as far as
learning how to provide evidence‑based treatment for these individuals.

I want to also, before I go on to that, I wanted to give you the names
of the individuals who are supporting this conference call discussion
from the field. We have Ken Perez from New York, the Office of Addiction
and Substance Abuse Services. Of course, Cynthia Graham is participating
with us in that. Jacqueline Hendrickson from OPT and CSAT; Dennis Moore
from the SARDI program with Rice State University in Ohio; Debra
Guthmann from the California School of the Deaf; Deborah Larson‑Venable,
executive director of the Granada House in Massachusetts, and she is a
consumer; Harry Kressler, the director of the Pima County Partnership in
Tucson, Arizona; and we have also a potential participant, Dr. Francis
Sparadeo, and he\'s been working in Rhode Island and has specialized in
traumatic brain injury. That has not been confirmed as yet, but that\'s
a potential participant.

So regarding this topic on TBI, if you look at some of the quick stats
you\'ll see that as far as U.S. hospitalization rates, it\'s on the
rise. Actually, the Centers for Disease Control has also stated this,
that TBI is on the rise. If you use the most recent available data,
there was a report published in the March 2 issue of the Morbidity and
Mortality Weekly Report, and it showed that overall TBI‑related
hospitalization rates increased from 79 per 100,000 in 2002 to 87.9 per
100,000 in 2003. So again, the CDC is also estimating that at least 5.3
million Americans currently have a long‑term or lifelong need for help
to perform activities of daily living as a result of TBI, so it is a
significant problem.

Some of the other discussions in regards to the group, those out in the
field are saying there are still attitudinal issues, of course, there
are some discriminatory policies and practices, there are some
communication barriers, architectural barriers, and of course, as there
always is in the behavioral health care field in general, there are
funding barriers. As far as with the disability community itself, they
often do not refer these individuals to substance abuse treatment, and
they are in need of such.

Additionally, our group has mentioned that there\'s a need to modify
TEDS data to be more inclusive of individuals with disabilities, develop
fact sheets on individuals with these disabilities, brochures for the
deaf and hard of hearing, TBI, MR, and the developmentally disabled and
the blind. They\'ve also recommended that we develop a TIP on the deaf
and hard of hearing and to increase capacity for individuals through
training and TA, for individuals to actually serve these populations.

There was a recommendation to develop a listening session in this area,
and one of the final recommendations was to include extra scoring points
on RFAs for potential grant solicitation, targeting treatment services
to individuals with co‑existing disabilities.

So in the midst of some of the financial constraints as far as what we
have done here in CSAT, there has been technical assistance provided to
state systems, and actually in DSCA they will be reviewing TA needed for
states who are seeking to develop infrastructure to provide substance
abuse treatment for persons who are deaf.

The other thing is that four members of the disability conference call
work group, they will be participating in the DSCA state systems
technical assistance program to actually be experts to provide TA to the
states that need to enhance their capacity to serve individuals in this
population. They would be Dennis Moore, as I mentioned earlier, Debra
Guthmann, and then also we have a potential person here again, Dr.
Sparadeo, who is a TBI expert, and then Ken Perez.

If you look at some of the SAMHSA data for 2004, the N‑SSATS showed that
3,886, or 29 percent, of the U.S. facilities provide services for
hearing impaired with sign language capabilities. Another 2,468, or 39
percent, have on‑call interpreters.

Something else we have done, as you know, CSAT supports the ATTCs, and
the Gulf Coast ATTC has recently developed its first American Sign
Language video, and this is to actually screen the deaf for drugs and
alcohol abuse. This was created with input from the deaf community
itself, actual deaf experts in their field, and it has shown to have
good reliability, and also validity. Some of the contents would include
start‑up information, frequently asked questions about drug and alcohol,
assessment for the deaf, and there is an answer sheet, and also
psychometrics of the data itself.

If you look again at some of the TEDS data and you look as far as those
in the labor force, there are 40 percent age 16 and above who were not
in the labor force. Out of that group, 26 percent were actually
disabled. Of course, they have substance abuse issues just like those
who do not have a disability. 40.3 percent are using tranquilizers, 40
percent heroin, 34.5 percent alcohol, and 30.5 percent smoke cocaine.

So we continue also to assist the youth who have co‑existing
disabilities. We need to help them to access substance abuse treatment
services. Again, these discussions have come from our conference call
group, but in addition, regarding some work that SAMHSA is doing with
the Administration for Children and Families, there is this
collaboration with ACF\'s Family Support 360 Program and the SAPT block
grant. Basically what it is is I was able to get the 360 Program. It\'s
a family support program. They provide services to individuals who have
developmental disabilities, but they also support the family members. So
if they have human service issues, whatever they are, they will refer
them to the appropriate human service agency. So we were able to swap
those lists. The SSA list we gave to ACF, and the 360 Program, we gave
it to DSCA to increase some type of collaboration between those two
entities. There\'s not a lot of money, but there are some things we can
do, even during this time of budget constraints.

Also in SAMHSA, we have the Cuyahoga County. They have a Strengthening
Communities\' Youth grant, and also a Systems of Care grant from CMHS.
The whole purpose of this is to provide treatment for youth with
co‑occurring mental health and substance use disorders. They are working
with the University of Akron in the ongoing development of integrated
co‑occurring treatment models.

So the reason why I included this one in here is because I know when you
think of co‑occurring, you think of mental health and substance abuse.
However, this model, they had the idea that these individuals had
multiple co‑occurring conditions. So it conveys a preference for using a
multiple co‑occurring conditions perspective when you\'re serving these
individuals. So it\'s not just mental health and substance abuse. It
could be substance abuse and many other types of disabilities that will
be associated with that.

Also, SAMHSA is working in partnership with the Department of Labor\'s
Employment and Training Administration and other agencies to support
DOL\'s ETA ‑‑ that\'s the Education and Training Assistance Program ‑‑
through the Shared Youth Vision Program, and that basically is to help
youth at risk who may have substance abuse and mental health issues to
get the services they need. Larke Huang actually is working with that,
and I\'m supposed to support her with that as far as looking at the
substance abuse, keeping that component in there too, to address those
needs for those individuals.

That particular program is called the Shared Youth Vision Federal
Collaborative Partnership. Some of the agencies that are participating
in that are the U.S. Department of Agriculture, Education, of course
HHS, ACF and SAMHSA, HUD is also participating, Justice, Labor,
Transportation, Social Security Administration, the Office of Program
Development and Research, and the Corporation for National and Community
Services.

I also wanted to speak to you briefly, and this will be it for me for
the day, about the disability as secondary condition. There was a
progress review relating to Healthy People 2010 that took place November
16, and I attended that particular meeting. There was a take‑home
message, and it was to include people with disabilities in
population‑based surveys, include people with disabilities in mainstream
health promotion efforts, and gather evidence for interventions
targeting people with disabilities.

I\'m currently having discussions with the SAMHSA Healthy People 2010,
and now 2020, representative, and we are trying to help out as far as
ensuring that we have measurements for substance abuse as well as mental
health for Healthy People 2020. The goal in Healthy People 2010 was to
promote the health of people with disabilities between secondary
conditions in this particular focus area, and eliminate disparities
between people with and without disabilities in the U.S. population.
Some other activities I\'m looking at right now is to pursue discussions
with CSAT and SAMHSA staff to include measurements for the disabled
community.

Also, I wanted to mention to you that Dr. Moore, Dennis Moore, who again
is from Rice State University, and again he\'s with the SARDI program,
he will present in June at the NAC meeting. So he\'ll give you more
information regarding what he\'s finding. He\'s done a tremendous amount
of research in the field around individuals with co‑existing
disabilities, and he will be available again in June to present that
information to you all.

That\'s it.

DR. CLARK: Thank you, Ruby.

For council, do you have any comments or questions you\'d like Ruby to
address?

Frank?

DR. McCORRY: Thank you, Ruby. Two quick comments, I guess, and a
question or a suggestion. They\'re kind of related. We had done a TBI
small study as part of our practice improvement collaborative in New
York. It was through Mt. Sinai in the city, but it was an upstate set of
providers who were interested. Sure enough, tremendous positives on the
TBI screen that they were developing and validating, which led providers
and CEOs to get really concerned because there were no psychologists
available to do the follow‑up assessment on the positive screens. So
they started to feel this vulnerability around having something in the
record that they weren\'t able to address in the treatment plan. So one
issue is capacity.

The related comment on it is when you think of the fact sheets, I\'m
thinking is there a way to do something ‑‑ I believe there\'s a TIP on
this, but is there a way to do something basic? Every provider has
people with traumatic brain injury on their caseload. Clearly, that\'s
sure. So are there things that can be implemented that are more
sensitive and responsive to people with those kinds of impairments,
cognitive impairments, that\'s just a matter of kind of restructuring
the way you help someone to schedule their appointments that might be
practical that could receive wide dissemination? And not so much around
informing, not the fact of its prevalence, but more like TIPs where we
could say, okay, let\'s do things this way, because for those we might
not want to diagnose, or we can\'t diagnose because we don\'t have the
capacity, but let\'s start to structure our program to allow this
responsiveness to the population.

MS. NEVILLE: Well, first of all, that first question, I remember that
came up at the earlier NAC meeting. Again, that can be a problem. As I
mentioned at the earlier NAC meeting, that\'s why it\'s so important for
us to engage in regular discussions around this topic, participate in
existing listservs, if there are any, to respond to those types of
questions, because there are folks out there who are successful in
having the right expertise available to address these individuals\'
needs. There needs to be some form of communication so we can make
others aware of what\'s available.

As far as developing the right type of evidence‑based treatment and
screening instruments and all of that, that\'s one of the reasons I\'m
having the discussions with ‑‑ actually, Dennis Moore has been working
with TBI, as well as Ken Perez. But most recently I found out that Dr.
Sparadeo, that\'s all he\'s done for 10, 15, 20 years, working with the
TBI. In having discussions with him, he is very familiar with what
works, because actually he\'s working with folks who have the TBI, as
well as some returning veterans who have those issues.

So it\'s folks like that, we want to get their information and we want
to share it with everyone else so that they can become familiar with it.
Obviously, I\'m not doing direct service, but I\'m familiar on the macro
level with what\'s going on, and that\'s the whole purpose of having
these conference calls, because we want to ensure that we get the
message out there. So a question like you have, that can be resolved,
and there are folks who are doing it. Somehow, maybe through the SAMHSA
newsletter or whatever, posted on websites ‑‑ Anne Herron has taken the
lead on the technical assistance that\'s going out there in the field
when we do have funds available, and we have these people who are
experts, and hopefully Dr. Sparadeo also can be involved in this, and he
said he would be willing to participate. We just haven\'t gotten it
approved yet through Dr. Clark and everyone else. But those folks have
that information for you. So I would think that providers can, when the
funds are available, if they are right now. I don\'t know because I\'m
not involved in that area, but they\'re there to provide that type of
expertise for providers, as well as on the state level.

DR. CLARK: Anybody else?

(No response.)

DR. CLARK: Thanks again, Ruby. We look forward to a more detailed report
at the June NAC meeting.

I also want to echo Ruby\'s reference to returning vets. As you know,
TBI is an evolving issue in our veteran population. Since some of our
treatment programs may be dealing with individuals from the National
Guard or Reserves who return, we need to have a better understanding so
that we can work with the VA and DOD on this issue, since they have the
primary mission. Nevertheless, individuals with military or combat
experience will show up in our treatment programs.

We\'ve set aside the next half hour to have an open forum for you to
talk to us. So far this morning you\'ve listened to us, and I think
it\'s only fair that we listen to you. So I\'m particularly interested
in your thoughts about the priorities for CSAT as we look forward to the
FY \'09 budget. The formulation process will be underway shortly, and
now is the time for us to receive your input because there is an embargo
on the process once the process becomes formalized and the process
becomes more tightly controlled. So we want you to feel that you have a
voice, and the council roundtable provides us with the opportunity to
put topics on the table.

Any thoughts? Comments? Val?

MS. JACKSON: Thank you, Dr. Clark. I appreciate the opportunity to
discuss this, and I thank you.

I had a question about the discussion that is to be had on the formula.
When that discussion comes up, is there anything that SAMHSA is
proposing to change at this point? What kind of rumors are out there?
That can always get to be a little Pandora\'s box in and of itself, so I
wasn\'t sure if I should ask the question, but I thought I\'d just throw
it out there.

DR. CLARK: The formula is basically something that the Congress is going
to deal with. They\'re the ones who came up with the formula, and
they\'re the ones who are going to have to negotiate the components of
the formula. So when you\'re not officially a member of the council,
which is the rest of the time of the year, that\'s an issue that you
should address at your local level, because indeed the struggle about
the formula is basically going to be between states. So I want to
encourage you to address it there.

MS. JACKSON: I understand. I think what I was asking more was that there
are certain set‑asides on particular populations and so on, and I guess
I felt that SAMHSA did have a hand at some point in suggesting certain
set‑asides in the past. Am I wrong about that?

DR. CLARK: You\'re distinguishing the formula versus the set‑asides.

MS. JACKSON: Which is a part of the formula. I am distinguishing that,
yes.

DR. CLARK: Rich, do you want to say something?

MR. KOPANDA: Well, with respect to the formula, SAMHSA historically and
this year is not taking a position. We have in the past made some
recommended changes to the set‑asides, particularly with the 35/35/30,
if you know that, but as far as I know, this year SAMHSA is not
recommending any changes to that aspect of the formula, or of the
set‑asides.

DR. CLARK: I\'m not aware of any.

Any other thoughts? Greg?

DR. SKIPPER: I just want to bring up my thanks and appreciation for the
advisory that went out regarding alcohol markers. I believe it\'s had a
tremendously positive impact. I\'ve had far fewer complaints and calls
and concerns. I think it was very effective, and I appreciate your
efforts in that regard.

DR. CLARK: Thank you. Obviously, the issue continues. We know that
people are very much concerned about trying to measure alcohol. Our only
thing is making sure that whatever they do, they do the right thing. I
appreciate your contribution and council\'s contribution. I think it\'s
an important thing to recognize that that was a substantial contribution
that was picked up by a wide range of media and has had a positive
impact.

DR. SKIPPER: In that regard, especially with the news recently about the
high rate of binge drinking on college campuses and so forth, I do think
that this kind of test that discovers recent alcohol use for people for
whom it\'s illegal or inadvisable to be drinking could be a very
effective thing, and we need more research to more clearly define that.
Today there\'s really been no funding, and I know we don\'t fund
research here, but if there\'s anything that we can do to encourage
that, I think there may be some opportunities coming. But it really
needs to happen, because I believe that drug testing is a very effective
deterrent. Addiction thrives in secret, and when we can test people ‑‑ I
know there\'s this question of civil liberties and all that, but as you
might have seen on the news, New Jersey schools have started using EtG
testing for kids, and I think it\'s a good thing. But we just have to
have common sense, and we need more research on this. Thanks.

DR. CLARK: Frank?

DR. McCORRY: I wish when I was speaking with Administrator Cline this
morning, I wish you had said, because you said it so much better than me
around this issue of systemic improvement. I know it\'s probably hitting
that horse one too many times, but one more time on this culture of
performance, and I\'m relating this to the executive budget and the
three elements of it, the outcomes that you see in NOMs, and the two
other elements of performance improvement, which has both a quality
improvement and a process improvement, a business practice, and finally
measurement, that if you want to have a culture of performance, we have
all the elements there in terms of NOMs, a performance improvement
delineation of quality and process improvement, and we have measurement.
The quality and performance improvement aspects, though, in measurement
are really out of this budget. NOMs is in this budget and projects are
in this budget, but the performance improvement as defined by quality
and process improvement, that element of this triad of culture of
performance and measurement are really out of this budget, and it\'s a
very minimal amount of money involved here.

But to me, that adds up to setting an expectation on providers and
states without addressing the capacity to meet the expectation. You can
always say payers, well, we just want the outcomes, you guys figure out
the rest, but I don\'t think, particularly in a block grant environment,
particularly when states and providers are so dependent on the federal
government for delivering substance abuse services, I don\'t think the
federal government can step back and say we\'re just payers, give us the
outcomes we want and that\'s all we\'re interested in.

The other two pieces of that triad have got to be as integral to the
outcomes initiative, and that is performance improvement as defined by
quality and process improvement techniques, and the development of
measurement that helps inform the quality and performance improvement
activities.

In a hospital environment it\'s less important because of Medicaid and
other kinds of services. There\'s an ongoing funding relationship, or
there\'s an institutionalized funding that doesn\'t rise and fall based
on congressional whims as much. In a block grant environment in which
whole state systems are limited to or defined by the money that CSAT
gives them in terms of treatment, to assert one without developing a
capacity for the other is just, to me, really short‑sighted and really
not in keeping with the kind of relationship that has to exist between
provider states and the federal government to actually improve care.

So again, a long‑winded way of saying it, but to me it\'s just
wrong‑headed to assert an outcomes measurement initiative that does not
include a dynamic and involved quality and performance improvement
capacity and a strong measurement capacity.

DR. CLARK: I appreciate your comments. I actually agree with the
importance of quality improvement and process improvement as a part of
performance improvement. One of the things that we\'re trying to do is
to operate with the limited resources that we have at our disposal, but
you are very much correct. We did support NIATx and STAR as a result of
that, and indeed we believe that those kinds of efforts actually enhance
the ability of programs to operate in a cost‑conscious environment. I\'m
fond of citing the Tarrows project that I visited in Phoenix. Fewer
dropouts means less resources diverted to assessments and more resources
are targeted toward increasing outcomes as a result of the intervention.
The point I\'m making is it costs a lot of money to assess a person
every time that person drops out and you assess another person. That
person drops out and you assess another person. Much of your resources
are spent at the front end. In order to be careful, you wind up using
far more sophisticated staff during the assessment process, but there\'s
no take if the individual is not engaged. So in essence, you\'re losing
a lot of that money. If you only retain 50 percent of the people you
assess, then you\'ve lost a lot of money because that person is
generally lost to follow‑up.

Part of the NIATx effort was, well, gee, how do we keep these people
engaged, how do we avoid no‑shows, how do we keep them long enough for
the program to begin to have an effect. So these are things that are
critical in terms of the service delivery system. Otherwise, the cost
bands are going to be distorted and the average outcomes won\'t be
nearly as impressive as they could be if we don\'t invest in trying to
discover more about the dynamic of service delivery, and most treatment
programs just don\'t have the resources to focus on that. They will do a
good job with whatever strategies that they have, but the state of the
art never changes, and in a cost‑conscious environment we want that
state of the art changing, and we want business practices changing. If
we don\'t change those things, then we may be losing funds that we could
squeeze out of the process by enhancing effectiveness and efficiency in
the delivery service. So I agree with that.

Dr. Fletcher?

DR. FLETCHER: CSAT has heretofore assumed a leadership role in terms of
addressing substance abuse and higher education, particularly among the
HBCUs, and with the demise of the Mitchell program, will there be a
continuing involvement particularly around the national survey of HBCUs
that you\'ve done heretofore that provided an invaluable source of data
on this population group that has been used by many of those
institutions, as well as those who have been doing research in that
area? Will there be a continuing involvement at some level?

DR. CLARK: As we look at the budget, the HBCU initiative would not be
continued in the \'08 period. So, of course, that is a concern, and we
would have to look around to see where else in the federal government or
the state and local communities that focus is being maintained. It\'s
also the Minority Fellowship Program, which goes beyond HBCUs. It
involves the Hispanic community, the Asian communities, and the American
Indian and Alaska Native communities in terms of individuals who are
interested in careers in mental health and substance abuse disorders.
That initiative will be discontinued. So social workers and
psychologists, psychiatrists and marriage and family therapists and
others would not have those additional resources should this process be
endorsed by the Congress. So we\'ll just have to adapt to changing
circumstances should the Congress agree with the proposal.

MS. BERTRAND: Dr. Clark, during your presentation, I noticed that the
Partners for Recovery and the consumer affairs education line items are
eliminated as well. What do those line items actually pay for?

DR. CLARK: Well, the Partners for Recovery helps facilitate a number of
activities, including some of our leadership institutes and some of our
outreach. So we would not have resources for the leadership institute.

One of the things that is implicit in some of the efficiency of our
system is having managers who have some sophistication. When you\'re on
a shoestring operation and your manager\'s got two weeks more seniority
than your service provider, than your counselor, then you\'ve got a
problem. Your hope is that you\'ve cultivated enough managers and you
not only know how to make the thing work in paying salaries and doing
billings and hopefully writing grants, but also providing management
supervision to the staff and leadership so that they\'re operating not
only for their program but for the community in the community, working
with cities, states, tribes, trying to address the issue of substance
abuse disorders or mental health disorders, forging relationships with
other entities in the community.

Those of you who work in communities know that it\'s a lot easier to get
business done if you have an operating relationship with other providers
in the community, and they\'re often reluctant to get out of their lane
if they don\'t know who you are and they don\'t know what you\'re about
and they don\'t know how reliable you are, and they ask what\'s the quid
pro quo. With some leadership and adequate sophistication, they know
what the quid pro quo is, and they know that you\'ll be there for them,
and therefore they\'ll be there for you, and that sort of thing. That
gets lost when you lose that leadership.

George?

MR. GILBERT: If I could, Anita, I just wanted to expand a little bit on
what Wesley said about the PFR program. We have supported the leadership
institutes, and we\'re continuing to do that. PFR has also supported the
Recovery Summit a couple of years ago, and we\'re now at the stage where
we\'re going to start rolling that out through some regional meetings.
Those kinds of things would have to be discontinued. We supported the
development of the \"Know Your Rights\" brochure, which was used for
some very successful meetings at the state level to make people aware of
rights under federal law and corresponding rights available under state
law to people that are in treatment or with histories of substance use
disorders in terms of employment discrimination and housing and things
like that. We\'ve also sponsored briefings for state legislators on
performance measurement with regard to treatment, and those have been
very well received.

So there have been a number of things that we\'ve been able to do with
those limited resources to try to promote notions of recovery and
recovery‑oriented systems of care, working on anti‑stigma efforts,
working on leadership training and workforce development efforts. We
supported the production and the development of the CSAT Workforce
Development Report. Those are the kinds of things that PFR has been able
to move forward.

In the consumer affairs area, the big thing that is going to be lost
would be the annual Recovery Month, which some of you may actually be
serving on the planning committee that Yvette Torres has. That\'s an
annual campaign, and of course she\'s presented on that many times. But
that would also be an activity that would be eliminated under the 2008
budget.

MS. BERTRAND: As I look at those line items, it seems like we\'re going
to have to continue to look at workforce development issues, because I
think that when we talk about looking at recovery‑oriented systems of
care, Recovery Month gives us an opportunity to actually celebrate the
work that we do, and I think there are so many individuals in our
community who do not know the work that we do or see the success. So I
think that communities will still be able to hopefully organize some of
the events, but when I think about workforce and recruiting new people
into the profession, we\'re going to have to think about creative ways
to make that happen.

DR. CLARK: Thank you.

Val?

MS. JACKSON: The question that I was going to ask previously really
related, in a sense, back to ‑‑ I think you made mention of the
returning veterans and the TBI. I think certainly in our news, and I
think it was national news, there seems to be quite a bit of attention
coming to that now, and also just recently I believe there was a news
item about methadone being prescribed and sent home as a painkiller to a
number of individuals, some of whom are now no longer with us either
because of accidental overdose or whatever happened.

It\'s a tragedy, and I wondered if this is handled totally separate from
SAMHSA, and is that over in the veterans department. I mean, how does
that work?

DR. CLARK: The care of veterans ostensibly is the jurisdiction of the
VA. Not all veterans go to the VA, so SAMHSA has a safety net supportive
role. We had a meeting on this issue. Arnie Owens is the SAMHSA lead on
this, and he\'s working with DOD and the VA so that we can establish the
appropriate role for SAMHSA in this process. We\'re very much concerned
about veterans. Again, not all veterans receive services from the VA or
DOD, and they go to community providers, and those providers need to
have adequate resources to address the unique needs of veterans. That\'s
one of our concerns. We will be working on that, and Arnie\'s got some
thoughts about how to increase this partnership because, as you know,
there have been a number of problem areas identified in the media that
the administration is trying to address so that we make it quite clear
that we support our returning veterans. They\'re heroes who deserve the
best that this nation can give them.

With regard to the methadone overdose deaths, we are also very concerned
about the use of methadone in terms of pain. We don\'t regulate the
practice of medicine, but Bob Lubran and his group ‑‑ Bob is in the back
‑‑ plan to have a meeting. So we work with pain docs to address the use,
the adequate education of practitioners about the use of methadone. I
mean, some of you are aware that we\'ve used methadone for years and
years and years and years when it was unattractive to the general health
care delivery system. It was basically reserved for opioid
medication‑assisted treatment, no problems. The occasional overdose
death, no problems. Suddenly, when the OxyContin scare came,
practitioners started diversifying, and I think also some of the
cost‑conscious issues, people started diversifying.

They were saying, oh, yes, methadone is a pain medication, I\'ll just
use it the way I use any other pain medication, and we think that that
thing has turned out to be a nightmare for a number of individuals,
particularly when you\'re dealing with complex cases, individuals with
substance use histories, individuals with other psychological problems,
and then practitioners don\'t seem to be as sophisticated with that
population. The veteran issue that you\'re describing, there have been
recent reports describing individuals who have complex presentations,
not just pain, not just PTSD, but a wide range of pain, PTSD and
substance use disorders. That creates the need for those practitioners
who are providing the prescriptions to have a lot more sophistication
than they would for a person with \"simple pain\" or a person with
\"simple PTSD,\" should we actually have that. So you\'re right.

We are working with that. Bob and his team will be having that meeting
sometime this spring or summer.

Greg?

DR. SKIPPER: I just want to comment on that because we did a methadone
mortality conference that you put together a couple of years ago. It was
great. But my thinking is that the issue really is long‑acting opioids,
no matter what they are, whether they\'re methadone or OxyContin or
whatever. There\'s really no data that I know of ‑‑ tell me if I\'m
wrong ‑‑ that shows that long‑acting opioids are more effective for
treatment of pain than shorter‑acting opioids. They just have to be
given a little more often, and there\'s a lot more risk of death,
particularly in opiate addicts or substance‑abusing children who get a
hold of these drugs. There\'s a lot more risk of death from the
long‑acting opioids.

For example, when the FDA was looking at releasing paladone, the
long‑acting ‑‑ what\'s it called? ‑‑ hydromorphone, Dilaudid, it was a
very potent long‑acting opioid, Dilaudid. I was involved in testimony on
that, and there was real concern that anytime you have a drug where one
tablet can cause death in a novice user, you\'ve got a dangerous
situation. So kids getting a hold of these things can be pretty
dangerous because they take the drug, they don\'t get an effect right
away, they take another one and another one, and then they\'re dead
eight hours later.

So I think from the point of view of substance abuse, we should really
oppose long‑acting opioids. It\'s really just a convenience as far as I
can tell for chronic pain patients. They get just as much good from the
shorter‑acting ones, and they possibly are a lot less prone to causing
death.

Anyway, I\'d like your opinion on that.

DR. CLARK: We\'re going to have the meeting, and we are also having a
panel at the American Pain Society meeting. So rather than speculate, I
think your considerations are the considerations that we\'ll also
incorporate in the deliberations we have with the clinicians in the
field. Clearly, something is awry. You\'re correct in terms of our fear
that young people get a hold of these medications. The data show that
with regard to non‑therapeutic use of prescription meds, people get
those meds not from drug dealers, not from the Internet, but from
friends and family. Sixty percent of those drugs are got from friends
and family. So if you\'ve got a bunch of paladone sitting on the shelf,
or if you\'ve got one of these new devices sitting unwrapped and someone
dies and leaves medication unattended, then those things get diverted
and we need to address that.

But because this is the practice of medicine, we need to do that in
concert with the medical community and organized medicine. Our principal
focus is the misuse of these medications requiring treatment and
prevention strategies to deal with that. So it is in our best interest
to work with the prescribers, to work with the medical community so that
we can come up with appropriate standards and appropriate advice so that
we can hopefully reduce that. But it is a major issue.

DR. SKIPPER: Just one final point of clarification. I think the meeting
should be about long‑acting opioids and not just restricted to
methadone, because they all have potential problems, whether it\'s
fentanyl patches, which are eaten or whatever, and that causes death, or
OxyContin or anything otherwise that could be a concern. It\'s not just
methadone.

DR. CLARK: Well, that agenda hasn\'t been fixed in stone. Bob Lubran is
back there listening and nodding his head. We appreciate your input and
we\'ll incorporate your themes into that meeting. We\'ll point that out.

Dave Donaldson.

MR. DONALDSON: George, you\'re talking about the removal of the Recovery
Month, the consumer affairs education, which encompasses Recovery Month?
What else is out? What else does that include, consumer affairs
education that\'s being cut?

MR. GILBERT: It\'s basically the entire consumer affairs activity.
Recovery Month is the largest portion, I think, of what Yvette\'s
activities are, but she also does other campaigns. She sponsors and
supports the annual Inhalant Week that SAMHSA is involved in. She has
campaigns on prescription drug misuse aimed at older adults and youth.
I\'m trying to think of what some of the other ‑‑ she has a group that
‑‑ Bob, you would know about this. She has a group that you worked with.
It\'s the opioid consumers group.

MR. LUBRAN: She calls it the Patient Consumer Support Education Project.

MR. GILBERT: The Patient Consumer Support Education Project. Can you say
a little bit about that, because I\'m not totally familiar with that.

MR. LUBRAN: Just briefly, this is a group of primarily patients and
families who are involved with methadone treatment and come together
periodically to talk about educational initiatives focusing on patients
and consumers, and we\'re meeting March 30, actually, to talk about the
issue of methadone‑related deaths.

MR. DONALDSON: Does it include, though, the ad campaign that Dr. Cline
referred to earlier?

MR. GILBERT: No, I think he was referring to the ONDCP partnership
campaign.

MR. DONALDSON: Is that still in the budget?

MR. GILBERT: Well, that\'s not our campaign. That\'s funded through the
Office of National Drug Control Policy.

MR. DONALDSON: So out of this agency here, is there any consumer
affairs, or is that all being cut?

DR. CLARK: Again, those activities are slated for cuts, and some of our
faith‑based activities are slated for cuts.

MR. DONALDSON: Because I agree with what Anita said. I\'ve been involved
in that Recovery Month. Besides the obvious education that it provides
to the general public, it does highlight the good work that CSAT does.
Three, I think it\'s been a great entry point for faith‑based,
community‑based groups that are not going to get involved right away but
they will participate in some kind of public affairs campaign. So just
based on reports that I\'ve heard in here and my own participation, I
think it\'s been highly successful and I\'m personally disappointed that
this is being cut.

MR. GILBERT: Well, I\'ll speak for myself. I share your disappointment.

MR. DONALDSON: I understand balancing the budget, too, believe me, but I
think this is back to what I talked about, multiplying and leveraging
resources, and you can do it especially through the media.

DR. CLARK: Dr. Fletcher?

DR. FLETCHER: Just a very quick question. Would you clarify if this
includes your TIPs, those publications that come out? Are they included
in the cut?

MR. GILBERT: Those are in the CAPT program. The CAPT line includes our
TIPs and those publications.

DR. FLETCHER: How sad.

DR. CLARK: We\'re going to have more time for roundtable discussion this
afternoon, but I won\'t be here. I\'ve been called away. So Rich Kopanda
will be chairing the meeting for this afternoon, but I will have lunch
with you.

Before we depart, let me thank the staff and the contractors. I want to
thank the staff for coming, taking time out from their busy day to be
here. I want to thank, again, Cynthia Graham and your contractors.
Everyone\'s got busy schedules. I think people needed to hear your
concerns about the budget, and we will move forward on this. Thank you
very much.

So let us adjourn for lunch.

(Whereupon, at 12:02 p.m., the meeting was recessed for lunch, to
reconvene at 1:30 p.m.)

[AFTERNOON SESSION]{.underline} (1:35 p.m.)

MR. KOPANDA: Good afternoon. I would like to get started this afternoon.
I trust everyone had a nice lunch.

We\'re going to deviate a little bit from the agenda because there have
been a number of questions come up on the 2008 budget and on the
presentation this morning, and I think it might be possible to have a
little bit more discussion with the council. We have a little bit of
time in our first presentation, which is on ATR, Anne Herron. Jack Stein
said that their presentations are fairly short, although we\'ll still
leave time for questions at the end of that. But we wanted to just put
up a couple of the slides, clarify some things, and George is going to
mention a couple of things on the budget. If there are any follow‑up
questions from this morning\'s discussion, we can address them.

The one thing we wanted to point out is that it was not clear in some of
the slides that the dollars were in thousands, which meant we were
looking at millions when we were looking at the slides.

MR. GILBERT: There were apparently a few things that might have been
confusing this morning, maybe more than a few things, so let me go back
to some of these slides. I want to make clear in this slide that this
slide is showing the discretionary program funding, not the entire
funding for the centers. So the \$352.1 million for \'08 is just the
discretionary programs.

Then this slide is showing the entire CSAT budget, if you will, and you
see the Programs of Regional and National Significance. That\'s the
discretionary line, and you see all the way in the right‑hand column
\$352.1 million consisting of \$339 million in the capacity programs,
which is our major services programs, like Access to Recovery, drug
courts, SBIRT, et cetera; and then the science‑to‑service programs,
\$13.1 million, and those are things like the ATTCs and the CAPT
program.

Then I think these slides showing programs that were eliminated, I want
to point out in the small printout in the upper right‑hand corner
dollars in thousands. All of these slides are showing you dollars in
thousands. So it\'s actually millions of dollars. For CMHS children\'s
programs, there\'s \$8.2 million in program activity that\'s being
eliminated, and going down to the CSAT slides, this display, the various
lines equate to lines that are in our budget document that goes to
Congress, the CJ if you will, the budget bible. There\'s a page in here
called the SLOA tables, Summary List of Activities, and these lines
relate to lines in that table. Then what Dr. Clark was trying to show
you was the summary, and then how that breaks out. So, for example, for
the STAR line, that\'s both grants and technical assistance. In 2008,
the budget proposes to eliminate funding for the STAR program, and in
this case for us this means we would have to terminate grants that would
otherwise be getting their third year of funding in 2008. Those grants
were first funded in 2006. They\'re three‑year grants. So if this
proposed cut is accepted by Congress, we would have to terminate grants.

MR. KOPANDA: I might just add that that\'s the only grant program that
would be terminated in terms of active grants terminated.

MR. GILBERT: In other grant programs where there are cuts, the cuts are
as a result of the natural expiration of current grant programs. So we
wouldn\'t actually be faced with terminating active grants.

This shows you the special initiatives outreach line in the summary
slide, what are the individual activities under that that would be
affected. Most of these are contract activities. The HBCU and Lonnie
Mitchell actually is supported by both grant and contract dollars. This
activity comes to a natural end at the end of 2007. We would not be able
to continue that activity in 2008, but we wouldn\'t be terminating it
early. This is, as Westley said, money that was in the Office of the
Director for special things that he would want to support that would not
be available. These are contract activities here. All of these are
contract activities.

Rich, did you have a comment on that?

If any of you have a question as we go along, just raise your hand.

In this state service improvement line, what we\'d be losing is HIV/AIDS
cross‑training and confidentiality training, things that we\'ve
supported for years to assist states. It\'s hard to say what was going
on when some of these decisions were made. We were talking about it at
lunch. We think that the kinds of things where you saw program increases
are things that people understood, like criminal justice, drug courts,
SBIRT, ATR. The kinds of things that got cut by and large were programs
that probably people didn\'t understand what this was. What\'s state
service improvement? We don\'t know. Okay, let\'s cut it. What\'s
special initiative outreach? We don\'t know what\'s there. Okay, let\'s
cut it. We\'re speculating that because maybe they didn\'t know what was
behind those lines, they didn\'t really understand what they were
cutting when they decided to cut that out of the budget, and these were
all things that were decided once the budget went to the Office of
Management and Budget.

Program coordination and evaluation. Well, that looks like something
that\'s nothing, right? But what\'s behind it? It\'s Partners for
Recovery, it\'s all of our consumer affairs efforts, the things that we
talked about this morning. It\'s Recovery Month. I think we\'re in our
17th or 18th year. I don\'t think the people at OMB understood that they
were making that cut, at least I\'d like to think that they didn\'t
understand it.

DR. FLETCHER: May I ask a question before you leave that? Would you back
up that slide?

MR. GILBERT: Sure.

DR. FLETCHER: Are these evaluation dollars for programs that you
currently sponsor? And if so, if those dollars are being eliminated, how
do you honor the results accountability, the culture of performance? How
do you honor that if you don\'t have the dollars to do it with?

MR. GILBERT: Actually, the line is a bit misleading, and I think this
may be part of what\'s going on. These are not evaluation activities.
These are small program activities that were lumped together into an
overall category. At one time there may well have been evaluation
activities in here, but as budgets change from year to year, some
activities will come out, new activities will come in, but it\'s a
category, a general category that\'s in the SLOA table that gets
displayed without a lot of discussion, without a lot of explanation and
opportunity to really say what is the activity behind that line. So we
are somewhat speculating here that people didn\'t understand program
coordination and evaluation. They didn\'t know what that was supporting.
Obviously, it was a very tight budget year. They had to make cuts. They
understood criminal justice. They understood SBIRT. They understood that
if you were looking at adolescents, they could see we had a cohort of
grants that\'s expiring. Okay, we don\'t need to continue money for
that. But they didn\'t understand this. So our speculation is they just
said let\'s get rid of it. We\'ve got to cut. We can save money here.

Yes, Val?

MS. JACKSON: So are you telling me, then, that you must submit a budget
up to them?

MR. GILBERT: We do. SAMHSA prepares a budget that goes first to the
Department, it\'s reviewed in the summer, they come back with a mark,
then we prepare a new submission which goes to the Office of Management
and Budget. It also gets reviewed by the Office of National Drug Control
Policy because it\'s part of the President\'s drug control budget. So in
the executive office of the White House, it\'s both OMB and ONDCP who
are reviewing our budget.

MS. JACKSON: So do you have a chance to either respond or prioritize any
of these things that are on there? I mean, there must be some
conversations at some level.

MR. GILBERT: Rich?

MR. KOPANDA: In addressing that, I\'d also like to respond to Dr.
Fletcher in terms of the evaluation. What George is saying is correct.
Some of these lines are just ‑‑ there are so many \$2 million things,
small things, which we have to aggregate in a line item like that, and
when we do, we come up with a title which may not indicate the
importance of that activity. So in terms of the evaluations, our
understanding is that services were accorded a priority, such things as
TA and evaluation, across the board and not just in SAMHSA, and across
the agencies was not prioritized, which is a little bit of a disconnect
with OMB\'s ‑‑ for example, the PART process. Dr. Clark referred to the
OMB PART process where they analyze your programs, and there\'s a heavy
emphasis on evaluation and the results of evaluation in that process.

Now, as George is explaining here, these lines don\'t include a lot of
our evaluation dollars. In fact, a lot of our evaluation dollars are
built right into the program. Take the Access to Recovery program. We
have approximately \$3 million per year built into that program for
evaluation of that program.

So this does not cut out all of our evaluation. But nonetheless, in
those areas where it stood out and where it might have been collapsed
with other things, it was not given the priority of direct services.

MS. BERTRAND: Under the special initiatives category, what were some of
the things that you all conducted, and is that line item ‑‑ I saw \$300
million or whatever. Is that the total amount that was there, or is that
a percentage of what was there? I think it\'s the slide before this.
There it is, planning and special initiatives. Is that the total amount?
So is it zero there?

MR. GILBERT: Yes, that\'s correct, the entire line was cut out.

MS. BERTRAND: And what kind of activities did you have under that
initiative?

MR. KOPANDA: As you can see, it\'s kind of a mixture of our activities.
It includes the HBCU grant, the Lonnie Mitchell conference. Planning and
special initiatives is, if you will, Dr. Clark\'s reserve for special
conferences, events, if he wants to pull together a special team of
experts to deal with an issue, those kinds of funds, a performance
measurement contract, work we do with other federal agencies, in this
case the Agency for Health Care Research and Quality, which is a small
dollar amount, and logistical support for some of our programs. So it\'s
a variety of things that we have to collapse in terms of that line item.
When you call it special initiatives, it just doesn\'t resonate as
something that ‑‑ but yet we have \$4.2 million when you add them all
up, and we have to put them somewhere.

MS. BERTRAND: In seeing this now, is there a department that analyzes
how the funding that you do have is distributed into the community? Like
who is responsible for that in terms of the RFAs and how they\'re
worded? Who is eligible for those grants and things of that nature?

MR. KOPANDA: Well, if I understand your question right, each of our
divisions, and you\'re talking about grant programs primarily, when
we\'re establishing the funds and analyzing how we\'re going to spend
the funds for a particular grant program, the work begins in the program
division. Our program divisions are set up such that the DSI division
deals with criminal justice, pregnant and postpartum women\'s programs,
drug courts, Targeted Capacity Expansion, anything in those areas. They
would initiate what we call an RFA, a Request for Application, and
that\'s kind of a long document that will eventually be published.

In that, they will have a discussion internally in terms of what the
best target population is, what have we done before, what kind of grants
have we gotten before, what kind of pressures are we getting either
internally or from the Hill to direct the funds in a particular way, are
they saying to do it through states or looking at the statutory
authority, what statute are we going to use to fund the program, and
they will make a recommendation. We\'ll review it in George\'s office,
the OPAC office, the Planning and Policy Office, and send it to the
Office of the Administrator. From there it possibly goes up the line.
Some, like Access to Recovery, ATR, get reviewed all the way up to OMB
and the White House, basically, but most of them stay within the agency.
So it would be an agency‑level decision, but many parties participate in
the discussion and analysis as to how a grant program is designed and
executed.

DR. FLETCHER: First of all, can I comment?

MR. GILBERT: Sure.

DR. FLETCHER: I want to thank you all for revisiting this issue because
it helps me to understand the process that you went through in arriving
at this, which I truly did not understand this morning. I\'m probably
the only one here who didn\'t, but I thank you for enlightening me on
that.

MR. GILBERT: We had the sense that there was some general lack of
understanding. We wanted to make sure that we came back to it because it
is important and it\'s confusing.

DR. FLETCHER: In the midst of my lack of knowledge in this area, I want
to make an observation. I make an assumption that budgetary decisions
and cuts are based on impact on budget. For instance, if you want to do
a budgetary savings, a significant savings, you have to make sure that
you get the volume that you want. Many of the cuts here would merely a
drop in the bucket, if you will. However, it has the potential
programmatically to impact a significant population.

Example, the HBCU initiative. There are 107 HBCUs in this country. There
is no program that I\'m aware of that speaks to substance abuse in
higher education at HBCUs. So it has a tremendous impact in terms of the
number of institutions that it reaches, but there are not a lot of
dollars tied to it. So how do we rationalize it? Help me understand
that.

MR. KOPANDA: Well, I think those of us within the center anyway would
agree with you in that regard. We understand the importance. We believe
in the program, and we think not only is it doing an excellent job, but
it\'s doing something that we need to be doing. Part of it is difficult
budget decisions, and we do as well as we can in terms of justifying
them, providing the data when it\'s requested. But at some point the
rubber just meets the road and the cuts are made, and we do the best we
can to accommodate.

Oftentimes what will happen, too, is we\'ll get an appropriation, say in
this case for 2008, and we\'ll have some flexibility, and within that
degree of flexibility we\'ll be able to restore some things and actually
make judgment calls as to which of the key priorities to continue.
Possibly that will happen in 2008, but we are waiting until the spring
here to see what the House and Senate action is on our bill.

MR. GILBERT: And I think, to kind of build on what Rich said, I think
you all got a copy of this. This is the CJ, the Congressional
Justification, that was submitted to Congress for the 2008 budget. It\'s
also available online. If you take a few minutes and you look at it, if
you look in the CSAT section, the treatment section, you\'re not going
to find the level of detail that Bettye is talking about. I mean, it\'s
going to focus on the big‑ticket items. It\'s going to focus on ATR,
it\'s going to focus on the increases in the budget, but it doesn\'t get
down to this level. Part of that may be something that SAMHSA may want
to reconsider in terms of the way we display and explain our budget.

I think there is a lack of understanding about exactly what we are
supporting. I don\'t think, when people made decisions, they understood
this, but I also think what was driving this was they had to meet some
targets for cuts, and they sort of looked at things and if they didn\'t
understand it, it was probably gone, not necessarily a rational process
in the sense of what makes sense programmatically maybe, but in the
sense of having to meet certain targets for reducing overall spending.
That\'s what they had to do.

The process, as Rich said, we support it as best we can, try to provide
explanations, but a lot of times I think decisions get made where the
questions don\'t get asked. You don\'t ever get a chance to explain
something. You don\'t know that something is on the block, so you can\'t
say wait a minute before you do that, you might want to consider what it
really is all about. So it\'s not a perfect process.

We talked about this a little bit. We talked about this. This one,
Frank, what you were talking about this morning, how do we take
successes at the individual project level and how do we go from there to
systemwide change. Well, our CAPT project supports our knowledge
dissemination program. It supports the TIPs. It supports materials
development. It supports the CAPT keys, all the tools that we\'ve used
traditionally to try to take the lessons that have been learned and the
best knowledge that we have about what works and disseminate it out to
the field. It doesn\'t seem to make a lot of sense to eliminate that.
But again, if you looked at information dissemination and you were a
budget examiner at OMB, you may not know that what you\'re cutting out
is TIPs, which has been sort of one of our flagship products, but
that\'s what it was. They didn\'t ask us what is this; we just found out
about it after the fact, so we never really had a chance to defend it or
to argue for it.

Technical assistance. This includes both printing and clinical TA.
Clinical TA is a problem for us, and this doesn\'t show the whole story.
If you were to look in the document, and you don\'t have it, this
doesn\'t really show the whole story either. Traditionally when we\'ve
budgeted, we have budgeted for TA within our program lines. So for
example, we have one large clinical TA contract, but that provides TA
for a variety of our discretionary programs, our PRNS programs. We take
money from each program and we pool it to fund this contract. Then we
have some other little pieces of TA that aren\'t included in that
contract, and that\'s what we use to show on this clinical TA line.
However, this past year a decision was made to put all the clinical TA
on one line.

So if you were at OMB and you got a budget that\'s showing roughly \$1.2
million a year for clinical TA, and all of a sudden it jumps to \$10
million, you\'re going to ask questions about that. They didn\'t accept
it, and not only that but they eliminated the \$1.2 million. So we lost
not only this little \$1.2 million, we lost \$10 million in TA. We\'re
going to have to go back as we move forward and build all over that
capacity for TA, starting with taking little bits and pieces out of
programs as we get it and building that back up. We didn\'t lose it all.
We have a very good budget person, and she\'s managed to protect some of
it, but we lost a lot of what we had had in TA, and probably part of
that is our fault because of the way the decision was made to display
that. But anyway, that\'s how things sometimes work out.

Yes, Frank?

DR. McCORRY: George, the clinical TA, does that include TA on COSIG or
out of COSI? I assume the clinical TA includes the TA provided after a
block grant audit. Does it include either or those, or no?

MR. GILBERT: No. Anne could speak to the block grant TA. That\'s
actually funded out of a separate account, the block grant set‑aside.
That\'s another story. We do have money that is available, but even that
is shrinking because of pressures on the set‑aside.

DR. McCORRY: And the COSI money for TA?

MR. GILBERT: Bob, do you know?

Bob is sitting in the back. He\'s in my office and works on budget
issues.

I think we\'re okay there.

PARTICIPANT: (Inaudible.)

DR. McCORRY: So what is in the clinical TA that\'s being cut?

MR. GILBERT: Well, it\'s money that goes into our large clinical TA
contract that supports clinical TA ‑‑

MS. HERRON: That\'s the TA that goes to the adolescent grantees,
pregnant/postpartum women, HIV, I believe drug courts too, criminal
justice.

PARTICIPANT: (Inaudible.)

MR. KOPANDA: Most, but not all, is discretionary grants. Primarily it\'s
discretionary grants in our DSI division.

DR. McCORRY: So when they X\'ed out the discretionary grants, they X\'ed
out the TA that comes along with it, in essence.

MR. KOPANDA: Well, as George mentioned, for the budget display purposes
for this year, it had all been consolidated in one line.

MR. GILBERT: Most of it did.

MR. KOPANDA: Yes, most of it did. In looking at that line, it looked
like that line all of a sudden grew because it wasn\'t built into all
the pieces. So that\'s why it got eliminated.

We are going to have to end the budget discussion fairly soon here. I
just wanted to mention one thing. If you think back to the table that
showed our percentage of discretionary reduction, we were the least of
the three SAMHSA centers. So these kinds of discussions and these kinds
of issues are being faced by all of the SAMHSA centers, and really it
goes beyond SAMHSA. Many of the department agencies are facing these
kinds of cuts in a whole variety of programs, and they\'re probably
doing the same thing, saying a lot of our support activities are not
being given priority in this way.

MR. GILBERT: Rich, if I could, let me just make two more short points,
because this chart apparently was confusing to some people.

These are showing decreases. These programs are not eliminations. So
it\'s showing you what we expect to have in \'07 and what the request is
for \'08, and the difference is the amount of the decrease. For grant
programs in this column, we\'re not going to have to terminate grants,
but this will reflect the natural termination of existing cohorts of
grants.

The other thing I want to say, as Rich was just pointing out, the cuts
in our budget all came out of the discretionary side of the budget, the
PRNS column. So while the SAMHSA cut overall was 5 percent of our total
budget, for CSAT, if you look at our discretionary, since it all came
out of the discretionary side, it\'s more like 12 percent, 13 percent of
the discretionary dollars. So the block grant was essentially protected.
The discretionary side is where the cuts came from.

DR. FLETCHER: Just one procedural question, Richard. If my colleagues
concur, can we come back to this issue during roundtable?

MR. KOPANDA: Absolutely.

We\'re pleased to have with us Anne and Jack to present on the Access to
Recovery program and the results today. Arnie Owens, who is one of the
senior advisors to Dr. Cline, was going to present on our recovery
support service conference in Florida. He will not be here to do that,
unfortunately can\'t be with us, so I think Anne is going to do that
part of the presentation.

MS. HERRON: I\'m going to be Arnie, I think. I asked Jack to please hum
while I did this for you, and he said no. So I just want you to know
that. It could have been very entertaining, and he refused to do it.

(Laughter.)

MS. HERRON: If they coax you? Okay.

(Laughter.)

MS. HERRON: There\'s just no integrity anymore.

(Laughter.)

MS. HERRON: What I did want to do, though, I wanted to take a few
minutes to let you know about a meeting that we had really following up
on some of the points that you had made earlier this morning about
taking some lessons learned from some of our grant programs and finding
a way to share them more broadly and share them with states and with
other providers. In this particular case, the meeting that we had was on
recovery support services. What we did is we added on two days to a
meeting that was already being scheduled for the Access to Recovery
program grantees, and we brought together the Access to Recovery
grantees, some of our RCSP grantees, Recovery Community Services Support
grantees, who are doing a great deal of work around utilizing and
supporting recovery support services, we brought together the regional
directors from NASADAD, and we brought together members of the CSAT
faith‑based expert panel that we had developed in support of ATR.

All together there were about 65 people that came together for a day and
a half to talk about lessons learned and how to share that information
with states and providers. The background of the slide showing that we
had this in Ft. Lauderdale is actually the view out the window of the
room that we had the meeting in.

What we wanted to do is we wanted to provide a forum really to discuss
the experiences of the grantees, both looking at the evidence that
supports the ongoing development and support of recovery support
services, what it is we mean about recovery support services, the
definitions, how they were implemented and some of the procedural issues
both from the community provider side as well as from the state side,
and then the experiences really from the provider perspective with
providing these kinds of services as part of an existing continuum of
care.

Again, we talked and brought in and utilized the experiences from ATR,
RCSP, some of the work that had been done last year that George
mentioned in the recovery‑oriented systems of care, the recovery summit,
and then looked at some of the research and some of the outcomes that
had been looked at and developed around the evidence base for the
services.

So I\'m going to tease you a little bit about some of the things that
came out of the meeting just to kind of foreshadow what you will be
seeing in a couple of months, we hope. One is we wanted to talk about
what the role of recovery support services is and continues to be.
Overwhelmingly, what the group was saying and reasserting is that
recovery support services really function as a way to expand the
continuum of care, that they allow the system and the field to focus on
strength‑based services, and the relationship between recovery support
services and treatment services is very much complementary and
compatible, and they in fact enhance the outcomes of each other.

The other thing that was talked about was how recovery support services
really provide the ability to respond to very specific clinical issues,
whether it\'s related to culture, experience, gender, age, any
particular specific issue that the treatment programs, because of the
limited funding and limited number, simply can\'t always respond to,
again looking at how we can expand this continuum of care using very
limited resources to provide ongoing, sustained support for recovery.

We looked at the evidence base. We looked at some of the information
coming out of the research around treatment completion. We looked at the
importance and the significance of ongoing connection with recovery
support services, mentoring connection with other kinds of supports, and
the impact that has on long‑term recovery and continuing sobriety.

The other thing that came out through the discussions from a number of
different venues was the importance that the addiction field has
developed in relation to the ongoing treatment of chronic illness,
simply that provision of wraparound services, of treating an individual
and family holistically and providing the kinds of things that people
need in their ongoing development and life.

Some of the challenges and the barriers we discussed had to do with
really how some of the recovery support service providers that were new
to the system lacked the necessary business infrastructure. Clearly,
many of the states were finding this issue and many of the providers
were finding the issue around financing, around clinical documentation,
around the ability simply to fill out all of the paperwork that we have
found is necessary in the field.

Another issue had to do with a lack of consistent ability and direction
and agreement on how to establish rates for recovery support services.
Some of the discussion from the states really talked about how they
would go into the phone book and find out what the going rate was for
transportation. That\'s how they set their rates. There was no other
information to use. There was no historical base of information.

Then we talked about really the sustainability of the recovery support
service providers and the networks as the specific grant funds go away.

From the state perspective, I mentioned the fee structure, how they\'re
reimbursing these programs, looking at issues of workforce quality and
credentialing, and some interesting things came out of the discussion.
Some of the states were looking at credentialing or acknowledging
individual providers. Others were looking at credentialing a program,
which is kind of an interesting change for our field. We typically talk
about credentialed individuals, not credentialed programs for a service.
So that was interesting.

Some of the other issues around state activity had to do with how they
conducted their outreach and how they brought new providers into the
system, and then the kinds of training that they developed and are
continuing to provide around business practices, and that, by the way,
was not only for the recovery support service providers but for
treatment providers as well. Good business practice is really something
that we need to pay attention to.

From the provider perspective, the difficulty of continuing and
sustaining their marketing of the strength‑based approach, that there
really was kind of a tension about focusing on not talking about the
deficits of individuals but talking about their strengths, and again
just trying to support a paradigm shift within the continuum. Instead of
talking about treatment planning, and this goes to the strength‑based
approach as well, talking about recovery planning and really developing
formal relationships and partnerships between the treatment programs and
the recovery support service programs; and then again expanding the
continuum of care.

The next steps, and this is what we hope you will see soon. We are
working on the development of a draft white paper which will go through
all of these issues and really provide a guidance document for providers
and for states for those who are interested in implementing recovery
support services. These are the issues. These are things you need to
think about, and here are some strategies that worked for some states
and providers. Then because of the individuals who were at the meeting,
the NASADAD regional representatives, membership from the faith‑based
expert panel, and our providers, talking about different ways in
dissemination strategies for getting this information out.

So that was the day and a half meeting in Ft. Lauderdale, and hopefully
you\'ll be able to see some of the products and the benefits.

Frank?

DR. McCORRY: Just quickly, the National Quality Forum is coming out with
a consensus. They\'re going to be voting on these evidence‑based
practices, 10 or 11 of them. One of the four domains that they have as
an evidence‑based practice ‑‑ they don\'t list a practice underneath it,
but it\'s a domain ‑‑ is continuing care management, because they
discussed addiction within a chronic care model. So it will be
interesting if this gets passed by NQF\'s policy group in terms of a
vote because it\'s really a domain. We didn\'t put a practice underneath
it. But this ties very nicely into it because continuing care is seen
both within but really after the completion of treatment, the extension
of the treatment model into a continuing care/recovery management kind
of domain. So it will be interesting ‑‑ this is well timed ‑‑ if that
report actually gets endorsed by NQF. NQF\'s endorsement is what\'s used
by CMS in the development of Medicaid funding and Medicaid performance
measures. So there is some possibility of some movement down the road on
this.

MS. HERRON: Great. Thank you.

MR. KOPANDA: Any further questions for Anne?

(No response.)

MS. HERRON: Thank you very much.

MR. KOPANDA: Jack?

DR. STEIN: Thank you, Anne, and good afternoon, everybody. It\'s nice to
be here and nice to see the council again. Last I actually spoke before
you, I think I was literally several weeks old at CSAT. I\'ve hit my
six‑month mark, and I have survived, and it\'s been quite a wild ride
and an exciting one, actually. I\'ve really learned an amazing amount
these last six months in terms of the operations of SAMHSA and CSAT and
how we work and the whole budget process. I really appreciate your
comment earlier around understanding this process. It really is a very,
very challenging one, and the more we\'re all aware of it and how it
works, the better it is for us.

Let me follow up with really what I wanted to provide, which is an
update on where we are with the Access to Recovery program. I\'m sure
most people here on council are familiar with Access to Recovery, and so
I\'m just going to really kind of give you a very quick overview of
that, but I think it builds nicely on the comments that Anne has just
mentioned.

I think we\'re really on to something very exciting, and Access to
Recovery has really been one vehicle to assist in that process, and that
is how we really shift the paradigm from an acute model of care to a
recovery‑oriented system of care. I think Access to Recovery is really
one of the grandest experiments in how to do so.

A quick historical perspective. I\'m sure most people are well aware of
many of these bullets, and I\'ll just highlight them very quickly.
Access to Recovery really was established in 2004. It was a presidential
initiative, so it takes very high priority here, with the goal really
being to provide clinical treatment and recovery support services to
those people who have been identified as having an alcohol or other drug
misuse or dependence problem. The goal that was set forth, our target,
was to serve 125,000 clients over a three‑year period with approximately
\$3 million funding. So that really is the target goal of individuals,
as well as the cost.

It was implemented officially in August 2004. Grants were awarded of
approximately \$100 million to 14 states and one tribal organization.
Overall, these 15 awards started up in August and were slated to end on
August 2, 2007. More than half of the grantees will ask for a no‑cost
extension until August 2008. So we really will be seeing in our first
cohort that many of them actually are continuing through \'08 with a
no‑cost extension.

The goals, as I mentioned, and just so you can see very specifically how
it was based, is a discretionary voucher‑based grant program designed to
expand capacity, support client choice, and to require the grantees to
manage performance based on outcomes that demonstrate patient successes.
The voucher‑based component of ATR is really one of the most unique
aspects of what ATR is all about. The idea is that we\'re really looking
at, in essence, an alternative approach to how treatment and recovery
support services can be both administered, managed and delivered, a very
unique experiment in how best to improve and expand treatment services.

Our objectives we actually teased out into five major objectives: to
expand treatment capacity; facilitate the pursuit of recovery through
many different personal pathways; increase the number and types of
providers, including faith‑based providers who deliver clinical
treatment and/or recovery support services; as I mentioned, the
utilization of vouchers as a means to obtain services; and manage
performance based on outcomes that demonstrate patient success. So it
really tries to incorporate many of those issues that Dr. Clark raised
this morning.

Just as a quick snapshot of our grantees, what I just posted here on the
left are what we call state‑based grantees. We gave each of the states,
the governors\' offices that were the recipients of these dollars, an
opportunity to determine, based on need, how they\'d like to spend the
dollars. Many of them actually chose to implement ATR on a statewide
basis. You can see them listed here. The rest of them actually decided
to do it on a more focused regionalized type of basis, again very
interesting to take a look, and we will do so this upcoming year, as to
where some of the successes lie.

I\'ll jump right to the bottom line here. Already ATR, in terms of
reaching its goals, has been a resounding success. As you see on the
bottom bar there, the three‑year target was 125,000 clients to be
reached. Already we\'ve reached that number. We\'ve served to date over
137,000 clients through this system. So already we\'ve been very, very
excited that, in fact, our grantees have been coming through and
reaching their target goals.

Quickly, some of the highlights that we\'ve seen. As just mentioned,
over 137,000 people have actually been served, exceeding the target, and
just some breakdown. I don\'t want to overwhelm you with a lot of
different statistics here, but recovery support services have truly
played a large role in the program. About 64 percent of the clients for
whom status and discharge data are available have received recovery
support services. Nearly 50 percent of the dollars redeemed were
redeemed for recovery support services, and over 50 percent were for
clinical treatment services. So it really was very, very balanced. About
30 percent of the dollars redeemed for clinical and recovery support
services have been redeemed directly by faith‑based organizations, again
one of the objectives of this initiative.

Very quickly, you can see the breakdown of the clients served, at least
in terms of data that we have to date. Over half were males, about 32
percent females. A breakdown of race and ethnicity; again, I think it\'s
pretty self‑explanatory. Again, some of these numbers will probably be
shifting as we collect the remainder of data over the next couple of
months.

I think this is actually pretty interesting as well in terms of the
service distribution of the type of services that are being delivered by
ATR. You can see that clinical treatment services accounted for about 35
percent of the services delivered, but case management and all these
other services that really fall under the recovery support services
really complete the complement of services that are provided through
ATR. This is kind of a nice breakdown. We\'re really beginning to get a
better sense that when we talk about recovery support services, what
exactly does that mean and how are they actually being delivered.

The services and voucher data, again, I think are interesting. About 64
percent of the clients received recovery support services. Almost \$150
million worth of services have been redeemed to date. Forty‑nine percent
of the dollars paid were for recovery support services, and 34 percent
of the dollars paid were to faith‑based organizations. Lastly,
faith‑based organizations accounted for 22 percent of recovery support
services and 34 percent of clinical treatment providers. So again,
we\'ve been really tracking the data on a number of different levels to
really get a much better grasp of how are these different states
cumulatively identifying where the need and the dollars should be
allocated.

I think one of the most exciting things, when we take a look at our GPRA
data to determine is this making a difference, is that we\'re seeing
some really significant changes, and it really is remarkable. From
intake to discharge, and this is what we\'re looking at here, we\'re
seeing nearly 70 percent of individuals who came in with a problem with
substance use report abstinence at discharge. That\'s pretty remarkable.
About 22 percent increased in stabilized housing. Nearly 30 percent
increased in employment. Over 50 percent increased in social
connectedness. Again, these are some of the NOMs measures that we\'ve
been talking about this morning. A very large percentage of individuals
reported a reduction in criminal justice system involvement.

It\'s important, of course, to tease out a lot of this data. This last
one, for example, the majority of people coming into the system actually
did not have a criminal justice background. So it\'s actually a very
small N that we\'re dealing with here, but again, we\'re seeing some
remarkable changes, and I think it really speaks to the fact that we\'re
talking about a continuum of care.

Just to wrap up, technical assistance has been a critical component of
the Access to Recovery. Many of the organizations that are part of
Access to Recovery are very small grassroots organizations and need a
lot of assistance. This past January right after the meeting that Anne
had talked about, we held a technical assistance conference for our
grantees. It was called \"Optimizing Outcomes Through Sharing
Knowledge.\" We focused on a couple of major issues. We\'re in the last
phase for this cohort of grantees, and so we were talking a lot about
grant closeout issues, how to keep on collecting follow‑up data, and
sustainability of course is one of the really key components.

Lessons learned I think is really one of the biggest areas of interest
for us at CSAT, and so I\'d like to just wrap up with two things. One is
that, in fact, we do have plans for an evaluation to really take a very
close look at the impact, both the process and the outcome, of ATR, and
we also recognize that at their own discretion many of the ATR grantees
have been conducting their own evaluations, which is actually quite
exciting to take a closer look at what have they been coming up with.

But let me wrap up with a couple of the successes that have been
reported over the last couple of years. I think one of the most
interesting ones has to do with the voucher management systems that all
of these grantees basically were required to set up in order to
establish a system to track and monitor the clients served. These
voucher management systems look very different depending on the state.
Some of the states have actually contracted out to similar companies.
Others have taken it upon themselves to do so. But we\'re seeing some
very unique, different approaches to how these vouchers can be managed.
These are all electronic systems.

They all seem to have streamlined the processing of information, of
offering services, increasing the capacity to monitor fraud, waste and
abuse. This to me is an area definitely worth investigating for future
funding of ATR grantees as well as other types of systems of care.

The implementation of evidence‑based practices I think is also another
really important lesson that we\'ve seen learned. Many of the grantees
are reporting how they have been implementing a number of the NIDA,
NIAAA evidence‑based practices that, of course, CSAT and SAMHSA have
been advocating over these last number of years. Tracking this even more
closely I think would be useful.

Sustainability strategies. For example, some states have implemented
what they call transition coordinators over this last year and a half,
how to really ensure that the legacy of ATR continues. Some states have
literally transformed their treatment systems so that ATR has actually
become more of a model for them, which is my next point here, the
restructuring of actual state treatment systems to include recovery
support services and faith‑based organizations. If you look at states
like Connecticut, for example, many of you know Tom Kirk. He actually
speaks very highly about how, in fact, ATR dollars really helped to
transform his state system, and as Anne had mentioned, the credentialing
of recovery support service providers. What does that mean? The
providers as well as the programs.

We have much work to be done in this area. I think ATR has really given
us much to build on. Many of them have actually also reported linkages
with other health care systems and other types of systems, such as the
criminal justice system.

So let me end and I\'ll field some questions, but I just wanted to
recognize the amazing work that the staff and the contractor agency,
AIR, have done for our work on ATR. I walked into ATR literally in its
very last year of operation, so I literally cannot take any credit for
the success of ATR, as opposed to having the luxury of being able to
report many of the successes. It was clear that ATR has been managed
incredibly well by the CSAT staff. Andrea Kopstein is the branch chief;
Natalie Lu is the team leader; Linda Fulton; Dawn Levinson; Carol
Abernathy, whose name is not here. She had left CSAT a couple of months
ago, but she also contributed; and our staff at AIR, particularly Roula
Sweis, whose name is here, who was onsite with us and just an amazing
contributor to the process.

So with that I\'ll stop and field any comments or questions on the ATR
update.

MR. KOPANDA: I want to first thank both Anne and Jack for their
presentation on an excellent program. Also, I\'ll just mention that, of
course, we are right now working on the new ATR announcement. We\'re
going to be able to announce approximately another \$100 million worth
of grants this year. In fact, George was just on the phone I think with
OMB discussing some technical aspects of the RFA.

DR. McCORRY: Jack, could you tell me the treatment outcome data, intake
to discharge? A couple of questions. One is what\'s the kind of average
length of stay in an ATR service? This would be like at report, the
intake into ATR to the discharge. There\'s a report by the individual,
and there was like 68 percent more reports of abstinence? That\'s what
that means?

DR. STEIN: Yes. What you\'re looking at is anyone who came in at intake,
for this data that you\'re looking at, we\'re only going to be looking
at an individual who reports within the last 30 days that they were
involved with the criminal justice system, for example, or that they did
not have stable housing. So we\'re just looking at that past 30‑day
period of time.

DR. McCORRY: The past 30 days in terms of their use, their housing
status?

DR. STEIN: Exactly, and this is being collected via our traditional
GPRA. It\'s not a unique one to ATR. We will then be tracking people
over the course of a six‑month period of time, as well as discharge.
Discharge could occur before or after that six‑month period of time as
well.

DR. McCORRY: And what\'s the average length of stay in an ATR program?

DR. STEIN: That\'s a good question. I don\'t have that at my fingertips,
but that\'s a good question. As you can tell, the nature of recovery
support service is so ongoing that it really can vary.

DR. McCORRY: Yes, and that\'s what I was wondering, because the end of
that service is discharge. So then I was interested in what would be the
average length of it.

DR. STEIN: We can easily find that because we seem to have data on
everything for ATR.

Other questions?

MR. DONALDSON: Well, just to congratulate you, Anne, and your staff. I
mentioned to Rich that CSAT has been a vanguard in engaging the faith
community, and this is further examples of that mission and success. So
thank you and your team. Outstanding.

DR. STEIN: Well, thank you. You know, last week I had the opportunity to
attend a grantee meeting for our HIV grants and was given the
opportunity to spend a good chunk of one morning being toured throughout
Atlanta by one of our grantees. It wasn\'t an ATR grantee, but it was
one of our RCSP, which is the recovery support program, and I got to
visit three small African American churches, all of whom had been
willing to open up their doors to be sites for rapid HIV testing and
counseling. These churches were getting nothing from this experience.
When I talked to all of the pastors there, what I heard from them is
this is what we do; we serve. It really was both obvious and not so
obvious from those of us who are on the side where funding is
everything. They were willing to basically contribute to the type of
work that we\'re doing so that, in fact, we can do HIV testing and
counseling in venues that are hard to reach populations.

Following that, I went to a homeless shelter for 700 men in Atlanta, and
again there were just individuals there who were clearly in need, and
the person who was taking me around literally was recruiting people
right then and there and bringing them into detox by encouraging them to
come on into the van that we were driving in. It was recovery support
services happening right before my eyes. So it really was quite
astounding to see. It really plays a critical role.

If I could just end quickly with one more note. Yesterday I was invited
to speak to the National Institute on Drug Abuse, NIDA\'s Clinical
Trials Network Steering Committee, particularly around the blending
initiative that we\'ve engaged with them for the last number of years.
But I used that opportunity to actually talk about the whole recovery
oriented system of care, because when I was at NIDA, which many of you
know I was, the concept of recovery is actually pretty narrowly viewed,
more from the concept of after‑care, somebody immediately comes out of
treatment and goes into some type of work release program or some type
of immediate step‑down type of care, versus this ongoing concept of
recovery support, and I really challenged them.

I asked these researchers there please help us with giving us the
science base behind recovery support services. It\'s what the field
needs, it\'s what everyone is asking for, it\'s the paradigm in which
we\'re working. I wasn\'t met with blank stares at all. I think people
are beginning to get it, but I think it\'s part of our responsibility to
keep on asking those types of questions, because the evidence base is
there. I think it needs to grow so that we can really identify what do
we mean by recovery support services and how do we start quantifying
them and figuring out costs for them, et cetera.

I know you\'re tight on time, so I\'m going to take my seat.

MR. KOPANDA: Well, thank you, Jack.

I just want to reiterate the thanks to the staff, and the grantees as
well. I think when we started this program we had no idea that this
would be one of our most, if not the most, intensely managed programs
that we\'ve ever had. We collect more data from these grantees on more
different subjects and do more frequent reports than I\'ve ever seen
before. It was eye‑opening to us, but the staff have borne a lot of the
pressure in terms of being in contact with their grantees and delivering
this, and they\'ve just done a fantastic job on that.

I\'d like to next introduce Kevin Hennessey. He works for our Office of
Policy, Planning, and Budget in the OA. He\'s going to present on the
National Registry of Effective Programs and Practices, or NREPP. Also
with him is Fran Cotter from CSAT, and she\'s going to provide some
background and be able to answer questions on CSAT\'s contribution to
NREPP.

Kevin?

DR. HENNESSEY: Unfortunately, I forgot to check with my eight‑year‑old
about the latest jokes so I could keep you guys entertained while we\'re
finding the slides.

(Laughter.)

DR. HENNESSEY: Well, it\'s a real pleasure to be here today. I checked
my notes, and the last time I addressed CSAT\'s council was September 14
of 2005. At that point we were right in the middle of the Federal
Register notice where SAMHSA, the agency, had outlined what we thought
should be happening vis‑a‑vis the National Registry of Evidence‑Based
Programs and Practices, and we were right in the middle of that public
comment period to hear what the field thought we should be doing. Lo and
behold, the field really gave us some good thinking in that regard, and
as a result we ended up making some major modifications to the National
Registry. So I\'m here and pleased to tell you that I guess a year and a
half later we actually have launched the system, we\'re up and running,
and I\'m here to tell you about it, as well as a few other things,
trying to give some plugs to a few other science‑to‑service activities
that we have going on. Then you\'ll hear a little bit from Fran Cotter
about a few specific CSAT science‑to‑service activities as well.

We all know that there\'s a substantial research to practice gap. It\'s
a well‑defined problem. We know that few research innovations are
successfully implemented in typical settings, that most in treatment
don\'t receive some sort of evidence‑based intervention. There\'s been a
lot of study about that in the last, say, decade or so, as well as many
fairly formal reports that have documented this problem and recommended
various courses of action, including all the way back in 1998, the last
millennium even documented this, an IOM report about bridging the gap
between research and practice, as well as several other seminal reports,
the Surgeon General\'s report on mental health in 2000, another recent
IOM report, \"Crossing the Quality Chasm,\" the President\'s New Freedom
Commission.

We have documented this problem, so now we need to move to solutions.
The knowledge to practice gap still stands at 15 to 20 years, meaning
the time it takes from an intervention being developed, in usually some
sort of more tightly controlled setting, to the time when it\'s diffused
or disseminated and adopted more broadly in clinical and community‑based
settings. So we need to do a better job of closing that gap because if
we don\'t, we\'re always playing catch‑up. The vast majority of people
would never be getting the best that we have to offer, and that\'s
simply not acceptable. So we need to do better in that regard.

What are we doing to try to improve that, try to reduce that research to
practice gap? We are providing decision support information on
evidence‑based services, and that really is our reformulation of the
National Registry of Evidence‑Based Programs and Practices. I\'m going
to spend most of my time talking about that. However, I do want to give
you kind of coming attractions a la the movie, and one is developing
clinically relevant effectiveness summaries. Our working title is
SAMHSA\'s Library of Systematic Reviews. It\'s really about taking the
aggregate research and trying to present it in very accessible ways so
that people can use it to make some decisions. Then finally, recognizing
successful implementation of evidence‑based programs. Many of our
activities and our systems are around identifying and making appropriate
selections of those programs, but the rubber meets the road where you
try to implement these interventions. So we really need to try to
provide some greater visibility and some greater attention and
recognition to the hard work that\'s being done by community‑based
agencies to try to implement these programs in typical practice
settings. So you\'ll hear a minute or two about that as well.

There you have our new website. We were going to try to have a live
Internet connection, but I really have some screenshots that will give
you the flavor of the Internet, plus it will hopefully encourage you to
log on to the new system yourself. You can get there very easily through
SAMHSA\'s homepage. There\'s an NREPP icon if you just scroll down a
little bit, right in the middle of the page. It\'s also listed under the
Browse By Topics in that alphabetical listing along the left‑hand side
of SAMHSA\'s homepage. So lots of roads lead to NREPP.

This is the homepage, and again it\'s a searchable database for
interventions for the prevention and treatment of mental and substance
use disorders, and we\'ve tried to really redevelop this resource to
help people, agencies and organizations implement programs and practices
in their communities.

A few contextual words. How do we put NREPP in context for people out in
the field who really might want to use this system? What is NREPP?
Again, this is the second paragraph, and I apologize if it\'s a little
hard to read. You do have slides of these screenshots as well. The
purpose, though, is to assist the public in identifying approaches to
preventing and treating mental or substance use disorders that have been
scientifically tested and that can be readily disseminated to the field.
So again, it\'s that balance of they have a pretty good scientific base,
but equally important, perhaps more importantly, they\'re ready for
broader dissemination to the field. Many things that have a scientific
basis aren\'t necessarily ready for that broader implementation. We\'re
trying to zero in in NREPP on interventions that do have that broader
base. It\'s one way that we\'re trying to improve the access to this
information and tested interventions and thereby reduce that research to
practice gap.

The third paragraph there talks about NREPP being a new registry and
that it\'s going to have continual updates. At this point we have
launched the system. We launched on March 1 with about 25 interventions
representing the full array of SAMHSA domains. We had some mental health
treatment and some mental health promotion interventions. We also had a
few substance abuse treatment and some substance abuse prevention
interventions, as well as a few co‑occurring disorder interventions.

We have over 200 interventions in the review queue at this point, and
every year we will be adding to that queue. So we\'re going to be
playing catch‑up for a little while, but what that translates into is
that we anticipate adding about five to ten interventions per month for
the foreseeable future. So you will want to revisit and come back to
NREPP on a fairly frequent basis.

We\'re in the process and should within the next week or so have an
opportunity where people can log on to the system, provide their email
address, and then get the monthly updates. It will say \"this month 10
interventions were added to NREPP, totaling 35 interventions,\" or
something like that, and it will have hyperlinks in the email directly
to the new interventions that were added. So we\'re trying to make it
fairly user‑friendly.

Contextually it\'s important what do we mean by evidence‑based practices
in the context of NREPP, and that\'s really the last paragraph here.
NREPP does not attempt to offer a single authoritative definition of
evidence‑based practices. SAMHSA expects that people who use this system
will come with their own perspectives and contexts for understanding the
information that NREPP has to offer. By providing a range of objective
information about the research that has been conducted on each
particular intervention, SAMHSA hopes that users will make their own
judgments about which interventions are best suited to particular needs.

This language is up here, and the language I\'m about to show you on the
next slide is up here very deliberately, and that\'s because we had a
lot of the public comments that weighed in on various issues, but one of
the consensus comments was that NREPP very much needs to provide better
guidance about how to use the system, and some cautions about how not to
use the system. One of the legacies of the previous NREPP was that there
were some unintended consequences where particular some purchasing
agents, states in some cases, and others, developed policies that said
you really only should select an intervention, we will only reimburse
for interventions that are on the NREPP system, or even more narrowly
defined that were model programs on the NREPP system. That\'s not
guidance that we would suggest purchasers follow, because clearly NREPP
is a limited registry. No matter how many interventions we add to this
registry, it will always have gaps. There\'s just no way that any single
entity could provide an exhaustive list of evidence‑based practices or
cover all of the population needs and service setting needs that would
be out there. So we\'re trying to be very, very proactive about the
guidance that we provide, which is directly tied to the public comments
that we perceived in response to how to redesign this registry.

With that in mind, we provide here an important note for NREPP users,
and I just want to jump back to show you that on the homepage you can
see it\'s the first thing we put on the left‑hand side because we really
do want to encourage people to go there. If you click on that box that
says \"Important Note,\" it will take you right to this page. Again, at
the risk of sounding like a broken record, we do provide this guidance.

The first paragraph there is \"NREPP users are encouraged to carefully
weigh all information provided.\" Just let me read you the first
paragraph, because I think that\'s important. \"It\'s intended as a
decision support tool, not as an authoritative list of effective
interventions. SAMHSA does not \'approve, recommend or endorse\'
specific interventions.\" Again, this is there for users to figure out
if this meets their needs. \"Being included in the registry, therefore,
does not mean an intervention is recommended or has been demonstrated to
achieve good outcomes in all circumstances.\" You clearly will find
interventions on the registry that have positive outcomes for particular
populations or in particular service settings. What you have to be
careful about is then extrapolating that information to say it would
work in all settings. That was, quite frankly, one of the problems with
the old NREPP, that the interventions would be posted there and the data
might have suggested that it reduced binge drinking over a 30‑day
period, 30‑day outcomes in reduction of binge drinking for 10th graders,
and suddenly the intervention was being marketed, in many cases by the
program developers, as reducing alcohol use, marijuana use, you name it,
for all teenagers or for all high school and middle school students. So
there was this overmarketing, really, of many of these interventions
beyond the specific data.

You won\'t find that happening, or at least it will be much harder to
do, with the new NREPP because the interventions are listed specific for
the outcomes that the intervention achieves. So it will be much more
difficult, if not impossible, to overmarket the interventions because
the new system is very transparent in that regard.

The last sentence in that first paragraph is also very important.
\"Policymakers in particular should avoid relying solely on NREPP
ratings as a basis for funding or approving interventions.\" We need to
be very clear about that, and that\'s why it\'s language on the website.
We want to really protect and caution against using this as an exclusive
or exhaustive list. There clearly are too many populations out there,
too many service gaps, to think that NREPP or any other single entity
could provide the exhaustive information.

Again, it\'s not a comprehensive list of interventions, although we are
adding to it each time, but we do think it\'s a good place to start to
begin researching interventions that might work for you, and the
emphasis is on might.

Okay, enough of my disclaimers, if you will. How do you go about finding
an intervention? As you can see, this is defined on the intervention
page, and it currently includes 25 interventions. You can search a
couple of different ways. If you know a program developers name or if
you know the intervention name, or any other word if you just want to
find interventions that have maybe been targeted to Latino populations,
you could use the free text up at the top left there in terms of just
putting that word in and hitting search, and it will come out with the
interventions; or you could use some of our check boxes, and you can
check more than one box at a time. So you can check the topics,
substance abuse treatment, and you can check the race/ethnicity,
American Indians, you could check age, you could check gender, setting.
You can also check the bottom right, proprietary or public. Many of the
interventions are a mix of both. There\'s some proprietary information
that you have to purchase, and some public information maybe through
their own website or whatever. But again, very important information if
you\'re on a limited budget and trying to decide what interventions are
going to work in my particular setting.

So if you do that search ‑‑ because I don\'t have a live Internet
connection I\'m not going to do the search for you, but it\'s very
simple to do ‑‑ these are the interventions that are posted currently on
NREPP. Of those 25 that are listed on NREPP, these are the ones that
have to do with substance abuse treatment, either specifically or
through programs for co‑occurring disorders. So Behavioral Couples
Therapy for Alcoholism and Drug Abuse, Dialectic Behavior Therapy, the
Matrix Model, Network Therapy, Seeking Safety, and Trauma Recovery and
Empowerment models. So those six are up there already.

Currently under review, and I would anticipate that they would work
their way in in the next, say, one to three months, that the
intervention summaries would be posted, are family behavior therapy,
brief treatments for cannabis dependence, Forever Free, multisystemic
therapy, and motivational interviewing. We have in the queue some
various stage of prereview but it\'s been identified for review ‑‑
generally it\'s because the NREPP contractor has to get additional
materials from the program developer ‑‑ we have probably a dozen or more
interventions. So we\'re working to populate the registry with substance
abuse treatment interventions.

I\'m going to quickly take you through what an actual intervention
summary looks like. When you print it out, and they are easily printable
from the website, it\'s anywhere from 10 to 12 pages. This one is on
TREM, the Trauma Recovery and Empowerment Model. You can see that you
can use these boxes, the blue boxes. If you click on that it will take
you further down the summary to that particular information. So you can
go to the descriptive information, outcomes ratings, demographics,
replications, contact information. You can see along the side that it
starts with topics, populations, then it tells you the outcome, it gives
you an abstract, tells you what settings the intervention has been
tested in, some areas of interest which kind of track to our \"Find An
Intervention\" page, whether or not it\'s been replicated, and that\'s
in many cases a formal replication, a study which is then listed below
on the website, whether it\'s proprietary or public domain, and in
general the costs of the program. We\'re trying to provide as detailed
information as possible. In some cases we\'re limited by what the
program developer can tell us, but we again try to provide you with some
general information about costs.

As is the case with much of this information, if you want more detail,
we encourage you to contact the program developer directly and/or their
agents. Sometimes they have a marketing arm of their intervention. So
that information is provided incomplete at the bottom of this summary.

Whether or not there are any adaptations, again that can be important if
you\'re thinking about a program that\'s only been adapted once versus
one that has over 1,000 adaptations or implementations. Then you get a
little bit of the implementation history, also adverse effects, which
can be very important as well to know when you\'re making these
decisions.

Each outcome has its own separate box which is a description of what the
outcome is and how they measured it, and some of the key findings, and
this is where we really are encouraging end users of the system to zero
in on, because you could have interventions that achieve certain
outcomes, but you really need to go into the details to see if it\'s an
outcome that fits for you in terms of how they began to assess it.

The research designs are there in case people want to make judgments
based on how rigorous was the design, was it a randomized control trial
or was it something that was less rigorous, and then down at the bottom
you can see quality of research rating, 2.7 on a 0 to 4.0 scale. What
I\'ve done, and this is a separate page on the website, is tell you a
little bit about what these two ratings that the NREPP system produces,
the reviewers under the NREPP system produced. The first is the quality
of research rating. Essentially, that summarizes the amount and general
quality of the evidence supporting the conclusion that the intervention
rather than another factor or other factors produced the reported
results or outcomes. So with this measure, higher scores indicate
stronger, more compelling evidence, and each outcome is rated
separately. Essentially, what you\'re getting is the quality of the
research, how confident are the scientists that are reviewing this
program, how confident are they that the intervention was produced
specifically by the outcome as opposed to some other factors, the
difference between the experimental group, the one that received the
intervention, and the control group that got treatment as usual, that
that difference is attributable to the intervention and not to some
other factors like passage of time or a lot of other factors that
scientifically can affect outcomes. That\'s one rating.

The second rating, and this is new to the system, is a readiness for
dissemination rating, and that\'s largely because, again, it\'s
important to have a strong scientific base, but you really need to know
how ready is this intervention for broader dissemination. So this score
summarizes the amount and general quality of the resources available to
support the use of the intervention, and again higher scores indicate
more and higher quality resources that are available.

Again, back to the TREM intervention, Trauma Recovery and Empowerment
model, it shows you what a typical summary looks like in terms of the
outcomes and the six factors or the six criteria that are used to assess
that outcome, as well as in the yellow box on the far right the overall
rating for each outcome on a 0 to 4 scale.

We provide a little bit of the strengths and weaknesses because while
the scores are important, and I know a lot of people are going to zoom
right to the scores, you want to know about the strengths and weaknesses
because that actually may be the most helpful thing, even more helpful
than the numeric ratings, in determining whether or not this
intervention is for your particular setting or your particular
situation. So you want to read the strengths and the weaknesses.

The same thing with readiness for dissemination, the single overall
score based on three criteria, and then the strengths and weaknesses.

The next section down in the review summary as you scroll down is study
demographics. This may be very helpful to determine if you want to look
for interventions in your particular setting to address Native American
populations, you might want to see whether or not the intervention has
ever included any subpopulations of Native Americans when they actually
tested the intervention. So this gives you kind of a quick box score of
whether or not age, gender and race/ethnicity factors. For some
interventions they may not have been tested in the population that
you\'re interested in implementing the program with, but maybe there\'s
enough data to suggest that it\'s something that is replicable with that
population. So that will give you some information.

This jumps to a little bit about the minimum requirements for
interventions that are considered for NREPP review, and again we want to
be very transparent with this whole system, so all of this information
is on the website. There are three basic requirements to be considered
for interventions to meet for consideration for NREPP review. The first
is that the intervention demonstrates one or more positive outcomes at
the conventional statistically significant level of P less than 0.05,
and those outcomes have to either be in mental health and/or substance
use behavior among individuals, communities or populations.

The emphasis is on actual behavior change in those individuals,
communities or populations. In some cases we will consider programs that
change knowledge or change attitudes, particularly if that was the
overall goal of the program. But in general, what most of the public are
interested in, and therefore we\'re interested in, is programs that
actually change behavior.

The second requirement is that the intervention has been published in a
peer‑reviewed publication or is documented in a comprehensive evaluation
report. Then the third requirement ‑‑ and this really is getting to that
broader dissemination issue ‑‑ is that there is documentation of the
intervention and its proper implementation which is available to the
public so that it can facilitate dissemination. If I\'m sitting in Cedar
Rapids and I\'m interested in putting an intervention in place to deal
with substance use and I see one that exists in Florida, if I call that
person up in Florida, I need to be able to get some materials to help me
implement that intervention and/or to get some training. If that
training or those materials aren\'t available, it\'s really not going to
help me all that much. So, therefore, this third requirement that you
have materials and you have the ability to train is pretty critical if
you\'re going to take that intervention to scale or implement it more
broadly.

In addition, because we anticipate over time as NREPP expands that the
demand for inclusion in NREPP may greatly exceed the resources available
that SAMHSA has to review these interventions, in addition to the
minimum requirements, we\'ve established a couple of priority points so
that all else being equal, we\'ll probably end up accepting for review
the interventions that meet these priority points before the ones that
meet just the minimum requirements. Everybody has to meet the minimum
requirements, but then you get a couple of extra priority points
depending on, again, if the primary targeted outcome is in one or more
of the priority areas established by SAMHSA\'s three centers.

I think we\'ve established a fairly interesting approach to this,
interesting in a positive way, that every year SAMHSA\'s three centers
will each decide what the priority areas are from a content standpoint,
the types of programs that they would like to see come in for NREPP
review. So if you submit during the open submission period and you\'re
in that content area, you\'ll get a priority point.

The second priority point is the type of study design. We\'re again
looking for more rigorous designs. They tend to be more replicable, more
generalizable. So you get a priority point for that.

Let me check on my time. Just let me do a minute or so on this. That was
NREPP in a nutshell, and I\'m happy to answer more questions about it.
Many of the questions probably can be answered by accessing the website
as well.

SAMHSA\'s Library of Systematic Reviews. There are some very simple
goals here, and this is something that\'s in development currently, and
Jack is part of the technical advisory group that\'s assisting us in
helping to develop this. It\'s to identify the best evidence from
systematic reviews. People who are familiar with the Cochrane
Collaborative and some of the other efforts that really look at
systematic reviews, meta‑analyses or other more rigorous reviews of
randomized controlled trials, step 2 is to present this evidence in
plain language synopses or journalistic style synopses. Sometimes those
reviews aren\'t particularly accessible. We\'re trying to make them much
more accessible by the way we describe them. Basically, the journalistic
style is to report the author\'s conclusions, that it\'s not a critique
of the science, it\'s basically just trying to present the science in a
very accessible way, and then to categorize based upon what the review
says. Is this an effective intervention? Is it an intervention where the
results are mixed and there are some tradeoffs? Is there not enough
research to really make any sort of definitive conclusions, or equally
important maybe, is it an intervention where the research has shown it
to be harmful?

So we\'ll try to provide some quick access on that, and then to provide
pathways or links to additional information. So if you want to dig
deeper, if you want to look at the abstract for that systematic review,
or the actual study for that systematic review, or additional resources
through SAMHSA\'s website or through other Internet websites, or PubMed
or other places where you can get even more information if you\'re
interested in that particular are.

These are the effectiveness classifications that we\'re talking about.
Two check marks is a beneficial form of care that the systematic review
said this is a beneficial intervention, all the way through forms of
care with a tradeoff, the check and the X, forms of care likely to be
ineffective, a question mark and an X, or harmful, a double X.

This is our working model. This is up on a beta test site at this point.
This is what one of these summaries would look like. So in this case
skill‑based programs in schools deter early stage drug use, particularly
hard drugs. It gives the two paragraphs. It tells you whether or not
there are any adverse effects, the original article. Along the
right‑hand side you\'ll see this is going to be hyperlinks. You can
click on the abstract. You can click on the original article. You can
click on SAMHSA‑related articles. You can click on other articles by the
author.

These next slides give you a look at what it would be like if you
actually clicked on that. So this is a case where you clicked on the
actual article, and it pulls it right up out of PubMed. Then this is a
case where you click on SAMHSA\'s related sites, and it does a quick
search of SAMHSA\'s website to pull out anything that\'s related.

I\'m pretty excited about this tool. I think it has a lot of potential.
It\'s still in the development stages, so hopefully, maybe in another
year and a half I\'ll be back to talk about this with council.

Finally, SAMHSA\'s Science to Service Awards. I\'m very pleased about
them. You can tell I\'m very pleased about a lot of things, but I\'m
pleased about this one as well. This is to recognize community‑based
organizations that are doing the hard work of implementing these
evidence‑based programs. The purpose is to publicly recognize them in
their work, and we\'ve done up to three awards each year in each of four
areas: substance abuse prevention; substance abuse treatment and
recovery; the third area is mental health promotion; and the fourth is
mental health treatment and recovery. The nominees were assessed
according to established criteria for successful implementation, and the
goal again is that these very visible awards will enhance awareness of
the role of implementation in promoting broader consideration and uptake
of evidence‑based services.

I\'m really pleased to say that we did the applications for this award,
the first ones being issued in 2007. No money is associated with these
awards. It\'s just the recognition, and if you\'re selected as a
finalist and get the award, the organization will get to send one or
maybe two people to an awards ceremony that will occur probably through
the National Press Club sometime later this year. We\'re working with
Mark Weber and the communications folks to make this happen.

We had over 100 applicants to this, again non‑monetary awards. So it\'s
putting effort into actually applying for this award. You\'re getting
the recognition. But that to me just underscores that there are a lot of
people and a lot of organizations out there doing some very significant
work. So my hope is that we can recognize them appropriately, and we\'ll
hopefully have the awards ceremony sometime this fall.

One of my favorite quotes about science to service activities: \"We\'ve
got a lot of this stuff, but it\'s just not widely distributed, so
we\'re working on trying to distribute that.\" For those of you with a
good memory, I actually used this quote the last time I presented to
your council, but I liked it so much that I thought it was worth a
second go around.

Let me turn it over quickly, and I\'m sorry I\'ve taken up some of
Fran\'s time, but there are a couple of things that she wants to go
through that are specific to CSAT science to services.

It\'s a delight. I just want to say how much I enjoy working with Fran,
too, on these efforts.

MS. COTTER: And then we definitely want to have time for questions.

First of all, talking about being pleased, I want to say that the
science to service lead within CSAT, working with Kevin Hennessey and
his leadership on NREPP has been just a delightful experience. We have a
system. It\'s managed, and each of the three centers provides funds to
the effort. It\'s about a half million dollars apiece. Kevin immediately
set up what he calls an investors group so that we are part of the
decisionmaking of each and every piece of the rollout, and I think it is
a wonderful model for all of us when we look at some of the
collaborative activities such as NREPP.

It was a long birth. I look around and see in the council I think,
Frank, you were there at a meeting we had almost four years ago as we
began thinking about the redesign of NREPP. What I would like to do is,
based on this and follow‑up discussions, encourage council input. We\'re
just starting a rollout phase. Every year CSAT is going to be looking
for your input and advice. You are in touch with elements of the field,
and I just encourage you to email me and/or others concerning your
thoughts about NREPP itself and the rollout of it.

I also want to acknowledge Linda Fulton, who is working at CSAT as my
collaborator on NREPP, and also will be one who can answer questions.

When we talk about what we\'re doing on NREPP, I wanted to reinforce
Kevin\'s statement that although we have a new system that\'s being
rolled out and it sounds a lot like the old NREPP, it is a very
different tool than was the old NREPP. Because of that, I think it\'s
going to be important for all of us to help educate the field around the
fact that this is a decision support system and tool and not simply a
comprehensive list of programs and practices that people go to and pick
and choose without closely looking not only at the registry but at the
other resources that are out there. That\'s why I wanted to give just
two slides identifying what I think all of you are aware of, of what the
full pool of evidence‑based practices is currently within CSAT, and
recognize that as people are looking at what practices to implement,
they should be looking not only at NREPP but at our other resources.

Of course, first and foremost, there\'s been a lot of discussion about
the TIPs, but they are a consensus‑based rather than a peer‑review‑based
set of protocols that are really at the core of the treatment field\'s
evidence base and always referred to and should continue to be used as
source material.

In addition, as you know under our Knowledge Application Program, we
have elected to put into training manuals and materials a number of
evidence‑based practices that evolved through CSAT initiatives, and I
think there you see the list, and I think the most recent one that\'s
been disseminated is the Matrix Program for Stimulant Abuse.

In addition, the ATTC program, if you go on to the national office, the
ATTC network also has a full series of online and other kinds of
training materials and products.

In addition to that, we have the blending products, and the Clinical
Trials Network. There was reference to this earlier today, but our ATTC
program and NIDA, through the Clinical Trials Network, are developing
both awareness and training materials for the findings that are coming
out of the NIDA Clinical Trials Program.

What have we done? CSAT, as I think many of you know, and I just
circulated this, has developed a listing that we call Effective
Substance Abuse Treatment Practices, and in doing this what we are
offering is a guidance to grant applicants and others that identifies
the full range of programs and practices that we offer the field, and
particularly grant applicants, when they\'re applying so that they have
the resource information they need on evidence‑based practices. We will,
of course, be adding NREPP to this list, but please keep in mind that
this represents a full group of materials and publications we have
available.

Finally, related to this whole area of evidence‑based practices, I
wanted to make known to you that I circulated another information on a
summation conference that we\'re doing in the area of business practices
and evidence‑based practices. As we talk about this whole area of
evidence‑based practices, I want to keep in your mind that we\'re not
only looking at clinical practices but also those kinds of business
processes that can improve treatment efficiency, access and retention.
You have that information and I\'ve circulated it.

Terms of issues related to rollout. We will be each year working within
CSAT to set priorities, as Kevin had said, for applicant submissions
under NREPP, and we will be looking at the balance within the portfolio.
We want to over time make sure that all matrix areas are addressed, and
we also want to continue to encourage as many applications as we can.
Currently we are limited to approximately 25 reviews per year.

So let me open it up for questions.

MS. JACKSON: Well, I just want to congratulate you on putting together
this arduous task that I know had lots of field comments and feelings,
because I was involved in a few of them and the feedback, and I think
that\'s a very healthy thing to have the national feedback that you did
have on the NREPP, and what you came up with is something that really is
usable. It was so affrontive a few years back to think that we were
going to end up with this list of some 15 programs that were kind of it.
While that\'s a very simplistic statement, that\'s what it felt like. So
as a provider, I\'m one person that really supports the idea that
you\'re promoting now that these are guides, these are support
mechanisms to help people find the treatment that is most appropriate
for their population. So I just want to congratulate you. This had to
take a lot of work. I know it did, and I really liked your presentation.
Thank you.

DR. HENNESSEY: Thanks very much, appreciate that.

MR. KOPANDA: I\'d like to just point out that the NREPP, our
contribution and the NREPP system in general is funded in the 2008
budget. It\'s fully funded.

The other thing I\'d like to point out is that the list Fran had is the
list of effective practices and programs that we really require our
service grant applicants to use, not the NREPP right now but the more
extensive list. If an applicant is going to come in for a service
program, they need to make sure it\'s on that list.

MR. GILBERT: Let me just clarify that a little. We tell our applicants
for services programs that they have to use an intervention that\'s
evidence based, and we provide this list in the RFA as a list of
practices that if they\'re going to implement, they can say we\'re going
to implement this practice and they do not have to justify it any
further. However, if they want to propose some other intervention, they
have to provide the evidence for it, and it\'s evaluated by the
reviewers. So they\'re not restricted to the list, but this is sort of
the preapproved list, if you will, and it includes everything that would
be on NREPP, as well as what\'s in the TIPs, as well as many of the
other products that Fran cited in her presentation. But the effort here
is to try to be sure that our services grantees are using evidence‑based
practices and that the evidence is evaluated by the reviewers when they
review the applications.

MS. COTTER: Yes, thank you for that clarification. The intent here is to
inform applicants of the broad range of evidence‑based practice
resources available.

DR. FLETCHER: Could I also echo Valera\'s comment, and also point out
another invaluable use of this resource, and particularly the TIPs. In
addition to you sharing that with your applicants, it\'s being used as a
training tool for those who are planning careers in the substance abuse
field. Some credentialing agencies reference TIPs as a primary resource
for those who are preparing themselves for credentialing. So it truly is
a valuable resource. I\'m on the user end, and it has been a valuable
resource.

MR. KOPANDA: Thank you for that comment.

Any other questions?

MS. JACKSON: You said NREPP continues in the funding, but I thought I
heard earlier, George, that TIPs wasn\'t going to be funded anymore.

MR. GILBERT: Yes, in the 2008 budget, the funding for TIPs would be
eliminated.

MS. JACKSON: I just want to go on record that I really object. You said
if there\'s ever flexible money, TIPs is probably one of the best
publications, as somebody said flagship publications, across these
United States that is so used, it\'s just really sad to hear that, and I
hope that there is some way that we can work around that in the future.

MR. KOPANDA: If there are no more questions, I\'d like to thank both
Kevin and Fran for their excellent presentation, and I think it\'s time
for a break. If we could have about a 15‑minute break and return just
maybe a little bit after 3:30. Thank you.

(Recess.)

MR. KOPANDA: We\'re pleased to have with us this afternoon Dr. Rita
Vandivort. She\'s acting branch chief in our Organization and Financing
Branch. She\'s going to talk to us about the National Expenditure Survey
for Substance Abuse Treatment.

DR. VANDIVORT: Thank you very much, Rich.

Well, it\'s been a long day for you all, and you\'re still here
listening to more reports, so I\'m going to try to intrigue you with the
only joke I know to try to lighten up and engage you, or the only joke I
can tell.

You all may remember a few years ago there was a lot of concern as
managed care came into some of our public systems. Well, this is a story
about a CEO of a managed care company. He was at his desk and he was
kind of squeezing the utilization and trying to be sure not one extra
dime went for services, and all of a sudden he had a massive heart
attack and died right there at his desk, and he wakes up at the Pearly
Gates. He\'s kind of looking around, and St. Peter comes over and says,
\"I\'m sorry, you\'re looking a little confused. Is something wrong?\"
And he says, \"Well, I did kind of squeeze those services and lower the
authorizations, and I\'m kind of surprised to find myself here.\" And
St. Peter said, \"Well, wait a minute, let me look it up. Yes, here you
are. You\'re authorized for three days.\"

(Laughter.)

DR. VANDIVORT: So, you know, maybe what goes around comes around. I
don\'t know, ultimately.

So I\'m going to talk about a report that I do, the National
Expenditure. I think it was actually sent to you, a blue book. This
comes out of the SAMHSA spending estimates. This is a cross‑center
project between the Center for Mental Health Services and the Center for
Substance Abuse Treatment to try to look at what this country is
spending on mental health and substance abuse care, both in the private
sector and the public sector. We now have data. This is our fourth round
of studies. We now have data back to 1986, and I\'m very pleased to
share that we did a specific article looking at substance abuse trends
in spending from 1986 to 2003 that has been accepted by Health Affairs.
We\'re pleased about that because it gets a broader audience thinking
about what\'s happening in substance abuse treatment.

Our prime contractors are Thomson Medstat. They also work with the
Actuarial Research Corporation, the Lewin Group, NASMHPD and NASADAD,
and as I said, it\'s from both centers.

As I said, the scope is to look at all public and private payers
nationally, and to also look at major provider types. We also compared
this to CMS\'s Centers for Medicaid and Medicare\'s National Health
Accounts, which is kind of the gold standard of health spending.

We also have some special reports. There\'s a copy of a journal article
from the Journal of Substance Abuse Treatment that came out of this
project which looked at detox, and it showed that those receiving only
detox compared to those that received detox and treatment were far more
likely to have to come in again for detox, and they came in at a shorter
interval than those who had received treatment.

We include all mental health and substance abuse diagnoses that are
usually covered by health plans. We don\'t include dementias, tobacco
dependence, developmental delays or mental retardation. We don\'t
include prevention services or the burdens and costs of illnesses.

As I said, we do this so that we can compare this to CMS\' National
Health expenditures, and we look at both the specialty providers as well
as what mental health and substance abuse may be occurring in primary
care and other general health care sectors. We also look at
pharmaceuticals.

So let me get into some of the results. If you look at 2003, mental
health and substance abuse spending was \$121 billion, which was as a
percentage of all health spending 6.2 percent for mental health and 1.3
for substance abuse treatment. That said, I do want to say that there is
probably some hidden substance abuse treatment in mental health because
the financial incentives are such that mental health has better
reimbursement. So providers, if you had a co‑occurring patient, you\'d
be smart to code them as mental health. So I think that substance abuse
is actually understated here, but it\'s very difficult to determine what
portion.

If you look at the years from 1993 to 2003, the dark line is substance
abuse and the pink line is all health spending. As you can see,
substance abuse treatment spending has not kept up with all health
spending. This was particularly true during the 1990s.

This looks at all public and private spending, and as you can see, we
are largely public spending for substance abuse treatment, more than
three‑quarters. The private spending includes private insurance,
charitable foundations, as well as out‑of‑pocket spending. But if you
look on the public side, you will see that state and local dollars,
which includes not only general revenue but also probably criminal
justice, some of those local dollars, is really the largest payer for
substance abuse treatment. Interestingly enough, I think a lot of people
aren\'t aware that the second‑largest payer is really Medicaid.

One thing about Medicaid is that if you look at one state, you\'ve
looked at one state. Every Medicaid program is different in every state.
So in your particular state there may not be a lot of Medicaid spending,
but in some states there is quite a bit. So it varies. This looks at it
nationally.

Then next to that, other federal, which includes the block grant, is a
large payer. Medicare is a relatively small payer.

If you look at the 10‑year period, part of this report looks at a
10‑year period. So if you look at the growth of spending between public
and private between 1993 and 2003, you\'ll see almost all of it is
public spending. This is 4.6 percent annually has been the growth rate
in the public sector. But if you look at private insurance, it\'s 0.1
percent. Essentially, over this 10‑year period, private insurance
spending has not grown. As a result, in 1991, one in every four dollars
was from private insurance. In 2003, only one in ten dollars is from
private insurance.

We also look at major provider groups, and what I have here is a look at
1993, the providers, and at 2003. So you can see the community specialty
substance abuse center was the largest single provider, and it is even a
larger provider today. What has declined? Well, you see specialty
hospital has declined from 9 percent to 3 percent. General hospitals
with specialty units have declined from 20 percent to 14 percent. A
little bit troubling, general hospitals without any kind of specialty
psychiatric or substance abuse beds have actually grown a little. I\'m
not sure if that\'s detox, we\'re seeing more detox or what. Another
fourth of the providers are M.D.s and other professionals. This strange
acronym, MSMHO, is multi‑service mental health organization. That\'s
really the community mental health centers. They have a small but a
somewhat growing portion in substance abuse treatment.

By the way, retail drugs aren\'t included because they are such a small
percent. They are a growing percent, and I gave the numbers down here.
In 1993, they were 0.2 percent of all substance abuse treatment
spending, and in 2003 they\'re 0.5 percent. Now, that is only retail
drug spending. That doesn\'t look at methadone. Those costs are built
into facilities.

If you look at that one‑quarter that are in kind of private practice, we
look at the M.D.s and the other professionals, the portion between
mental health and substance abuse is similar, around a fifth of all
spending, but where it\'s spent or what professionals are very
different. So on the mental health side, physicians account for 62
percent of all the spending in this category, whereas in substance abuse
other professionals, other counselors, CACs, social workers, account for
61 percent. So our portion that\'s M.D. is significantly less, and
what\'s interesting is that the other M.D., not the psychiatrist, is
actually a larger portion.

We\'re doing some studies right now looking at who is writing the
prescriptions for the substance abuse drugs, and it\'s very interesting
that it looks like primary care docs are pretty comfortable writing
prescriptions for alcohol treatment drugs, but the psychiatrists are the
ones who are involved for drug treatment more often. We\'ll be coming
out with that.

One of my favorite payers, because I\'ve been studying it for 20 years,
is Medicaid. Believe me, Medicaid is always changing, so I can keep
studying it forever I figure. What\'s interesting is that it has really
become a growing portion of substance abuse treatment. In 1986, Medicaid
accounted for only 10 percent of all spending, but in 2003 it accounted
for almost 20 percent, at 18 percent. If you look at that Medicaid
substance abuse spending, you\'ll see that our largest provider,
substance abuse clinics and specialty centers, are really taking an
increasing share of those Medicaid dollars.

Because of that, I want to digress just a little bit to mention some
changes that have been happening in Medicaid, because they are affecting
states, and some states rather dramatically. So I want to just mention a
few of those changes. There are some audits going on by the Office of
Inspector General, OIG, looking into Medicaid spending, and they are
finding and asking for reimbursement for services that in the past were
covered. So, for instance, they have identified wraparound services
often used for children and adolescents. They no longer want to have
that in bundled rates. They want you to break out each individual
service. We saw in Georgia that they looked at a residential treatment
facility and they said that they wanted all of the charges unbundled for
residential treatment. They didn\'t want a day charge. They questioned
psychosocial rehab as a Medicaid reimbursable service, and they also
questioned residential supports.

Another area that OIG and CMS have been looking at is something called
the rehab option, and it\'s a more flexible financing option under
Medicaid and has been used a lot in the substance abuse treatment field
for intensive outpatient, and other kind of community‑based, consumer
support recovery services. Well, it is clear that some of the
interpretations are now changing. For instance, they are now making a
distinction between rehabilitation, which is restoring functioning for a
client, versus habilitation, which could be new services. So, for
instance, a March 2005 audit in Iowa, they were providing socialization
skills to some clients, and CMS said it should not be reimbursed by
Medicaid because this wasn\'t restoring functioning, it was creating new
functioning, and therefore it was habilitation.

They also have interpreted that treatment must be very specifically
directed at children, not the family, the child who is eligible. So, for
instance, they have an audit to disallow any reimbursement for services
if the child is not in the room. If the therapist is talking to the
family, as we all know in terms of family therapy, without the child in
the room, Medicaid no longer considers that directly service to the
Medicaid beneficiary and is denying those services.

I think for you providers who may use these options, it\'s very
important to know that their requirements to have specific treatment
goals, to document every service date, to be sure that your providers
have Medicaid status is another area of audit. So in Illinois in
September 2006, the lack of service documentation in treatment plans not
signed off on by all specified parties resulted in CMS asking Illinois
to pay them back \$5.971 million.

Other states have also been impacted. Massachusetts was asked to return
\$1.7 million because CMS said they should not use targeted case
management to pay for social work salaries of child protective services
workers. In Georgia, they were asked to return \$40 million because they
didn\'t deem all of these rehab services to be treatment. Some of these
were social services, like recovery or psychosocial education, and those
aren\'t medical services. They came to that conclusion. Texas is paying
back or is supposed to pay back \$9 million because the school did not
well document that their providers had Medicaid provider status or the
individualized educational plan wasn\'t sufficient for treatment.

So I just mention those to give you all the heads‑up about that.

Getting back to the National Expenditure report and kind of summarizing
some of the trends, when we look at payers I think it\'s important to
see that private insurance\'s share of all substance abuse treatment has
declined. So over three‑quarters of the substance abuse treatment
spending costs are being borne in the public sector. It\'s important to
recognize that states have a tremendously important role in directing
and designing some of those dollars, although clearly federal leadership
is called for in terms of promoting the best practices.

Looking at providers, I think the slide that I had about two‑thirds of
substance abuse providers being other professionals indicates that our
workforce interventions may be something a little bit different than
mental health workforce interventions, where physicians predominate. So
I think workforce is an important issue both sides of the fence, but I
think it\'s important to recognize differences in the make‑up of the
workforce.

Also, the specialty facilities are very important providers who are
increasing using Medicaid, but as they enter into those Medicaid
arrangements, they have to develop infrastructures for claims‑based
billing, for encounters, for checking eligibility. It is an
infrastructure that many of them who have been used to program grants
are really struggling to adapt to, and I think it may be an area that
greater attention could be paid.

So that\'s my short and sweet little report. I don\'t know if you all
have any questions or comments.

MR. KOPANDA: Bettye?

DR. FLETCHER: Thank you very much for your presentation. I\'m sitting
here trying to digest this, so I need to verify if I heard right. You
said that the private share of expenditures for treatment is declining,
the public share is not level but dipping a little bit, and Medicaid is
narrowing its definition of treatment. Am I correct thus far?

DR. VANDIVORT: Yes.

DR. FLETCHER: What does all that mean?

DR. VANDIVORT: Well, I personally, as somebody who is always trying to
figure out how to finance substance abuse treatment, I think we focused
a lot on the specialty substance abuse provider in the substance abuse
treatment field. I think we need to, as Dr. Cline mentioned, look
perhaps more broadly at some of the general sector. I think we also need
to wrestle with employer‑sponsored health insurance, which has really
been a huge decline in terms of payment. So I think we need to think of
strategies that can make the case better, I suppose, to employers that
there is value and there is value that they will gain if their employees
have access to private health insurance that covers. In fact, we
recently did a study tagging onto the Kaiser employer study looking at
substance abuse treatment benefits and limits, and what they indicated
was that clearly substance abuse treatment has day limits, has visit
limits, has higher deductibles.

That said, almost 90 percent of those employed have some substance abuse
coverage, and yet we see declines. I think some of it is utilization
management controls that are part of the managed care arena. But I will
tell you that private health insurance knows they serve the employer,
and if the employer says we need to be sure we have access to substance
abuse treatment, utilization management guidelines can be loosened so
that the needle you have to thread to get into substance abuse treatment
is not quite so difficult.

Does that answer? Does that help? That\'s part of it.

DR. FLETCHER: That does help some. I\'m just sitting here reflecting on
where we were 10, 15, 20 years ago in this field, and it looks like
little has changed. We\'re still struggling with some of the same
issues.

DR. VANDIVORT: I think we are. Clearly, some other numbers I didn\'t
share today show the huge shift from inpatient. The 28‑day residential,
which was the gold standard in the \'80s, is just not available to most
people, whether you\'re covered publicly or privately. So I think we
have to be sure, though, that we support alternative models, like
intensive outpatient. Commercial insurance tends to have inpatient and
outpatient. It has nothing in between, and I think we need to look at
the reimbursement for those kinds of community based so we have a real
continuum in benefit structures.

MR. KOPANDA: Val?

MS. JACKSON: What you\'re saying makes a lot of sense to me.

DR. VANDIVORT: Great.

MS. JACKSON: I think that from your numbers, the percentage of insurance
has not gone up, it\'s gone down. However, Medicaid, which is a national
insurance, is expanding and going up for a certain group of people. If
in this country we recognize that addiction is a disease, and there\'s
quite a bit of evidence to show that it is, then it seems like it would
be the job of SAMHSA to really help to educate ‑‑ I mean, it\'s the job
of all of us, but I\'m talking as a council person here.

What can we do to help get the message that you just said across? And
that is that someplace along the line, there\'s the parity in Congress.
Folks need to get out and support that. That\'s an outside thing. I
realize that. But at the same time, can you as SAMHSA ‑‑ you can\'t
lobby, but you can certainly provide information, and that information
that you gave is pretty key, and I\'m sure there\'s some other
information that you probably have that you didn\'t even present that
shows an even more stark thing.

I mean, when you see it in the papers ‑‑ I\'ll speak for Florida ‑‑ that
50,000 kids, 60,000 kids, whatever it is, don\'t have any insurance, and
another 20,000 are running out of insurance before the year\'s end that
are supposed to be covered by the state that we pay taxes for, you kind
of wonder, gee, what happens, and what\'s happened to our country that
we don\'t have some insurance benefits not only for kids, but then I
take it to this and I say for substance abuse and mental health? It\'s
an issue that used to be on the table a lot more often. I don\'t know
how to get it back on there, but it\'s frustrating to see this report. I
mean, it\'s a very interesting report. Don\'t get me wrong. But it\'s
frustrating to see ‑‑

DR. VANDIVORT: The trends.

MS. JACKSON: The trends, yes.

MR. KOPANDA: Frank?

DR. McCORRY: Thanks, Rich.

I love seeing this information, and of course it\'s kind of
overwhelming. You don\'t know quite what to do with it.

I wanted to ask you, Rita, so this gives us the Medicaid picture
relative to private insurance. I count about seven or so actual funding
sources going into any program in any state in varying degrees from
Medicaid, commercial insurance, block grant, state appro, local appro,
self‑pay, grants, foundations, six or seven, right? Some states don\'t
have Medicaid at all, no substance abuse services, and I hear also now
Medicaid is starting to get more finicky about what they\'re going to
consider to be a medically necessary condition for reimbursement.

DR. VANDIVORT: Absolutely.

DR. McCORRY: I try to figure out state by state how Valera and Anita do
it. How do you construct a sustainable program of services when you\'ve
got these kinds of constantly shifting dynamics around funding within a
particular locality? That\'s one question. Have you figured out a way to
get a handle on that?

Secondly, is there a way to ‑‑ for example, for the State of New York
versus the State of New Jersey, how these funding streams, the
percentage of services covered and the arrangements by which the funding
is used? I\'m not sure I\'m saying it correctly, but it\'s such a
patchwork, it\'s such a quilt, that it\'s really difficult to
understand. It\'s hard almost to call it a system. It\'s hard almost to
call it a financed system of care. It\'s so variable by locality, by
provider, by policy. What do we do about that? Give me some hope.

(Laughter.)

DR. VANDIVORT: Well, I don\'t have a magic wand, but I will say I think
we were talking earlier about sustainability being something that people
should worry about from day one when they get a discretionary grant. I
have a very large document that I\'m trying to finalize that\'s a
financial catalog looking at all funding streams for children and
adolescents for mental health and substance abuse. The problem with it
is we can point to programs, but as you say, every state is different.

So we can say here\'s the general outlines of the program, now go talk
to your SSA, or go talk to your Medicaid director. So I think part of it
is trying to empower people with some tools to say ‑‑ because I think
what people have to do is have a very diverse strategy. I\'m sorry Chilo
isn\'t here because he\'s one of the best providers to speak about that.
I\'ve had him at my finance meetings. He says I\'m looking for the payer
of least resistance, because everybody wants to be the payer of last
resort. Unfortunately for providers, it is a struggle, I think, for the
states. But I think you have to diversify as much as you can, try to see
what other states have done, see if it works for you.

DR. McCORRY: I\'m sure you\'ve spoken to NIDA and NIAAA, because they
talk about health services research all the time and they always have a
financing piece in their RFA. I haven\'t seen any financing studies
myself. They might be out there, but I haven\'t really looked. Is there
a way for CSAT and NIDA and NIAAA to figure out a study in which the
state profile of expenditures that support ‑‑ and I\'d use the NIDA
principles as the standard of care, and that we would be able to do a
descriptive study of what elements in what percentages and with what
conditions exist.

Can we develop a protocol that would allow for us to have a view within
a particular political district or division, a state or some
subdivision, of how these monies flow in and out to create what we call
the substance abuse treatment system?

DR. VANDIVORT: Actually, I think my boss has much better connections to
NIDA than I do. I mean, I think it\'s a very interesting idea, Frank. I
think we need that kind of data. I was earlier this afternoon in a
conversation about Medicaid and some regs that are trying to be cleared
around the Deficit Reduction Act, and we\'re going to have a
conversation with them to try to portray what happens to our populations
when some of these regulatory changes are made.

But Kathryn Power came to me and said, now where\'s the data for this,
and can you show that if this changes, that it will have a negative
impact? We\'re going to scramble and try to get some data, Jeff Buck and
I, but it\'s a struggle.

MR. KOPANDA: I\'d like to mention just very briefly that I represented
Dr. Clark on the recent SAMHSA National Advisory Council meeting, and
the council had a very interesting, not very long but an interesting
meeting in terms of all the changes, kind of putting on the table with
extensive discussion all the changes that are happening in the system,
from in our case buprenorphine being prescribed by physicians and
therefore we have a whole other set of treatment providers even that\'s
represented in these data, the fact that we\'re moving more toward
recovery‑oriented systems of care, the fact that we have more
paraprofessionals in our system and what does that mean for the future,
the fact that we\'re really providing more services, moving more toward,
as Dr. Clark mentioned this morning, the primary care system being more
engaged through not only screening but through the provision of referral
to treatment through community health centers, the fact of the realities
of the funding change that we\'re seeing here, and as Rita mentioned,
the more intensive use of outpatient treatment.

So everything that\'s happening, we describe it more like a sea change
is happening in the entire system, and we didn\'t come to any
conclusions, but there was some initial thinking that maybe we need to
develop some kind of an overall construct for where we want the system
as a whole to go. But within that mix was the reality of cuts in
Medicaid funding, the changes in the whole funding structure and the
fact that we may or may not get parity legislation.

DR. McCORRY: I don\'t know if anyone could actually define it, but what
is the financing model of addiction treatment in this country? What does
it look like? Because I think the variability is so great that not only
is it each state but it\'s so variable and it\'s so unique in its
expression that to call it a financing model is perhaps an
overstatement. It\'s a collection of accommodations and opportunities,
the payer of least resistance, as well as tremendous reliance on the
feds, as Rita describes here.

It\'s just interesting to think that such a huge public health issue can
be funded in such an ad hoc kind of sixes and sevens, let\'s grab
what\'s available kind of approach. It just doesn\'t make sense to me.

MR. KOPANDA: One thing you see from these data is that really it\'s the
state and local funding which is the core of the support for the whole
system. It\'s really not federal funding, even counting Medicaid.

DR. McCORRY: Even counting Medicaid?

DR. VANDIVORT: Yes, that\'s true. Those data were built up from the
facility level up.

I think it is a patchwork, but I think it would be helpful to have more
data. I think we need to make our case better. For instance, one of the
things we\'re looking at for private insurance is that you\'ll see in
private insurance disease management techniques right now, and they\'re
very willing to go into depression because they\'re spending a lot of
money on depression drugs. They don\'t think they\'re spending money on
substance abuse treatment, but they are spending money. It\'s in their
medical services, and we\'re trying to tease that out. We\'re using some
AHRQ data sets to try to tease that out so that we have better data to
make our case.

MS. JACKSON: And maybe as you look at that, you\'re looking at it from a
kind of an aggregate and from a large picture, although I appreciate the
fact that you pointed out some Medicaid things in certain states that
are going on. It might be interesting to take a sampling of some of the
agencies. Like if you take The Village in Miami, there are anywhere from
25 to 30 funding streams on any given day. It is amazing, and managing
it is amazing.

DR. VANDIVORT: Yes, it is.

MS. JACKSON: And being audited for all those 25 funding streams is
amazing.

DR. VANDIVORT: You\'ve got to keep it straight and report it separately.

MS. JACKSON: Exactly. But also diversification became a goal of ours in
the \'90s with this trend, saying we can\'t just get our funding from
the state block grant or DCF because, frankly, we\'re putting ourselves
and our agency and our clients in jeopardy and at the mercy of whatever
happens there. So our goal became to diversify, and we were very
successful at it, which I\'m pleased to say. The other side of that,
though, is that we have this ball juggling thing, and it\'s a
never‑ending ball juggling thing. Then you go to the agency down the
street and they\'re barely hanging on with some homeless funds, along
with getting paid \$40 a day for residential and barely hanging on with
a little bit of outpatient here.

We have these wonderful health maintenance organizations who knock on
the door and say please sign up with us, we want you as our provider.
We\'re Joint Commission accredited, all kinds of things, we\'ve got lots
to offer, and we say great, that will be really nice. I\'m sure that we
have 50 of those things signed, and how many referrals do you think we
get? We don\'t. I mean, it\'s very small. There are maybe one or two of
those HMOs who actually recognize that there are some people with
substance abuse problems, and they will refer them usually for some
outpatient, and they do recognize intensive outpatient. So there are a
couple I give credit to, and maybe you\'d find those, and there might be
some answers there.

So not to carry on, but to say it\'s maybe a look from the grass up and
from the top down to see if we can figure out some answers.

DR. VANDIVORT: Great suggestion.

MR. KOPANDA: Anita, do you have a question?

MS. BERTRAND: Yes, just a comment on what Val and Frank were saying. I
think that, Val, you\'re exactly right, because I had the opportunity to
go to Florida and to look at a model program, and what I found as I
visited the program and looked at the diagrams that they showed me,
it\'s almost like when we walked out of there I had a couple of board
members with me, and we looked at how they actually had maxed out other
systems, and not just this system but our clientele are struggling with
housing, and our clientele are struggling with trying to retain their
children back. So you have all these other departments who you could
partner with, and it\'s really an art to be able to do that.

So I commend providers that are able to do it, and I\'m still trying to
learn that. But it\'s something that could be taught to executives. A
lot of times executives are grandfathered up into those roles, but do
they really have the skills in order to pull those kinds of things off?

Dr. Stein and I talked about this over lunch, how do you set up a
structure like that, and one of the main things you have to have is an
infrastructure. You have to have your directors and a good finance
person to be able to manage it so that you can juggle that ball, and I
agree with you, Val, that we could look at a couple of model programs
around the country to see what they\'re doing and how they\'re doing it,
because I think it does help our system to look at it more globally.

A question I had was about the IMD rule, if you know anything about how
that\'s going, because I look economics in terms of leasing a building,
and we could lease the third floor of a nursing home, but we can only
put 16 beds in there. It\'s like if we wanted to expand those services
for individuals and to pay, we would expand on the light bill a little
bit more. But it\'s just more economical to be able to have our clients
held in one building. So where are they in terms of looking at that
room?

DR. VANDIVORT: IMD, just real quickly for people who aren\'t familiar,
stands for Institutes of Mental Disease, and when Medicaid was passed,
you all may remember in the mid‑1960s, there were huge state hospitals,
and Congress was very clear they didn\'t want to pick those up. They
wanted the states to keep paying for those. So they put in this rule
that said Medicaid funds can\'t go to an institution that\'s primarily
directed at mental illness, to which they include substance abuse
because we\'re both in the DSM‑IV.

I will tell you that in the late \'90s there were some states that were
able to waive the IMD through an 1115 waiver, but CMS has telegraphed
that when those 1115s come up for renewal they will no longer continue
those IMD waivers. I wish I could give you a lot of hope on that, but I
think it\'s pretty much going to be continually enforced. There isn\'t a
way around it right now. I\'m sorry.

DR. FLETCHER: Rita, could you speak to what you think will be the
programmatic impact of this redefinition or reinterpretation of support
services? For instance, the notion that service can\'t be paid if the
child is not in the room. Are we redefining what constitutes treatment?

DR. VANDIVORT: Again, some of these are being done by audits. There are
a number of regs from the Deficit Reduction Act that should be coming
out soon to clarify this. I think we as SAMHSA are trying to make a case
that as CMS says that it supports community‑based living, what our folks
need for that community‑based living are these types of supports and
flexibilities. But we\'re still trying to discuss that. Medicaid is the
100‑pound gorilla, and when you look at it, in their whole funding,
substance abuse accounts for a little over 1 percent. So it\'s like
trying to wave down the gorilla when you\'re a little mouse. So you\'re
trying.

DR. FLETCHER: You eat gorillas one bite at a time.

(Laughter.)

DR. VANDIVORT: I like that. Thank you.

MR. KOPANDA: I\'d like to thank Rita for that enlightening presentation.

I know it\'s been a long afternoon. We have one more presentation. Val
Jackson, who is a CSAT E‑Therapy Subcommittee member, will present on
e‑therapy initiatives, along with Captain Stella Jones from our Division
of Services Improvement.

MS. JACKSON: I\'m going to say that I\'m sort of the nodding head up
here, because fortunately Stella and her colleagues have been working
very hard on this initiative. So I\'m going to ask Stella to give us a
presentation today, and then I\'d just love to hear a little bit of
comment about how we might go forward with this, because we were talking
at the break about the fact that the contract time for this is really
pretty much up. We\'re coming up with a publication, and where are we
going to go from here? So as you\'re looking at the presentation, I hope
you kind of think about e‑therapy in a general way and what\'s going to
happen to it. It\'s going to go, it\'s going to happen. Are we going to
have input, and where do we want to go with that?

Thank you, Stella.

CAPTAIN JONES: Thank you, Val.

The title of today\'s presentation is \"Implementing E‑Therapy in
Special Populations.\" An overview of today\'s discussion will include
lessons learned from the literature review with regard to e‑therapy. I
will highlight and brief what providers of care may consider when
implementing e‑therapy in special populations. I will identify some of
those hard to reach populations, some of the key factors to consider
when implementing e‑therapy, and talk about challenges when implementing
e‑therapy and proposed solutions. I will provide a response to a
discussion from the National Advisory Council meeting held in September,
and lastly I will discuss next steps, which is a follow‑up from
September National Advisory Council meeting.

What literature informs is that e‑therapy can potentially provide
treatment to underserved and hard to reach populations. Providers must
be knowledgeable of issues related to cultural and linguistic
competence. Successful implementation of e‑therapy, however, requires
more providers to be trained in online counseling, possibly additional
languages and cultural nuances within special service populations.

We\'ve learned that more research is needed on the efficacy of e‑therapy
within diverse populations. Also, what\'s critical is that licensure and
regulations for e‑therapy must be clarified, particularly for treatment
provided across jurisdictions, and that implementing e‑therapy requires
a certain level of technological savvy for both the providers of
services and for clients.

Some of the special populations that we\'ve identified are the elderly,
American Indian, Alaska Native, rural populations, as well as
adolescents.

Some of the key factors in implementing e‑therapy are accessibility,
cultural competence, and usability, and I will expound on those.

Accessibility requires more availability of computers, telephones, video
equipment, Internet access and other uses of technology. Equipment costs
for service providers can be very costly; and, of course, the digital
divide.

With regard to cultural competence, language is a big factor,
educational level, the level of psychological and physical functioning,
and recognition and respect for the ethnic, language, cultural, and
age‑related characteristics.

Usability. These, of course, are the challenges: skill and experience
with technology, fine motor skills, as well as visual and hearing
impairment.

Some of the proposed solutions. With regard to accessibility, there
should be increased availability of computers and Internet access. This
may occur through community centers, schools, faith‑based organizations,
and also senior organizations for the elderly. There should be training
programs to train staff on use of various kinds of technology. Software
for novice users is also a solution.

With regard to cultural competence, service providers trained to
understand social and economic factors that may initially impede
treatment efforts, that\'s a proposed solution. Cultural appropriate
assessment and treatment tools, this is very useful in particular for
use with the Internet and has been very successful with adolescents.
Translation and interpretive services, there may be a great need for
those. Bilingual and bicultural providers should be part of the staff
that one considers.

Usability. The provider of care may need enlarged graphics, interfaces
and targets, universal access to new technology, support for older
hardware and software to accommodate fixed incomes, and implement
programs to facilitate comfort with technology.

I would like to respond to some of the discussion from the National
Advisory Council meeting held in September with regard to a question
having to do with research findings on the efficacy of e‑therapy. We
found that for substance use disorders, treatment is promising for rural
populations as well as for adolescents. Research investigating the
efficacy of Weight Watchers and other 12‑step programs, use of e‑therapy
is limited, and that was another question that was raised.

Next steps. We were to synthesize and finalize the review of e‑therapy
literature, and the review and synthesis has been completed. Develop an
e‑therapy guidance document; development of guidance document is in
progress. Assess readiness to provide e‑therapy. Literature review can
be used to inform the development of readiness assessments for e‑therapy
service delivery. The last is determine the feasibility of e‑therapy
demonstration projects, and literature can also be used to inform the
feasibility of e‑therapy demonstration projects, we found.

I\'d like to recognize the CSAT advisory council e‑therapy subcommittee,
Val Jackson, and other members that are here. Also, I\'d like to thank
the SAMHSA CSAT e‑therapy staff who are present here for their support
in this effort. I\'d also like to recognize the contractor, MayaTech
Corporation, who has been very, very helpful in helping us with this
particular document and this initiative. Thank you.

Are there questions?

MR. KOPANDA: Any questions?

I just might mention that for this year for our Targeted Capacity
Expansion Program, we have a program called Targeted Capacity Expansion
General. We generally have it available for different kinds of
activities, and this year for the first year we intend to have a focus
area on e‑therapy. So for the first time ever we expect to make some
e‑therapy‑related grants this year.

Question?

MS. JACKSON: Did the whole council or the members of the committee get
the document that you sent out?

CAPTAIN JONES: The entire council. No, the subcommittee.

MS. JACKSON: Right. The subcommittee was sent only a couple of weeks
ago, so I\'ll have to get in touch with the other members who aren\'t
here today. You sent us a draft of the guidance document that is being
developed. I have had a chance to partially review it, so I\'m as guilty
as anyone for not getting information back. Judge, perhaps we\'ll have
to get together and have a conference call or a talk or something, but
if you want to go through that and make comments, that really would be
helpful because what they need to do is to get the guidance document
completed. I think they have a limited time frame for that. So I\'m
going to get my comments back in very quickly and we\'ll work on this,
and maybe we can get in touch with the others who aren\'t here today.

CAPTAIN JONES: Thank you. Thank you so much.

MR. KOPANDA: Other questions?

(No response.)

MR. KOPANDA: No questions?

(No response.)

MR. KOPANDA: Thank you very much, Stella. We appreciate it.

I think we\'re just a tiny bit ahead of schedule. We have now time for
council roundtable. We do have at least 25 minutes. We could get back to
the 2008 budget or any other issues that the council would like to
discuss.

DR. SKIPPER: Thank you. I\'m eager to talk about two things that I think
are really important, and to make it concise I\'m going to look at my
notes here. One is about drug testing. There\'s a growing body of
evidence regarding the benefits of drug testing both in improving
outcomes of treatment and in prevention of substance abuse, like in
schools and so forth. Preemployment, random and for‑cause testing in the
workplace is known to decrease substance use in the workplace, and I
think SAMHSA oversees drug‑free workplace rules and so forth. Testing in
schools I mentioned. The concern I have is while the ONDCP and NIDA both
are supporting more drug testing, and I suggested SAMHSA develop an
interest in promoting appropriate use of drug testing both for
prevention and treatment of substance abuse, currently there\'s no
agency that oversees drug testing in schools by licensing boards, from
homes ‑‑ there\'s a growing group of people who buy the test kits and
test their children and so forth in homes ‑‑ and I suggest SAMHSA do
three things about this.

One is, like I said, promote an increased use of drug testing, which I
think has been shown to prevent initial use and decrease relapse in
aftercare situations to improve outcomes.

Two, promote training of licensing boards, schools, courts, parents, et
cetera, in the proper use and interpretation of the drug testing. A lot
of people are doing drug testing, and nobody regulates how they
interpret the result and how they use it, and it would really be good if
we set up some educational programs for boards, did something for
parents and schools and so forth to let them know, yes, it\'s a valuable
resource, but it needs to be used in a certain way. We kind of launched
into that a little bit when we issued the advisory about EtG testing. I
just think we need to do it more.

Three, I think we need to promote increased training of MROs. These are
the medical review officers under federal testing guidelines that we
oversee for the drug‑free workplace. MROs get one day of training and
certification, and I\'ve been very disappointed in these physicians that
are supposed to oversee these testing procedures, that they don\'t have
the training or knowledge to really interpret tests properly. They
generally just see their role as being sure the form is signed, and
there\'s no prescription, and they\'re not looking into issues around
incidental exposure and so forth, and they don\'t want to because it
takes them more time. So I think SAMHSA might want to look at what can
we do to improve the education of the doctors who are supposed to
oversee drug testing.

So I\'m going to throw that one out there and see if there are any
comments, but I have another issue.

MR. KOPANDA: Thanks for your comments and your recommendations. As you
mentioned, drug testing in SAMHSA is primarily done within the Division
of Workplace Programs for federal drug testing in the Center for
Substance Abuse Prevention. We\'ll provide them with your comments.

DR. SKIPPER: Well, I think it needs to be looked at from the point of
view of CSAT, and I\'m going to try to get on the agenda next time.
There\'s a growing body of data that if we take people after treatment,
and very few receive ongoing drug testing, but there\'s research now
under contingency management protocols where if you do drug testing
periodically and set up some kind of reward, either positive or negative
reward system with money, work, different ways to do rewards, families,
privileges for teens to drive the car, this and that, outcomes just
really improve, almost double in the studies I\'ve seen. So we\'re not
just talking about prevention. We\'re talking about introducing this to
improve outcomes. Like the program I run for physicians, I think it\'s
one reason we have such high success, because we do long‑term, periodic,
random drug testing. So I don\'t want to just relegate this to CSAP. I
hope CSAT looks at it, too.

MR. GILBERT: I think that we\'re getting a little bit maybe on thin ice
here, but I think that we already do address drug testing in the context
of treatment. I think a number of TIPs talk about the appropriate use of
drug testing for exactly the kind of thing you\'re talking about. So I
think it\'s an issue that we have looked at, but there may be some way
to pull together a more cohesive response or something. But it\'s not an
issue that has been ignored by the treatment side of SAMHSA. We
recognize that testing can be an important incentive.

DR. SKIPPER: Let\'s boil it down to I would propose that we set up some
educational programs for medical boards, maybe even drug courts and
others that are already doing testing to be sure they do it properly. I
don\'t think that\'s really been proposed, and maybe some literature for
home testing and school testing.

DR. McCORRY: I thought you were going, Greg, with a kind of aftercare
testing as well, which I don\'t think has been studied. I don\'t think
there\'s much literature on that, as you want the continuing care
management issue and the role of testing in that capacity, as well as
contingency management, which could be a little bit controversial but
it\'s an interesting idea. I hadn\'t thought of it.

MR. KOPANDA: Any other comments? Anita?

MS. BERTRAND: In light of our budget and where we are, I would like to
see us continue to support community‑based and faith‑based organizations
in some manner, and even as we look at the initiatives that are coming
out and the language that we put into those RFPs, that we make sure that
those that are in need of the services can get the services and that the
dollars are not eaten up in administrative costs, not that I have
problems with state bodies and local bodies, but just those
administrative pass‑throughs sometimes, or if there\'s things that we
can do. As we talk about having a recovery‑oriented system of care, that
we continue to keep the consumer in mind. If I had to sort of look at a
couple of things up there that it sounds like the council really thought
about, it would be like the TIPs we\'d like to see things around, and
the Recovery Month event, because that\'s an opportunity for us to
continue to showcase the success of the work that we do. So I just want
to kind of put that on the radar, that I think that\'s something
important and just ask the council to consider it as we draft up those
things that we remember, that the end result is getting the services
that the people need.

MR. KOPANDA: And, by the way, the previous discussion that we had on the
2009 will be all considered in the 2009 budget as we begin to develop
our proposals for 2009. The issues you\'ve raised about Recovery Month,
about all the activities that we\'re not able to do, we will take that
into account, as well as any other suggestions you have for things that
have come up during today or for new activities.

I\'ll just mention a couple of things with respect to what you just
mentioned. It\'s a small amount of money, but the TCE money that we\'re
going out with this year, we\'re also going to have a focus area on
recovery‑oriented systems of care whereby the grantee applicant would
come in and have, for lack of a better term, grassroots organizations,
small organizations with operating budgets of, say, \$500,000 or less,
and that they would operate a system or propose to operate a system of
care involving those small organizations, which could include
faith‑based organizations. We may take that approach in other programs
as well.

MS. BERTRAND: Just also in looking at the review process and what I know
about it historically, and just to empower the staff, because I know
that you all have a lot of expertise around knowing what a best practice
might be, just to consider having some input from the project officers
around what they may think would be a good initiative to invest in, as
opposed to having an outsider that knows absolutely nothing about this
particular system, or maybe not even about the application that they\'re
looking at, because we\'ve got some wonderful places that can write very
well, and then you have some that can\'t write very well but can do very
good work and reach the people who are really out there in the trenches.
So I just wanted to say that as well.

DR. SKIPPER: My other issue is around the issue of prescription drug
abuse. As it\'s growing and has become the greatest source of drugs of
abuse now, prescription drugs, I\'m thinking that SAMHSA needs to take a
little more active role in talking with the FDA about drugs that may be
the most risky and whether, as we talked earlier, their availability
should be reduced, and if they are available, to encourage training of
the doctors who prescribe these drugs. Right now we require training for
doctors to prescribe buprenorphine, and yet no training to prescribe
Dilaudid, Demerol, OxyContin and so forth, not that doctors don\'t have
training, but no specific training around addiction. I think the
availability of all these drugs obviously is coming from physicians who
prescribe mostly for chronic pain, and some states have taken some
action toward requiring training, specific training for the doctors that
treat chronic pain.

I think on behalf of addicted or potentially addicted patients and those
that will relapse because of all these drugs out there, we should take a
little more active role. I know we can\'t regulate what drugs are
released. That\'s the FDA or the DEA\'s job. But we can certainly make
recommendations. I don\'t know how that works, but I would like to see
SAMHSA move toward getting concerned and expressing that concern, even
to the point of saying we think this drug should be pulled off the
market. That\'s pretty bold, but we can say that to the FDA. I\'ve done
that myself.

MR. KOPANDA: I see we have Ken Hoffman here with us, Dr. Hoffman, and
our Division of Pharmacologic Therapies will be holding a meeting, as we
discussed earlier, on methadone, and we\'ll take that up at the meeting.

DR. McCORRY: During this time, we say things we\'d like to do? Is that
what we\'re on? I just want to make sure.

MR. KOPANDA: It\'s a roundtable. It\'s basically open.

DR. McCORRY: Great. I\'d like to add one to the list. I\'d like to see a
presentation here from ONDCP, because I understand it\'s still about a
one‑third/two‑thirds split between demand reduction and supply
reduction. I\'d like to understand how the two‑thirds supply reduction
related to outcome data, the impact that they\'ve had relative to the
work of ‑‑ I understand statistics about the number of metric tons of
cocaine taken off the street. I want the policy issue of impact on
actual availability of drugs. I\'d like to hear ONDCP talk about that
and square that up with the two‑thirds/one‑third split in federal money
for supply versus demand reduction. My understanding is that we\'ve
never been more efficient in taking drugs off the street and that it\'s
had minimal impact on availability or on price. So the policy question
becomes why are we spending all that money on supply reduction when
there seems to be a greater need on demand reduction.

MR. KOPANDA: Thank you. We will talk about that at one of the upcoming
council meetings, inviting ONDCP to present.

Judge White‑Fish?

JUDGE WHITE‑FISH: I tried to understand this budget, but I was still
lost in the budget process. I\'m not a financial individual, but it kind
of scares me overall. If we look at Native American Country, I don\'t
believe the addictions have decreased. I can\'t speak for all nations,
but I would hope in some part of the Native American nations the
addictions have decreased. Yet, our budget in looking at addictions,
it\'s decreasing and they\'re cutting. It\'s really sad to see it. I do
realize that I\'m happy that none of SAMHSA employees are going to be
losing their positions, and I don\'t say that facetiously, because of
the work and what\'s trying to be done in addictions, and it\'s sad that
we have to allow our monies in order to control that. By the cuts in the
budget, one would naturally assume that addictions are in a decline.
Does the board agree with that? That\'s exactly what they\'re trying to
tell us is the way I feel inside.

My people have told me that we start at home with taking care of our
people, taking care of our elders and taking care of our youngsters, and
I\'ve heard different presenters talking about prescriptions on the rise
in our elders, and I see that at home. A lot of our elders are beginning
‑‑ we have a pharmacy. Our tribe is very fortunate. We have our own
pharmacy. I don\'t believe how many elders I see up there at the
counters getting prescriptions, and I\'m questioning myself because of
my background.

But to see the cuts in the overall budget of SAMHSA and CSAT, it saddens
me, and I say that wholeheartedly because I know the addiction is still
out there and I haven\'t seen any reports or anybody telling me that
it\'s on a decline here, but yet they will cut the budgets drastically.
Anita and I were sitting here, we were trying to figure it out, and then
we found out it was in the millions of dollars. That wasn\'t just
\$4,000. That was \$400 million or something. It\'s, like, uh‑oh. I
mean, we\'re talking about lives out there, and yet we know where the
money is going, and lives are being taken there. But we still have to
take care of our people at home. I guess I would question it. Maybe we
need to look at starting new programs. If SAMHSA and CSAT are going to
do new programs coming up, we\'ve already got programs that work.
Weren\'t we talking about evaluating and what\'s working? If we\'re
going to let this work, if this works, then let\'s keep doing it. If we
have a program that\'s working right now and the budgets are being cut,
then let\'s continue those programs that are working rather than
exploring new programs that we don\'t know are going to work if they\'re
going to continue to cut.

I\'m going to use a quote that I heard. I was back here two weeks ago.
As we all know, I come from the north woods. I come from Wisconsin, and
this is my most favorite place to come because I get lost all the time.
Something always happens to me in Washington, D.C. No clothes until this
morning. I didn\'t know I had a ticket until the day I took off, and
then I ran from one plane to another in Milwaukee, Wisconsin. My clothes
couldn\'t run as fast as me, I guess.

(Laughter.)

JUDGE WHITE‑FISH: But thank goodness they got here and everything worked
out. I had the attitude that if everything is meant to be, then that\'s
the way it is, and I told the airline that, and they were quite
surprised, and I told Mr. Basher that. It was not meant, then a ticket
will not arrive, and that\'s okay, I have to accept that.

But there are things I can accept, and there are things I cannot accept.
It\'s real hard for me to accept that budgets are being cut so
drastically. When I was out here for the National Congress of American
Indians, I heard it stated, and I\'m only quoting it because I
remembered it very well: \"If there\'s \$700 billion that\'s being
spent, take 1 percent of that and leave it at home for our people.\" We
have people that are suffering from this disease, and the monies need to
take care of our people at home. I don\'t know how much more I can say
on that, but I hope that the people further up, instead of cutting these
just because they didn\'t have an explanation, as I was talking ‑‑ they
explained it that they didn\'t have an explanation. Okay, what is this?
They didn\'t understand it, so we\'re cutting it. Some of the monies
were meant for a good reason and a good cause, and they\'ve been
effective. It\'s sad that they were cut looking at that, but we\'re
affecting our people, our own people, and I hope their eyes open and at
least release some of that money so that we can continue to do and
progress in the job that we\'re meant to do, I guess, that we were put
here to do. Thank you.

MR. KOPANDA: Thank you for your comments and your sentiments on that. I
think they\'re widely shared here.

DR. FLETCHER: May I please, Richard? I\'d like to echo the distinguished
Judge\'s comments. I think they\'re quite apropos.

As I listened to the presentations this afternoon, the morning
discussion really framed and created the window through which I received
those presentations. For instance, I heard in the recovery support
system presentation, the need for infrastructure support. When we had
the ATR presentation, I heard talk about the need for technical
assistance for faith‑based organizations. When the NREPP presentation
was made, the extent to which our knowledge in this field is driven by
some of the work that has been done with the TIPs. So saying that, my
question was, my God, is this budgeting process one that is lacking
evidence‑based budgeting, if you will, to use my own terminology?

(Laughter.)

DR. FLETCHER: It does not appear to be evidence based.

Two points I want to make to that extent. One is the extent to which the
reductions do not reflect efficiency. I use that as an example of the
HBCU program, which has an expansive scope but few dollars. Is that
informed decisionmaking when we decide to cut such a program that\'s
reaching 107 institutions of higher education in this country for a very
modest amount of money? So it raises an efficiency question for me in
terms of that process.

My second point is the extent to which the budgeting decisions have the
potential of retarding our progress in the field of substance abuse.
Again, I use as the example the TIPs documents that have become a major
reference source and a knowledge dissemination tool that we are using to
advance the field. My question becomes ‑‑ and it\'s a rhetorical
question ‑‑ whether or not there\'s a potential there for retarding our
movement in that regard.

So I would close my comments with the question not to the staff here but
to my colleagues whether or not we as a collective body, the council,
share a need to somehow express our concerns regarding the budgeting
process? While we might all do things individually, is there an
opportunity here for us to speak in unison on this issue? And that was
not a rhetorical question.

(Laughter.)

JUDGE WHITE‑FISH: I just want to say as a judge they tell me I can\'t
lobby, and I heard Dr. Clark mention that we can\'t lobby. I guess for
me right away Dr. Fletcher comes to mind. Okay, if I can\'t lobby, what
can I do? Can I call it education, as I do on the Hill when I go?

MR. GILBERT: I think in the lobbying question, I think the point that
was trying to be made this morning that as a council member ‑‑ Cynthia,
keep me correct here ‑‑ when we travel you in here for the council
meetings, it would not be appropriate for you to be up on the Hill
lobbying. As a private citizen who also serves as a council member, if
you are in contact with your legislators, it\'s appropriate for you to
express your opinions if you want to do so, but it would be
inappropriate for our funds to be supporting your lobbying efforts. So
there is a distinction there that I think was trying to be made. Maybe
it wasn\'t clear.

MR. KOPANDA: But it would be possible if you had a statement of your
sentiments in that regard, for you as council members to put together
some kind of statement that you would provide to Dr. Clark or to Dr.
Cline or someone within the agency and express yourself in that way.

MS. GRAHAM: We don\'t have a quorum right now.

MR. DONALDSON: It appears to me also that we\'ve got to do a better job
when this budget is presented on defining what these line items are and
their value, because, George, what I have heard from you is that it just
seems so arbitrary. It looks like it\'s not worth the budget investment;
cut it. I mean, is it that? Is it about scissors and paste? Because
that\'s tragic. You look at the major corporations that are succeeding
globally, like General Electric, they\'re putting a lot of money into
evaluating their programs, their marketing. They take that bottom 10
percent and they move that money to the top 10 percent of the high
performance. It just seems unsophisticated for such a sophisticated,
evaluative process, like Bettye said.

MR. GILBERT: I don\'t know all the conversations that went on and the
negotiations between the Department and OMB and SAMHSA and OMB this
year. Looking at it, I think a lot of the comments that you said about
how it just doesn\'t seem to make a lot of sense ‑‑ I mean, certainly
some of the decisions that were made strike us that way as well.

One of the things we recently had an opportunity to brief Dr. Cline,
Westley briefed him on the substance abuse treatment capacity matrix
area and the programs, and the issue of the budget came up, and he
indicated that he wanted to review the way we present our budget. He
thought that maybe we could do a better job of doing that. So I think
that\'s on his radar.

I think part of it is we do need to try to do a better job of educating
OMB as to exactly what it is we\'re doing and the successes that we\'re
having. I do think a lot of what was going on this year also was the
drive to be able to present the big picture that the administration was
making the commitment to head towards a balanced budget by 2012 and
showing that there were cuts being made to head in that direction in
spending. So it\'s probably a lot of factors. I think we need to try to
figure out what are the ones where we can try to make sure that the
information is available so that people know what the programs are, what
the outcomes are, and what\'s behind some of these lines so that they
aren\'t making arbitrary decisions.

MR. DONALDSON: So even the faith‑based initiative part of CSAT, even
though you wouldn\'t know it, that\'s being significantly cut.

MR. GILBERT: Yes.

MR. DONALDSON: You would never know that, even though that is one of the
President\'s initiatives, a presidential initiative.

MR. GILBERT: And on its face, it doesn\'t make sense. It doesn\'t make
sense to you. It doesn\'t really make sense to us. I\'m thinking that if
I had to try to look at what were the criteria they used to make that
judgment or what the criteria that had been offered as to why the
decisions were made, people examining the budget may have said, well,
you know, you\'re doing a lot through the ATR program to involve
faith‑based and community‑based organizations, so there\'s another way
to address that issue rather than this little program over here. That\'s
if they understood that that money was even there. But we weren\'t in a
position to really know how the decisions were made, so we\'re kind of a
little bit in the dark too.

Even in the discussions we\'ve had with the SAMHSA budget folks, I think
the process this year was characterized overall by kind of a lack of
information sharing. A lot of times information wasn\'t available.

DR. McCORRY: I was just trying to do some quick math. When you look at
the Programs of Regional and National Significance in which almost all
of the X\'ed out programs exist, it\'s about \$46 million. Then I tried
to go through all the X\'ed out areas in which there\'s no money, and I
came up with \$40 million, but I\'m probably just not adding it up
right.

I think one point can be made around simply the closing of programs
versus a reduction in programs as a way to do budget reduction, budget
curtailment in light of other priorities, to X out, to no longer fund
programs that aren\'t slated for defunding, or even in the areas I think
is a legitimate point to make. It\'s only \$46 million. I\'m not sure
how that squares with your 12 percent reduction in CSAT money. What\'s
the overall reduction to CSAT? It\'s 12 percent. Is that \$46 million,
or no?

MR. GILBERT: Yes. That\'s percent of the discretionary funds.

DR. McCORRY: And most of the \$46 million is in the Programs of National
Significance and have been X\'ed out, including Bettye\'s comment on
HBCUs, David\'s comment on faith based, my comments on performance
measurement, and it just makes no sense. You could even argue it might
make sense to reduce things in light of a curtailed budget. I wouldn\'t
argue that in this instance, but you could at least argue that. But
certainly to discontinue funding, to abruptly end makes no sense, and
perhaps that point should at least be made from this council to
Administrator Cline and to Dr. Clark, just a letter saying it exactly as
Bettye said it, that some of these programs have huge impact, and
they\'re very modestly funded. We\'re not talking \$100 million, very
modest, but they have a long reach, and that the council opposes the
elimination of programs, much as it understands the need to balance the
budget, and that we encourage Dr. Clark and Administrator Cline to look
to restore these funds within the context of their budget, and that we
endorse the introduction or the reintroduction of funds to keep these
programs whole, something like that.

If we get consensus on that, maybe we could draft something up. I could
draft something up and send it around.

MR. KOPANDA: I think Cynthia would be the contact person. She would
probably work with you if the council would like to pursue something
like that.

DR. FLETCHER: I would support the council drafting a letter or whatever
is appropriate to articulate what Francis has just described. So what is
the mechanism? Can I offer a motion?

MS. GRAHAM: We can\'t do a motion because we\'ve lost our quorum, but
what we can do, as we\'ve done in the past if you remember, if there\'s
a position that the council wants to take, you can certainly draft
something and send it to us. You can draft it to Dr. Clark. We will go
through that and send it to all of your colleagues to get them to sign
off on it. From there it would go to Dr. Cline for his consideration.

So please feel free if you want to work with Frank to draft this
document and send it to us. We\'ll get it back to you guys and all of
the council members will sign that.

DR. SKIPPER: I\'d like to have a chance to look at it and make a little
edit or whatever. So not just sign it.

MS. GRAHAM: It will go to everyone before it\'s sent out, before we send
it to Dr. Cline.

DR. McCORRY: It sounds like the members here want to be part of the
initial writing committee. So I\'ll do a first cut, send it just to our
folks, to these folks, to all of us, and then after everyone gets their
comments, then we\'ll send it to the larger council to say we\'ve
drafted this. But we\'ll all get a chance at the early level of writing.

Also, if someone else wants to take a crack at it, that\'s absolutely
fine with me. If someone prefers to be the initial drafter, that\'s fine
with me, too.

Okay, I\'ll do the initial cut, and the six of us will get the first cut
at shaping it the way we want. Then to send it on to our colleagues for
approval.

MR. DONALDSON: Could you use a better word than \"cut\"?

(Laughter.)

DR. McCORRY: Oh, that\'s a terrible word.

MR. KOPANDA: Are there any other comments on this or other subjects?

MR. GILBERT: I just want to kind of emphasize, of course, and I hope
it\'s clear to everybody, that the budget that has been submitted to
Congress is the first step in the process of the congressional
consideration of the budget. So they still have to go through their
process. The Administrator testified before the House Appropriations
subcommittee earlier this month. The subcommittee will mark up, the full
committee will mark up, and the same process will occur in the Senate.
They\'ll take their bills to the floor, and then once they\'ve passed
their bills, they will then meet in conference and resolve differences.
So this represents the administration\'s proposal and it\'s now up to
Congress to decide what they want to do.

DR. McCORRY: Can I ask, George, because I didn\'t get down when you were
breaking apart those categories a little bit more on what\'s inside it,
could you give me something like that? Or give it to us all? I\'ll send
it around as well. So the categories that are being eliminated here or
defunded had some further ‑‑

MR. GILBERT: Yes. They\'re in the slides, but we can talk about it
afterwards. You can give me a call on the phone and I can help walk you
through and explain it to you.

DR. McCORRY: Great.

MR. GILBERT: So whatever questions you have, we\'ll explain the
information that we were trying to convey in the slides.

DR. McCORRY: Very good.

MR. KOPANDA: Any other issues?

(No response.)

MR. KOPANDA: Well, if not, I\'d like to thank you all for your
participation today. I hope you enjoyed the presentations and you found
them enlightening, as I did I, for sure.

I certainly appreciate all the comments and suggestions you\'ve made,
and I think your recommendations will certainly be well received within
the agency. That\'s, after all, the role of the advisory council, to
give us some advice, and that is what you\'ve done on both the 2008
budget and hopefully moving into 2009.

So with that, unless there are any other suggestions, I will entertain a
motion to adjourn.

PARTICIPANT: So moved.

PARTICIPANT: Second.

MR. KOPANDA: Moved and seconded. Council agrees. Council adjourned.
Thank you very much.

(Whereupon, at 5:11 p.m., the meeting was adjourned.)