SUBSTANCE ABUSE AND MENTAL HEALTH

SERVICES ADMINISTRATION

NATIONAL ADVISORY COUNCIL

41st Meeting

Wednesday,

March 7, 2007

Sugarloaf Mountain and Seneca Rooms

Substance Abuse and Mental Health Services Administration

1 Choke Cherry Road

Rockville, Maryland

IN ATTENDANCE:

[Chairperson]{.underline}

Terry L. Cline, Ph.D.

Chair/Administrator, SAMHSA

1 Choke Cherry Road, Room 8-1065

Rockville, MD 20857

[Executive Director]{.underline}

Daryl W. Kade, M.A.

Executive Director, SAMHSA National Advisory Council

Associate Administrator for Policy, Planning,

and Budget, SAMHSA

1 Choke Cherry Road, Room 8-1083

Rockville, MD 20857

[Executive Secretary]{.underline}

Toian Vaughn, M.S.W.

Executive Secretary, SAMHSA National Advisory Council

1 Choke Cherry Road, Room 8-1089

Rockville, MD 20857

[Members]{.underline}

James R. Aiona, Jr.

Lieutenant Governor

Executive Chamber

Hawaii State Capital

Honolulu, HI 96813

Gwynneth A. E. Dieter

Mental Health Advocate

U.S. Embassy Belize

Unit 7401

APO AA34025

Faye Annette Gary, Ed.D., R.N.

Professor, Case Western Reserve University

Frances Payne Bolton School of Nursing

1099 Euclid Avenue

Cleveland, OH 44106-4904

Barbara Huff

Consultant

The Federation of Families for Children\'s Mental Health

2837 North Plumthicket Circle

Wichita, KS 67226

IN ATTENDANCE:

Thomas A. Kirk, Jr., Ph.D.

Commissioner

Department of Mental Health and Addiction Services

410 Capitol Avenue, 4th Floor

P.O. Box 341231, MS #14 Com

Hartford, CT 06134

Kenneth D. Stark

Director, Transformation Grant Division

Department of Social and Health Services

111531 Washington Street

Olympia, WA 98504-53311

Kathleen Sullivan

Journalist

Four Mission Court

Rancho Mirage, CA 92270

[Ex Officio Members]{.underline}

Laurent S. Lehmann, M.D.

Chief Consultant for Mental Health

Department of Veterans Affairs

810 Vermont Avenue, N.W.

Washington, D.C. 20420

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

PAGE

Welcome and Opening Remarks

Terry L. Cline, Ph.D., Chair, SAMHSA National

Advisory Council and Administrator, SAMHSA 7

James R. Aiona, Jr., Lieutenant Governor,

Hawaii, and Co-Chair, SAMHSA National

Advisory Council 13

Consideration of the Minutes from the April 26,

2006, and June 29, 2006, SAMHSA Council Meetings 13

Administrator\'s Report

Terry L. Cline, Ph.D. 15

Discussion 32

Hill Update

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

Director of Legislation, SAMHSA 44

Discussion 50

SAMHSA\'s Budget and Appropriations

Daryl W. Kade, M.A.

Executive Director, SAMHSA National Advisory

Council, and Associate Administrator, Office

of Policy, Planning, and Budget, SAMHSA 65

Discussion 70

Public Comment 99

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

PAGE

National Registry of Evidence-Based Programs

and Practices

Kevin Hennessey, Ph.D.

Science to Service Coordinator

Office of Policy, Planning, and Budget, SAMHSA 103

Discussion 124

Update on SAMHSA\'s Strategic Prevention

Framework Program

Dennis O. Romero, M.A.

Acting Director

Center for Substance Abuse Prevention, SAMHSA 144

Michael Lowther, M.A.

Director

Division of State Programs

Center for Substance Abuse Prevention, SAMHSA 149

Kentucky\'s Commonwealth Alliance for Substance

Abuse Prevention SPF/SIG Program

Connie R. Smith

SPF/SIG Director

Kentucky Commonwealth Alliance for

Substance Abuse Prevention 151, 169

Ohio County Together We Care Drug-Free

Communities Program

Dianne McFarling

CPP Prevention Specialist and

SPF/SIG Master Trainer

Ohio County, Kentucky 163

Discussion 173

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

PAGE

Update on Methamphetamine Use

Richard Kopanda

Deputy Director

Center for Substance Abuse Treatment, SAMHSA 185

Discussion 200

Discussion on National Advisory Council

Meeting Process 205

Closing Remarks

Terry L. Cline, Ph.D. 219

[P R O C E E D I N G S]{.underline} (9:08 a.m.)

DR. CLINE: Good morning, everyone. My name is Terry Cline. I\'m the
Administrator for SAMHSA. I\'d like to welcome you to the meeting. I
know that some people are worried about the weather and I appreciate you
braving the storm. It\'s not quite a storm yet and hopefully won\'t be,
but I appreciate you being here.

I also would like to thank Lieutenant Governor Aiona as the vice chair
today. If at any point I\'m called out, you\'ll be in capable hands with
the Lieutenant Governor. So I appreciate your stepping up to the plate
for that, as well.

I also would like to welcome our council members and would like to ask
the council members at this point to introduce themselves so that most
of you know each other but also for our audience today.

Barbara, if we could start with you and the council members, and then
we\'ll do other introductions after that.

MS. HUFF: Hi. I\'m Barbara Huff. When I started on the council I was the
executive director of the Federation of Families for Children\'s Mental
Health. I since have semi‑retired and moved home to Wichita, Kansas,
where I still work part‑time for the Federation, and I also do some
consulting work part‑time as well.

I\'m happy to be here and happy to see Terry. Thank you.

DR. CLINE: Thank you, Barbara.

MR. STARK: Ken Stark. I\'m from Washington State. I\'m the director of
the Mental Health Transformation Grant, a grant from SAMHSA, and the
grant is through the governor\'s office. We are working very hard to do
what transformation we can around mental health in our state. It\'s a
very, very busy year this year with legislative stuff going on. We\'ve
got over 22 pieces of legislation around mental health, so it\'s really,
really hopping.

DR. CLINE: Wow. Thank you.

We\'re going to do other introductions after the council members.

DR. LEHMANN: Thank you. I\'m Larry Lehmann with the Department of
Veterans Affairs. Again, I\'m very pleased to be here. We\'ve really
based our mental health strategic plan on the President\'s New Freedom
Commission initiatives, and we\'re very pleased to participate in a
number of the work groups, including those for disaster, suicide
prevention, and primary care integration.

It\'s a pleasure to be here.

DR. CLINE: Welcome.

MS. DIETER: Hi. Good morning. I\'m Gwynneth Dieter, and I have a family
member who has a co‑occurring disorder. So I\'m a family advocate, I
guess I would say. When I began on the council we were from Colorado. We
were living in Colorado. Right now I\'m living in Belize, so I\'m also
becoming more interested in international efforts in which SAMHSA is
involved.

DR. CLINE: Thank you.

DR. GARY: I am Faye Gary, professor at Case Western Reserve University.
I am a psychiatric nurse. I do research and also teach medical students
and nursing students. My area of specialty is child mental health
psychopathology and working with families and children in the
communities. I\'ve also just been invited to join the National Board of
Directors of the National Mental Health Association, which is now Mental
Health America.

DR. CLINE: Great. Thank you.

DR. KIRK: My name is Tom Kirk. I\'m the commissioner of the Department
of Mental Health and Addiction Services in the State of Connecticut, a
psychologist by training. Similar to Washington State, we\'re one of the
mental health transformation states. The major things that I\'m
particularly interested in are focuses on the whole aspect of recovery
and the recovery service system, co‑occurring disorders, services for
women, trauma, things that will truly result in improved quality of life
or quality of services for the people we serve. Our legislature is in
session and we\'re going to be finished in June.

DR. CLINE: Thank you, Tom.

MR. AIONA: Aloha. My name is Duke Aiona. I\'m the Lieutenant Governor
for the State of Hawaii. In my former life I had the honor and privilege
to start up the first drug court in the State of Hawaii. Currently, the
governor has charged me to lead our state in developing a strategy for
our drug abuse and alcohol abuse in the State of Hawaii, and we\'re
doing very well.

DR. CLINE: Thank you.

We also have Ms. Sullivan on the line. Ms. Sullivan, would you please
introduce yourself?

MS. SULLIVAN: Good morning, Terry.

DR. CLINE: Good morning.

MS. SULLIVAN: My name is Kathleen Sullivan. I\'m a former broadcast
journalist, and I have bipolar disorder.

DR. CLINE: And I understand you\'re a little bit under the weather
today.

MS. SULLIVAN: Yes. Interestingly enough, I know that you are all
suffering the effects of the very cold storm, but I was borderline
pneumonia in 85‑degree weather. So go figure.

(Laughter.)

DR. CLINE: We appreciate you joining us today. Thank you.

I\'d like to go ahead and move to the introduction of our center
directors as well, or their representatives.

Kathryn, if we could start with you, please?

MS. POWER: Good morning, everyone. I\'m Kathryn Power, the director of
the Center for Mental Health Services, and I\'ve been here for a couple
of years. So I know most of you, and it\'s nice to see everyone this
morning.

MR. KOPANDA: Good morning. I\'m Rich Kopanda, deputy director of CSAT.
Dr. Clark sends his regards from Vienna.

DR. CLINE: Rose?

MS. KITTRELL: Good morning. I\'m Rose Kittrell. I\'m the acting deputy
for CSAP, and I\'m representing Dennis Romero, who is the acting center
director. He\'ll be here this afternoon.

DR. CLINE: Thank you.

At this time I would like to recognize, as the new Administrator here ‑‑
obviously, there was a period of transition, so I\'d like to publicly
recognize the contributions of Dr. Ric Broderick, who stepped into the
fray and has done a remarkable job during that transition, as well as
assisting me in this part of the transition. So if we could all join in
thanking Ric for his contributions.

(Applause.)

DR. CLINE: And, of course, any time you have a transition like that, it
tends to disperse the responsibilities not just to the person who is
filling in in that position but also to a number of other people. So I
would like to thank the rest of the leadership team who all stepped up
to the plate and contributed during that time. That meant that they had
additional hours, additional responsibilities, and have carried that out
beautifully, as well as their own responsibilities that they carried on
with.

So thank you to all of you who did that as well. Thanks.

At this time I\'d like to make note that we have two more members who
were not able to be here because of prior commitments. One is Ms.
Holder, and the other is Ms. Bush. So we look forward to seeing them at
our next meeting.

We also had one resignation from the council, Ms. Racicot. I had the
good fortune of talking with her on the telephone and also meeting her
last weekend at a Leadership to Keep Children Alcohol-Free board meeting
here in D.C., and I can tell that that will be a significant loss to the
council. She obviously had a lot to contribute. Hopefully we\'ll still
be able to get a little advice from her on the side. I think that
she\'ll be more than happy to stay engaged with us.

At this time I will ask our vice chair if he has any comments he would
like to make.

MR. AIONA: Very briefly, and good morning, and thank you again, Dr.
Cline. Nice to meet you.

Thank you, Dr. Broderick, for what you\'ve done in the interim.

I just want to remind the members that we serve as advisors and
ambassadors of SAMHSA. So as we proceed in the next day and a half, if
you could just, as we discuss various issue and items here, could you
think about what your roles as ambassadors and advisors are, and also
think about future agenda items or agenda items for our future meetings.

That\'s it, Dr. Cline. Thank you.

DR. CLINE: Thank you.

At this time we will move more into the business, and hopefully you had
an opportunity to review the minutes. So I will entertain a motion to
approve the minutes for the April 26, 2006 SAMHSA National Advisory
Council meeting.

PARTICIPANT: So moved.

PARTICIPANT: Second.

DR. CLINE: And second. Any comments, changes, edits that need to be
made?

(No response.)

DR. CLINE: We have a motion and a second, and I\'m not sure if we
actually take an official vote. This is where I\'m walking through the
process. Or do we just do this through consensus? Consensus.

All those in favor, please say aye.

(Chorus of ayes.)

DR. CLINE: Anyone opposed, please say nay.

(No response.)

DR. CLINE: Okay, the motion has passed.

We also have a call for a motion to approve the minutes for the June 29
meeting of the National Advisory Council. Do I hear a motion to approve
those minutes?

MR. AIONA: So moved.

MS. HUFF: I\'ll second it.

DR. CLINE: Okay. The motion has been moved and seconded. Any comments,
changes, additions, edits?

(No response.)

DR. CLINE: Hearing none, all those in favor of the motion, please say
aye.

(Chorus of ayes.)

DR. CLINE: Anyone opposed, please say no.

(No response.)

DR. CLINE: The motion has passed. Thank you.

I am going to move into my Administrator\'s report, and as part of that
I\'m going to start by providing you with a little bit of background
information about myself. I know a couple of you fairly well over the
years, but some of you I\'m brand new to the scene, so I\'d like to just
tell you a little bit about my background and then move more fully into
my report.

I think this is my sixth week on the job as the SAMHSA Administrator.
I\'m starting to lose track of the weeks, so that\'s a good sign I
think.

(Laughter.)

DR. CLINE: I think it\'s a very good sign.

I have come to this position from my previous position in Oklahoma,
where I served in two different capacities. One was as the Secretary of
Health for the state, appointed by the governor, and the other hat was
as the commissioner for the Oklahoma Department of Mental Health and
Substance Abuse Services. I held those positions for about six years.

Prior to that, I actually had completed the Health Care Policy
Fellowship here at SAMHSA, which was an APA/SAMHSA fellowship. I\'m very
pleased to have been able to do that really looking at organization and
financing of mental health services across the country as part of that.

Prior to that, I lived in Cambridge, Massachusetts for about 15 years
where I was a clinical director of a community mental health center, as
well as chairman of a governing board for a teaching hospital, very
involved in public health issues. The hospital system was also
responsible for the Department of Health, the city health for Cambridge
and had merged with several other hospitals in the area. So I\'m
bringing that bit of experience as well.

I\'ve been very active in both the National Associations, NASADAD and
NASMHPD, which were wonderful experiences just to get that breadth of
exposure with the other states, and then hearing about what other issues
states are grappling with, and that I think has been a helpful
experience in coming into this position, having that broad base of
experience.

So that\'s enough about my background. I\'m going to move through my
report. I\'m going to encourage you, rather than waiting until the end
of my report, if you have questions or if you have comments or there\'s
anything you\'d like to discuss that\'s triggered by my comments, I
would encourage you to please just jump right in there, rather than
trying to keep track of your questions and saving those until the end. I
think that, too, will make the flow a little bit more consistent.

One of the very first questions I was asked when I came on board was
what are your priorities? What direction will we be going here at
SAMHSA? My response was that I don\'t know and that I was not walking in
with a pre‑formed agenda that was based on whatever priorities I felt
were most important. I believe it\'s important to establish those
priorities as part of a process, and that process is much broader than
just my perspective. Obviously, I\'ll bring my perspective into the mix
as well, but for me that process includes hearing from you all here or
other advisory councils, hearing from the various constituency groups,
hearing from consumers and other stakeholders out in the field. So we
have been on a very aggressive schedule of meetings over these last five
weeks, and we are continuing to gather information, and it has been a
very interesting process and I think a very important process.

Certainly my experiences are limited, so it is reassuring to me to know
that we are gathering input from many other sources rather than having
to rely on what may be my somewhat narrow scope. So that really is the
process that we\'re following in terms of establishing those priorities.

What is in place and what will continue to be in place ‑‑ and I don\'t
know if everybody\'s packet had it. I always get a few chuckles from
this. Has everybody seen this before? This is the matrix.

MS. HUFF: We all have it as placemats.

DR. CLINE: Do you? Okay. This was at one of Charlie\'s going‑away
receptions. Actually, there were kind of masks that were made out of the
matrix, and when Charlie walked out, everybody pulled out the mask and
put it in front. The matrix is something that will continue. I think it
was a groundbreaking effort to really cut across some of those silos
that we\'ve seen and some of those somewhat superficial barriers that
many people have experienced within SAMHSA and external to SAMHSA. So
having the crosscutting principles and programs I think has been very
helpful, and we will continue with that.

Knowing that this has been a document that is in development and
evolution, there may be changes over time, but there is no plan at this
time to do that other than making those adjustments as we see fit, which
was the case before. So I\'m pleased to say that we\'re continuing with
that. Again, I think that keeps the issues front and center for us. It
keeps us focused on why we\'re doing what we do, and these are the
issues that are closer to the source of people who are actually
receiving services in communities and neighborhoods across the country.
So I wanted to let you know that that will continue. It continues to
guide our budget discussions, and it continues to guide our priorities
in terms of resources within SAMHSA. So I\'m pleased to let you know
that we will be continuing with that.

The other thing, and this is again having come from a state, I am a big
fan of SAMHSA\'s vision and mission statements. I particularly enjoy the
notion of a life in the community for everyone. I think that it is
straightforward, to the point, and it\'s something that rings true for
everyone who has received services or been struggling with recovery in
communities or anyone who has been involved in providing and supporting
people who are living with mental illness and serious emotional
disturbance and addictions and substance difficulties.

So I think that having a vision statement that you can internalize, that
we can all internalize, is not something that is three paragraphs long
but is something that we can take to heart I think is very meaningful.
So we are keeping the vision and the mission, which keeps that focus on
resiliency and recovery, which is what we\'re all about. As we make
decisions moving forward, we can simply ask the question does this
support the mission, does this support the vision for SAMHSA, and if it
doesn\'t, then we need to question why in the world we\'re considering
moving forward with something if it doesn\'t support that mission and
vision.

So again, I know there was a great deal of work that went into those
efforts for both the matrix and for the vision and mission, and I think
it\'s important to continue with those. So we will be continuing.

I don\'t know. Were there any kind of similar responses or responses
that were different as this process rolled out in the past? Does anyone
have recollections of the matrix development or of the conversations
around the vision and mission? I\'ll just put it back to you with a
question mark. Anyone care to make any comments on that? Ms. Dieter?

MS. DIETER: Barbara has been here a little longer, I think. The vision
hasn\'t changed, but the matrix has changed in response to
recommendations here at the advisory council and input from other
places. There have been several changes. Suicide prevention, criminal
and juvenile justice was added. I\'m trying to think. Has homelessness
been there all along? Yes.

DR. CLINE: And the workforce development?

MS. DIETER: Workforce development was the most recent, I think. In terms
of the crosscutting principles, help me. I\'m trying to remember.
Disaster readiness and response was added.

MS. KADE: It was moved from program priority to crosscutting.

MS. DIETER: Crosscutting. Well, the science to services, that was a huge
push in that direction, and what I can\'t recall is whether that was
already in the crosscutting or was added to it. I remember that effort
took quite a bit of time and work. I\'m not sure of other additions.
Does anyone want to add? Barbara? Daryl? Kathryn?

DR. CLINE: That\'s helpful. That really speaks to the evolutionary
nature of the document, a living document that\'s responsive to needs
and one that integrates our current thinking.

MS. DIETER: Right, and that I think that was the concept, that we have
this formulation which can respond to additions, changes, adjustments as
you go along.

DR. CLINE: Thank you.

Any other comments? Barbara?

MS. HUFF: I think for those of us in the field, and especially when I
was the director of the Federation, I think that we were really excited
and thrilled about all of this, because we could kind of see some of our
work on paper, and that\'s always fun. But I think the problem, the most
trouble we\'ve had, but we\'ve worked around it ‑‑ Kathryn probably
knows this, and that is the sentence that a life in the community for
everyone by building resilience and facilitating recovery. We weren\'t
sure how that fit for kids, were we? I mean we, not you. We. But Kathryn
was really good at kind of helping us work through that, because that
was really difficult. I think we\'ve made due with this okay. I mean, at
first it was like, no, this wasn\'t going to work for us around
children, but we\'ve kind of figured out that recovery is bigger than
adults and that building resilience is always important. We just
weren\'t sure that those were exactly the right ones, but we\'ve made it
work.

DR. CLINE: Thank you for that comment. I would love to have more
conversation with you at some point about that. Thanks.

MS. POWER: I think, Terry, that Barbara really highlights the fact that
when it comes to children and families, recovery really grew out of the
adult population with mental illness, and resiliency had really not
taken on a life of its own relative to an application across many of the
children and family programs. So I think with the definitions of
family‑centered and youth‑guided and all of that clarifying language, I
think we\'ve really moved toward, as Barbara indicates, a broadening of
both recovery and resiliency in a wellness approach, in a total health
integrated approach, in a family approach and in a community approach,
which I think has been really from the guidance of members like Barbara.

DR. CLINE: Thank you.

Any other comments? Dr. Gary?

DR. GARY: I certainly appreciate the comments of Barbara and Ms. Kathryn
Power. I just wanted to comment that from a child psych community health
perspective, I think we could really use children as the model to look
at resilience if you frame it in terms of growth and development.
That\'s where we get our data, our clinical issues regarding resilience,
because that\'s what you see given their age, their growth, development,
the support systems from families, communities. Being a child psych
nurse, I think I see resilience and recovery there more and quicker many
times than I see in adults. It\'s just neurologically programmed to
happen with a few other extra supports from organizations such as
SAMHSA. So I truly embrace that for children and families.

DR. CLINE: Thank you.

DR. KIRK: I think as state director what I find very, very valuable
about this is this is a great communication document. One of the
challenges I have is that people in the field will say some particular
initiative is the flavor of the month, the project du jour, and they
don\'t see how things tie together. So in terms of trying to move the
system, something such as this helps people to see how these things tie
together, and whatever I do in my next job in life, these things stay in
place and become embedded. So you build on the things that went on
before. But like you\'re saying, I think the word that used to be used
was \"matrix reloaded\" or \"recharged.\" It changes, and it should
change based upon experience. But in terms of a communication document
for what we do and all the different elements and how complicated it is
for people, legislators and others who don\'t necessarily pay attention
to this, I think it\'s a great, great approach. So I applaud you for
keeping it on the table.

DR. CLINE: Thank you. That\'s very helpful feedback, and I appreciate
the comments. Thank you.

I am going to talk just a little bit, and we have a couple of other
presentations on the agenda, one talking about some legislative actions
as of late, and also more time on the agenda talking about the budget
and appropriations. But I\'m going to just reference both of those as I
conclude my comments.

I had the pleasure of participating in the House Subcommittee
Appropriations meeting last week, and it was a very interesting process
for me. It was my first Congressional hearing. I snuck into one the day
before just so I could see how it actually worked and make sure there
were no surprised for me, and there were a lot of similarities to what
I\'ve experienced at the state level. So there wasn\'t a complete shift.

But what I would like to say is that prior to that Joe Faha, who you\'ll
hear from later, had worked very hard at getting me in the door with a
number of our Congressional members. So I had met with quite a few
people prior to that. We had a little bit of a time crunch because this
was scheduled so early in the legislative session. I think one day we
had five visits back to back with Congressional members, and that\'s a
real testament to Joe\'s relationships on the Hill that he was even able
to get that many scheduled that tightly as members were preparing for
the hearing committees. So thank you very much for that work, Joe.

One of the comments I would like to make, and then I\'m going to just
run through some of the basics of the President\'s proposed budget, and
then Ms. Kade will go through more specifics with that in her
presentation, but it was very clear that there is strong interest for
issues from our Congressional members. The questions were well informed
questions, both in the individual meetings and at the hearing. It was
clear that many of the members are very passionate about particular
issues and are strong supporters of the work that SAMHSA has done, and I
believe they will be strong supporters of SAMHSA moving forward. So I
think it\'s important that you know that, that there is strong support,
I believe, from our Congressional members.

In looking at the budget, and I know this is information that you\'ve
heard in the past, at least some of this, but I\'ll talk about some of
the specifics for that, the President\'s budget was proposed at \$3.2
billion. I believe that that budget sets an aggressive agenda that again
supports our vision and mission, tying back to our vision and mission.
As an overarching principle, there was the drive to be wise fiscal
stewards of taxpayer dollars while also advancing our nation\'s health.
So we have these two dynamics that are in motion with the President\'s
budget. So you can kind of overlay that to everything.

In doing that, there were many decisions to invest available resources
in priority areas, and what that may mean in some situations is that we
have core programs that are being supported at the same level they were
supported before. It may mean that there are core programs that we\'ve
kept on the radar screen but are not funded at the same level that they
were funded in the previous year, and those areas include children\'s
mental health services, suicide, school violence prevention, prevention
services, HIV/AIDS, screening and brief intervention, and criminal and
juvenile justice. Again, you will hear more specifics in Ms. Kade\'s
presentation.

We also saw support for the administration\'s priorities, which are
expanding choice through the Access to Recovery Program, transforming
the mental health system, and also creating a healthier U.S. through the
Strategic Prevention Framework. I\'m assuming that these are programs
that you all are familiar with and have heard about from either your
work here or your work back in your communities.

Another guiding principle for us is making sure that as these decisions
are made, that they tie back into SAMHSA\'s strategic plan, and that
strategic plan has three core areas which are easy to remember as this
ACE mantra, which is looking at accountability, capacity, and
effectiveness, and again trying to tie in decisionmaking around programs
to these strategic pieces of SAMHSA\'s overall plan, with accountability
to items. Again, if you have questions, feel free to ask them. There may
be some more information coming later.

One is around our data strategy. The second, which is related, is around
the National Outcome Measures, referred to as NOMs. Both of these are
critical for multiple reasons. Although they\'re in this accountability
category, this information is helpful in terms of also gauging
effectiveness of programs. It\'s also important in terms of SAMHSA being
able to demonstrate to multiple stakeholders, including Congress, states
and others who are interested, the effectiveness of programs. Also, as
we need to make adjustments, and we\'re looking at performance measures
so that we can make informed decisions with that, then we\'re actually
basing that on data rather than basing decisions on either the crisis of
the day or the loudest voice in that particular moment. I think that
anyone who has administered a program knows that that can be a dangerous
way to make decisions, because it will be a different voice or a
different crisis next month. If we want to maintain a course that moves
us toward that vision and mission, we can\'t afford to make those
detours along the way. So we want to make informed decisions as we move
forward.

Has there been much discussion here about the National Outcome Measures
data strategy? No? Okay. We\'ll make certain that there is much more
discussion and presentation here. These are very important and reflect
an incredible amount of work that flows out so easily to talk about it
here, but it\'s years worth of work that is pretty remarkable because it
speaks to levels of collaboration between SAMHSA and multiple
stakeholders in terms of the NOMs, especially with NASADAD and NASMHPD
in finding measures that have some consensus support from those
associations given that the states are the primary gatherers of data
through the systems. So you can imagine trying to find 10 measures or 8
measures or 15 measures that everyone would agree on, not an easy task.
There is great variability between the states, and some states have
wonderful data systems that have been collecting information. They use
that data to manage their systems and inform consumers in terms of
choices. Then there are some other states that have not made that
investment in data systems and are not in the same place. So trying to
pull all that together has been a huge task, and everyone here at SAMHSA
who has been involved in that is to be commended for that work.

MS. HUFF: I just wanted to say that the Federation served on a committee
around outcome measures. I haven\'t been the one who served on it, but
Trina Osher has, and others from the Federation, and it\'s been enough
to just give a person a nervous breakdown. It\'s so hard. So I think
what you\'re saying about the differences in coming up with 10 or 15 or
whatever the number is of outcome measures has been really an amazing
challenge.

DR. CLINE: And it\'s a monumental task.

MS. HUFF: Yes, ongoing.

DR. CLINE: Ongoing, but one I think that people will be quite pleased to
see the results. Again, we\'ll have more discussion about that. There
are, again, multiple reasons that\'s important. One is for the data and
decisionmaking for SAMHSA, but also decisionmaking for states as they
make determinations about their programs and have data that may indicate
whether they\'re able to move the ball down the field or move the needle
in the right direction. So that is an important accomplishment.

The other piece of the strategic plan is around capacity, and we have a
couple of things I would like to note. Of course, you\'ve heard some
conversation already about Access to Recovery and expanding choice
through Access to Recovery, looking at the Strategic Prevention
Framework and infusing that kind of general principle, which includes a
lot of the public health framework and actually fits in very nicely with
the resiliency and risk factors and things like that.

Another critical piece is around the Federal Mental Health Action
Agenda. That action agenda is really historic in terms of pulling
together nine Cabinet‑level departments around these 70 action items.
There\'s been a huge amount of work and attention to the commitment to
transform the behavioral health system, the mental health system across
our country. I don\'t know that I\'ll be able to do this publicly, but I
would like to thank Kathryn Power for all of her work on this effort and
her continued work on this effort. Again, I know from that state
perspective that Kathryn was the face of transformation as it first
emerged, and I think was often swimming against the tide and was a real
champion who was out there.

I think you\'ve done an incredible job on that front and you have
brought that vision to a lot of hearts. I know it hasn\'t been an easy
task, and we\'re just at the beginning of that. So I appreciate all of
your work, Kathryn.

(Applause.)

DR. CLINE: The last piece is around effectiveness. Even as we increase
capacity and we have this level of accountability and data, how do we
know that what we\'re doing is as effective as it can be? When we\'re
making decisions with limited resources, that dollar that we spend, that
limited amount of time that one individual has, has to be as effective
as possible. We don\'t have the luxury of being ineffective in what we
do. Again, people\'s lives are at stake, and SAMHSA has that commitment
to move the field forward, to move the country forward in providing the
most effective care possible to individuals, and the most effective
services possible. You\'ve heard already some discussion about the
science and service, so I know you had some discussion about that in the
past, and you will hear more today on the National Registry of
Evidence‑Based Programs and Practices, which we believe is a very
important tool that will really help spread that. I won\'t say anymore
about that because you\'ll hear more about that later.

I\'m going to close now simply by saying that you can tell there\'s a
huge amount of information, a huge amount of guidance in terms of
strategic plan, in terms of the matrix, the mission statement, the
vision statement. But part of what keeps that fresh and part of what
keeps all of this alive and evolutionary is the input from our
constituent stakeholders and the advisory council. So I again want to
thank you for your commitment to be here today, traveling great, great
distances for many people, and all of you are leaders in your respective
fields who are in great demand. I recognize that your time is very
limited and very precious, and there are many ways that you could be
volunteering your time, either in your communities with your families or
nationally. So I\'d like to thank you for that. Your participation here
is greatly valued.

I think I\'m about to get a note here. Ms. Sullivan, I\'m being
prompted. I hope I\'m not neglecting you.

MS. SULLIVAN: No.

DR. CLINE: I\'ll see if there are any comments you\'d like to make at
this point.

MS. SULLIVAN: No. First, Ric, I\'ve been meaning to compliment you and
thank you so much for what you did in the interim. I think you looked at
the matrix and you kept the matrix going, and thank you for all of the
programs. Kathryn, what you\'ve done ongoing for the past couple of
months especially, and your attending to all of the programs that I care
so much for has meant so much. Terry, how you\'re addressing the matrix,
it\'s just all good, good, good from the West Coast.

DR. CLINE: Thank you, Ms. Sullivan.

Dr. Gary?

DR. GARY: Thank you, sir. Thank you for your report. I just had one or
two questions and probably comments.

Could you also just make comments about how the New Freedom document,
the President\'s New Freedom document might have driven the decisions
regarding budget? And also, the Healthy People 2010, where the specific
goals that the nation should be able to meet, address, measure that
relates to healthy people in the United States, were those documents
integrated into the discussion, and how will SAMHSA continue to address
those issues, which in many ways the matrix is subsumed under a lot of
those different areas?

The third issue is would you also include comments, observations about
the next step in helping the Katrina victims? We know that children are
still not in school. There are a lot of mental health issues, housing
issues, general public health kinds of issues. Will SAMHSA have a
specific role with regard to how we could look at this, the matrix, and
apply it to the Katrina population? I think if we\'re not careful, the
people who were in that hurricane in Louisiana, Texas, Mississippi, I
think we have to continue to advocate for them. So I would just like to
hear a bit of discussion about your future thinking about those
populations as well.

DR. CLINE: Okay. I see Kathryn\'s hand at one time was moving close to
the mike, so I\'m going to ask Kathryn if she would take the first
question. I\'ll take the 2010 question. Ric, I\'m giving you a heads up
that I\'m going to ask you to address the last question.

MS. POWER: I can probably add a couple of things about the others as
well.

The President\'s New Freedom Commission did inform, Faye, the budget
process, as it has in the past several years since it came out, and
particularly it informed the process because we\'re continuing under the
Federal Action Agenda, those 70 steps that the Administrator mentioned.
One of those steps, obviously, is to continue the Mental Health SIG
Program in the states that are getting the Mental Health Transformation
grants, as well as a variety of other initiatives, including our
continuing work with all of those departments and agencies. So those
departments and agencies derived those 70 action steps from the six
goals that are in the Commission report.

So it is continuing to inform them, along with the guidance from the
executive order. They were cross‑walked, and that document, as far as I
am concerned, will continue to be informing what we do and where we go
in terms of the direction as the federal partners interpret it. For
example, the Department of Labor will make decisions about their
activities based on one or more of the six goals and the five executive
order principles.

So yes, it\'s a living document. The agenda which we\'re about ready to
come out with in terms of an update to the Federal Action Agenda ‑‑ it
should be cleared, hopefully, fairly soon ‑‑ will show you evidence of
how the New Freedom Commission report has continued to resonate across
successive budget years.

I\'ll just add, Terry, for purposes of Faye\'s question, that the
Healthy People 2020 issues are really, from a mental health perspective,
being reflected because we are taking in \'07 a much more integrated
wellness approach. In looking at the morbidity and mortality of
individuals with mental illnesses, looking at an integrated approach in
terms of not only their mental health care but also wellness and looking
at that primary care/behavioral health care integration. So that is
really a reflection, I think, of the Department\'s Healthy People 2020.

I can add something to Katrina, if Ric would like me to.

DR. CLINE: I\'m going to just give you a heads up, both Rich and Rose,
to jump in on this, too. But I\'m going to give you a little time while
I make one comment about the public health piece of this.

I think one of the most significant movements that\'s taking place is
SAMHSA\'s embracing of the public health model and really looking at the
public health approach toward improving overall health of communities
and understanding how our issues impact that overall health. One of the
places I think where that\'s most apparent ‑‑ and, Rose, you may want to
say something about it ‑‑ is through the Strategic Prevention Framework,
which is really a concept I think that has been well received by the
field that is embracing this kind of public health approach. What that
allows us to do is to back up a few steps and look at things that we
have typically had difficulty looking at population‑based data. A lot of
the data that we\'ve looked at has been driven by our service system,
and that\'s not population‑based data. It\'s important data, but it\'s
not population‑based. Then we\'ve had some of the larger surveys, like
the National Survey, the old Household Survey, and now the National
Study on Drug Use and Health, which only recently has started to look at
some of those mental health issues.

So you can see the kind of step‑wise progression closer to getting that
type of thing. If we\'re looking at impacting, again it goes back to
that kind of broader based resiliency, and our system has been so
incredibly reactive out of necessity and limited resources. How do we
ever expect to get ahead of the curve and impact the population at
large? That public health approach I think is essential to that.

Rich, would you like to make a comment? And then Rose, and then we\'ll
move to Dr. Broderick.

MR. KOPANDA: Well, I was just going to mention a little bit about the
Katrina effort. In terms of our assistance in CSAT with the State of
Louisiana, Anne Herron had previously worked very closely with their
state substance abuse treatment system to kind of, at first, recast the
system and see how it might be redesigned to more or less reestablish
the treatment system to make sure it was well integrated with behavioral
health in general, and also the primary care system.

Recently they\'ve asked for additional assistance both in terms of
reestablishing the system and in terms of looking at how to bring more
providers, substance abuse treatment providers, back into the system.
We\'re in the process right now of developing a response plan for that.
We\'re also going to engage some of our contractors who assist us with
the block grant generally to really focus on Louisiana, and that\'s kind
of in process right now.

DR. CLINE: Thank you, Rich.

Rose?

MS. KITTRELL: As Terry has said, we are working with the Strategic
Prevention Framework. We have funded some SPF/SIGs, states as well as
travel organizations throughout the country, and through this process,
through this five‑step process, we are helping states to identify their
resources, to identify the gaps in services, and strategically place our
resources in areas of greatest need. As Terry indicated earlier, we are
not catering necessarily to the group that has the loudest voice or to
areas where they have excellent grant writers and they\'re able to draw
down the funds. We have epidemiological outcome work groups that are
working in concert with the states to really strategically place our
resources so that we can drive down our numbers.

If the money is in the wrong area, if it\'s going toward a population
that\'s not in the greatest need, our substance abuse numbers will not
be driven down.

DR. LEHMANN: One of the things that SAMHSA is involved with is an
interagency group on workforce support in the case of pandemic flu. I
mention that because I\'ve got to absent myself from the committee for a
moment to take a call for that group, along with Terry Spear from
SAMHSA. It\'s been an opportunity for me to meet her. So that\'s by way
of explanation for why I\'m scuttling off right now. Thank you.

DR. CLINE: Thank you.

Dr. Broderick?

DR. BRODERICK: Thank you. Thank you for adding that, Rich, and I know
Kathryn has something to add here too.

I guess the first thing I would say, Dr. Gary, is that as you know, as
I\'m sure you know, half of the people in this building, 250 people from
SAMHSA, actually physically went to the Gulf States to respond. So there
are personal connections that were established among those folks that
remain. I think that serves as a basis for a clear understanding here
among our staff that much remains to be done.

The second thing I would add is to reiterate a name that you just heard
that I was going to mention as well. Terry Spear recently joined
Daryl\'s staff in OPPB. She is our new emergency coordinator. We\'re
very fortunate to have her. She came to use from HRSA, and she is
actively engaged in emergency response in general and pandemic flu in
particular.

With regard to Louisiana and the Gulf States in general, the Secretary,
as you probably know, has engaged with those states to endeavor to
rebuild the health system across the board. We participate closely in
that effort. There\'s been an opportunity for us to contribute to the
overall planning process within the Department, which we have done.
We\'ve met on several occasions with the staff from the Secretary\'s
office that have created that response plan with Louisiana.
Specifically, you heard Rich mention efforts from CSAT. I\'ll ask
Kathryn in a minute to talk about efforts from CMHS. But suffice to say
in general that we have a number of grant programs that are currently in
process around suicide prevention, and our efforts continue to help the
states with their rebuilding efforts of both their substance abuse and
mental health systems.

Kathryn, would you talk a little bit about our emergency response?

MS. POWER: Sure. Admiral Broderick mentioned what is really a broad
recovery plan approach to the hardest hit areas in Louisiana relative to
the infrastructure. So there\'s a tremendous amount of effort going into
the planning on the rebuilding of the infrastructure and the capacity.
In addition to that, the disaster response staff inside CMHS is
responsible for the Crisis Counseling Program. We call it CCP or the
Crisis Counseling Program, which is a program that we basically
implement. It is FEMA money, but we are the implementers and the
overseers of that program, and there is a massive amount of funds that
continue to go to those states, particularly in Louisiana and
Mississippi, under the Crisis Counseling Program, and we continue to
have a tremendous response to the use of those funds for the needs of
the people in the Katrina devastated areas.

DR. CLINE: Thank you.

Dr. Kirk?

DR. KIRK: Two questions, and maybe one is to solicit a comment. In
looking at the matrix and the kinds of things that SAMHSA and the field
as a whole are involved with, I\'ve been involved in the field for a
long time, but what is particularly exciting and I think very evident is
the opportunity for extraordinary system change. Maybe this is a
question for Kathryn. What I find is that the leadership required to
support and sustain this type of system change is different from
operational leadership. Within the workforce development piece, can you
share any comments about SAMHSA\'s initiatives to support the
development of more transformative leadership?

Let me go to the second question. Whether you look at the Freedom
Commission\'s report, the Surgeon General\'s report, Access to Recovery
and so on, I think some really exciting things have been brought to the
table. Again, from a systems change point of view, I\'m interested in
your read, Terry, and the leadership of SAMHSA. Do you still sense a
sense of urgency in that larger choir? And how do we make sure that
sense of urgency to follow through on these things stays on the plate
and doesn\'t get diverted because of the latest crisis of one type or
another?

So the Freedom Commission, the Surgeon General\'s report, things on
addiction, to me there\'s extraordinary opportunity for major system
change that will outlive many of us, but the sense of urgency has to be
there to say we can\'t stop now, we have to continue to move it. So I\'d
be interested in comments on those two points.

DR. CLINE: Kathryn?

MS. POWER: Well, I\'ll start, first of all, with the fact that Tom\'s
question I think comes from the fact that he is a transformational
leader and understands that transformational leadership requires a very
different kind of approach and a very different kind of set of skills
and competencies in not only being able to build that sense of urgency
yourself within your state but also being able to express it. So I will
be talking tomorrow about the workforce development issues that SAMHSA
is approaching, and leadership development is a key component of that.
We have had a variety of different experiences in terms of supporting
leadership development programs across SAMHSA over the last several
years, and I think everyone really resonates with the fact that we have
a responsibility to inculcate and incorporate leadership and leadership
principles and leadership competencies across these systems, and
transformational leadership which has really changed management
leadership is a special and unique requirement.

We are going to be looking more closely, particularly over this year, in
\'07, at what are the nuances of that, what are some of the specialized
approaches that are derivative of some of the prevention training,
derivative of some of the treatment training, derivative of some of the
mental health services training that has gone on in the past, and yet
apply another level of change management work.

So there are really two pieces, Tom. The first is that we are working on
workforce development broadly, and we do see leadership as a component
part of that, and our experiences at SAMHSA have been that we really
need to step out further and step out more deliberately and assertively
about promoting the kind of transformational leadership that is
necessary and needed over the long haul to build that very sense of
urgency that you talked about.

DR. CLINE: Any other comments or questions?

(No response.)

DR. CLINE: All right. Well, thank you all very much.

At this point I\'m going to go ahead and conclude my comments, and
we\'re a little bit ahead of schedule, which I think is almost always a
good thing. It means we have a little bit longer for break.

I will go ahead and turn it over to Joe Faha for legislative updates.
Joe, have you presented to this group before?

MR. FAHA: Yes, I think so.

DR. CLINE: Joe is the director of legislation for SAMHSA. As I mentioned
earlier, he does an incredible job.

MR. FAHA: I think most everybody here recognizes me as being the best
looking man east of the Mississippi. I think that\'s how I last
introduced myself.

(Laughter.)

MR. FAHA: I just saw Rich\'s eyebrows go way up in the air. Boy, is that
a stretch.

In the next couple of minutes I want to kind of quickly go through a
summary of what is going on legislatively so that you\'re aware, and if
I go quickly enough you\'ll be able to have time to ask some questions.

The first thing. Since Terry started out talking about appropriations,
you\'re all aware that the President entered a budget request on
February 25. We have been over the past couple of weeks in a what I
refer to as a perfect storm. Several things have come together all at
the same time, including both reauthorization and appropriation, and has
made our lives as far as legislation and Congress\' concern very busy.
But I must suggest that while dealing with Congress is a lot different
than dealing with your state legislatures, while it\'s in Washington or
Oklahoma or Connecticut, the skills that go into dealing with those
legislatures are very much the same. Fortunately, Terry has a lot of
very good skills for dealing with all of them.

We have had so far nine visits, and we have one tomorrow with another
appropriator. We have met with the appropriations committees in both the
House and the Senate to go over the budget request and to hear their
remarks, which were typically what one would expect. It went something
like \"dead on arrival\" kind of comments. So our efforts between now
and the time in which we get House and then Senate action, which will
probably be early this year considering the pace they\'re on right now
and the number of hearings, is to try and make what comes out what we
would like it to be. I\'ll just leave it at that.

That will be quite an effort, but I assure you that from our vantage
point we will be working very hard to effect a good budget.

I told you reauthorization as well. SAMHSA has been up for
reauthorization since 2004. This has not affected our ability to get
appropriations since it is not necessary to be reauthorized to receive
funds. The fact that you get funds actually legally reauthorizes the
program for the year in which you receive the funds. So it\'s not been a
difficulty in terms of getting appropriations.

However, what it means is that the last time we had a substantive
expansive discussion about mental health and substance abuse issues with
Congress was back in 1999. Now, that\'s eight years ago, because that\'s
when the discussions happened in preparation for a reauthorization in
2000.

DR. CLINE: Could you just say a word about what reauthorization is?

MR. FAHA: The first point is that reauthorization does not mean that the
agency itself is being reauthorized. It\'s referring to our programs as
being reauthorized. If you were to go into the statute, say, for
children and violence, Section 581 of the Public Health Service Act, at
the bottom it would say something along the lines that there are
appropriations for carrying out this section \$50 million for fiscal
year 2000, 2001, 2002, 2003. I\'m just making that up.

What that\'s saying is that Congress is authorized to spend money
through 2003. Literally, reauthorization means you change those years to
something that might say 2007, 2008, 2009, 2010. That\'s literally what
it means. So reauthorization in and of itself doesn\'t mean that much
unless it is that you have changes you\'re looking for in statute that
prohibit you from carrying out the activities that you\'d like to carry
out, and if indeed it\'s time to have a serious conversation about
mental health and substance abuse issues with Congress.

So that\'s what we will be trying to achieve in reauthorization. We have
a hearing that will likely come up the first week or second week of
April. It first was set for March 29 and March 23. Now it\'s the first
or second week in April. The important thing is that it\'s going to be
soon, and we are finishing the touches on what proposals SAMHSA is
looking for. Dr. Cline, in his comments to the committees, has been
talking about four different things. One is inclusion in primary health
care; secondly, a systems approach which Tom was just talking about and
how we need to be able to address these programs through systems. The
third is mental health promotion and the prevention of mental illness,
and the fourth is accountability. So those are the things that we\'re
walking into reauthorization wanting to talk about.

There are other issues on the table, as you can expect. There are a lot
of constituent groups out there who have ideas of their own about what
they\'d like to see in reauthorization. Much of that comes from the fact
that we\'ve made the point that we really don\'t need any more
authority. We have plenty of authority to do anything that we want to
do. What we really need is money, and their comment is yes, but two
responses. One, by promoting some of these provisions, this is one way
that we get Congress to focus on some of these very important issues.
Secondly, by doing this and then seeking money is the only way that we
can get you to spend the money the way we want you to spend it. So
there\'s that dialogue that goes on and will continue to go on.

But some of these issues that are on the plate include custody
relinquishment where parents have to give up custody of their kids in
order to get the mental health services that they need, care for older
adults, methamphetamine, FASD, workforce development. These are just
some of the issues that have been raised typically by members of
Congress themselves by introducing legislation that we know will wind up
being considered in the context of reauthorization.

The final one that I\'d like to report on is parity, not that anybody
here is interested in that issue, but you probably know that the Senate
Committee on HELP did pass a bill for parity several weeks ago that was
a compromise, not just between Republicans and Democrats but also a
compromise amongst insurers, employers, mental health groups, and
substance abuse groups. No one in the Senate is suggesting this is the
be‑all and end‑all, but it was a compromise that managed to get passed
out of committee.

The House, as of today, is going to be introducing their own bill,
authored by Mr. Ramstad and Mr. Kennedy. While it addresses many of the
same issues, it takes a different view on some of those. For example,
two things that come up are that it would require that employers have
mental health coverage in their plans, and it would also place
restrictions on the ability of insurers and employers to use medical
necessity and utilization reviews to limit services for individuals.
There are several other differences between the bills. The difficulty is
that many of the senators who bought into the Senate legislation
indicated that they do not want to have to conference this with the
House. They bought into this compromise bill and that\'s what they want
the House to do, to buy into that conference. So the mere fact that the
House has decided to go differently does not bode well for the passage
of a parity bill any time soon.

I\'m going to stop there and offer you an opportunity if you have any
questions.

One other thing that I mentioned in there is that methamphetamine, it
was very startling to me that the issue never came up in any of our
visits to members and was not a topic at the hearing. So it would seem
as if much of the emphasis on methamphetamine seems to have dissipated a
bit.

Having said that, Barbara?

MS. HUFF: Well, since we have the time, I\'ve known Joe for a lot of
years. He gets real tired of this, but he\'s going to have to sit
through it one more time. I just want to go back in history a little bit
because Joe and I have been around for so long. I\'m not going to say
we\'re so old. We\'ve just been around a while.

MR. FAHA: And we look it, right?

MS. HUFF: Yes, we\'re beginning to look it.

I want to go back in time and say that in the mid‑1980s, when the
Federation of Families for Children\'s Mental Health hadn\'t even
started yet but we were kind of in our development stage in the late
\'80s, the mid to late \'80s, and I went out to NIMH before there was
SAMHSA as it is now, I went out to NIMH and I met with Dr. Lew Judd, who
was the director at that time. He came out in his white coat, like a
doctor, a doctor‑doctor. It\'s so interesting how things have changed. I
asked him for enough money to fund some family organizations in this
country, and I left there not knowing for sure if he would do that or
not, but he did, and he funded five, five states.

He had a certain amount of money, funded them all at about \$10,000
apiece, and one of them was Hawaii of the first five. After going to
advocate from Kansas for that, I didn\'t get any of the money. Isn\'t
that the way it goes? Yes, that\'s the way it goes. Anyway, I hadn\'t
written such a good grant either. I was an interior designer trying to
be an advocate.

Anyway, I want to give you that history because it started very
modestly, and over the years it turned into 10 grants, and then 15
grants, and now there are 42 family organizations funded with about
\$60,000 to \$70,000 each. Even Guam has applied this year, I know, for
a family organization grant. I think South Dakota does not have a family
organization, and Arkansas currently does not have it. Most states do
have it. It\'s 42 of them, and quite a few were funded. Their funding is
basically ‑‑ well, let me go back and say that the family organizations
do a variety of different things. They provide information, support,
training and advocacy to families in their state who have children and
adolescents with mental health needs, and \$60,000 to \$70,000 is not a
whole lot of money. If they get \$70,000, there\'s a requirement that
they put together an organized effort around youth. So that\'s the extra
\$10,000 that 10 of them, I believe, get now.

So that\'s a little bit of background. Of late, since I would say the
New Freedom Commission, and maybe even before that, most of them are
funded ‑‑ this amount of money gives them the ability to sit in
decisionmaking places and pay for their time, effort and energy for
families to sit at the table on mental health planning councils, on
transformation efforts across agencies, which I think is phenomenal,
that SAMHSA has been visionary enough to fund an advocacy effort. We may
not call it that, but it is around helping to plan for systems change.

Now, a number of years ago we ended up getting enough money, also in
that line item ‑‑ and I\'m going to talk about that line item here in
just a second ‑‑ to fund consumer organizations as well. So now there
are family and consumer organizations both funded. Since I\'m not as up
to date on the consumer ones, I\'m not sure how many they fund. I\'m not
sure how many organizations get funding for consumer organizations,
which really meet the needs more of adults.

So when we got this money, it was kind of hidden away, and we did that
on purpose because we didn\'t think anybody would like us well enough to
keep us funded. But what has happened now is it\'s in jeopardy all the
time where it is. It sits in Projects of Regional and National
Significance, and you can see that it\'s taken this huge hit, and in the
\'08 budget the consumer and family organizations are gone.

Now, I know I don\'t have to say it to you, Joe, and I know that I
don\'t have to say it to you, Terry, or Kathryn, or probably any of the
SAMHSA folks here at this table, but it is a lifeline for most families,
and we have got to figure out how to keep it safe, maybe even give it
its own line item so that families can advocate for this in a different
sort of way, because now they have to advocate for it through something
that people go when they call their legislators. \"Where is that, and
how much money is that?\" It would be really nice to just be able to
point to the line item and say, okay, the consumer and family
organizations are funded right here, and we\'d have something different
to fight about with Congress, or not to fight about but to advocate
around.

So we\'re family driven, kind of on the move out of Kathryn\'s office,
which SAMHSA has totally supported, the whole notion of family‑driven
and youth‑guided, and with all the transformation efforts happening at
the state level, with things funded to help states transform themselves,
how are we going to do this without the family and consumer voice
sitting at the table? This is what funds that to happen.

So we\'ve got all the values in the right place, but now we\'re going to
have to have the dollars that reflect those values, and this is a minute
amount of money in the big scheme of things.

So, Joe, I\'m done, and I know I\'m preaching to the choir here, but
I\'m getting too old for this and, I\'ve got to tell you, it just breaks
my heart in many ways. I mean, this is not big money. Sixty thousand
dollars to try to manage transformation efforts for 42 family
organizations, and many of them it really is their lifeline, and many of
our family organizations are taking a huge hit right now at the state
level. Jane Adams in Kansas has lost \$300,000 in state funding. So
we\'re going to need for people to be underneath this. NAMI also lost
their money in Kansas. So it wasn\'t just Keys for Networking. It was
NAMI as well. Some states are moving forward and some aren\'t, and I\'m
amazed at how far backwards things can go.

MR. FAHA: Can I comment? Would that be all right?

MS. HUFF: Yes, Joe.

MR. FAHA: Barbara, we do go back a long ways. One of the things is that
as we both have gotten aged over time, your enthusiasm and support has
not wavered in years, in all those years. You are as much the advocate
today as you have always been.

A couple of points, though. You say line items, and I want to clarify
that it was Congress that created the single line item back in 1996 that
pulled all of our specific programs. Prior to that, there used to be a
listing for every program in our report, and then a dollar amount. It
was in \'96 when we took a heavy hit in terms of all of our funding,
when they went to a single line item for discretionary grants so they
could basically say that they can spend as much money on pregnant
addicts, for example, as they did last year, in essence. So it didn\'t
show that they were reducing. I just wanted to clarify that.

Basically, we\'re responding to Congress\' insistence. We tried to
offset that, however, in our own budget justification by putting in what
they refer to as a SLOA table, where it lists all the different
programs. Number one.

Number two, and this is very important. Dr. Cline has met with the
constituent groups and will continue to meet with the constituent
groups. For example, the Campaign for Mental Health Reform has several
members from the family and consumer networks who made sure he
understood the same concerns at that meeting, and he will be meeting
with those groups again, and with substance abuse groups, by the way, to
talk about budget and reauthorization. He has also indicated that he is
expecting that the constituent groups will play a role in the
development of the \'09 budget and has indicated to the center directors
that that should be part of the process.

So I\'m trying to get at the fact that Dr. Cline is ensuring that there
will be a voice at the table from all of these groups.

I\'ll leave the justification for why those are being zeroed out to
Daryl\'s presentation on the budget, but I would point out that despite
the fact that there has been an ongoing debate about funding for
consumer and family networks, I do not believe that they have never not
been funded, even when the administration continues ‑‑

MS. HUFF: (Inaudible.)

MR. FAHA: I know, Barbara. I know, I know.

MR. STARK: Kind of keying off that, Joe, I\'m not sure if you would be
the one to respond, or maybe Dr. Cline might be the one to respond to
this. But given that all of those programs got lumped into Programs of
Regional and National Significance, when you do get your budget, once
you get it, you mentioned that SAMHSA is going to be looking at whatever
process that you might use around planning for this next year, what are
those timelines? I\'m not asking you to identify any of the priorities,
but what are the timelines that you kind of perceive both relative to
developing your list of priorities for the upcoming budget as well as
once you get a budget, going back and revisiting, depending on how much
money you got and what cuts you might be taking, how you\'ll establish
the priorities within that sort of grouping? How do you see, if you\'ve
had time to think about this, this body playing into giving input around
that?

DR. CLINE: I\'m going to ask Daryl to take part of that, and I\'ll add
to that.

MS. KADE: With regard to \'07, we actually developed an operating plan
that had to be submitted to OMB last week, and then submitted to the
Hill. That operating plan is based on budget lines and also the
significant items identified in the Congressional justification.
Although OMB looks at what we call the SLOA table, which is the summary
listing of activities, which I have in the handout for my presentation,
it basically goes to the program level. So OMB has been looking at us
very closely so that there\'s a great relationship, direct relationship
between what we plan to do in \'07 and indeed what we told the Congress
we would do based on those SLOA tables.

Now, if there are changes, we have to negotiate them with the Department
and OMB. So that\'s happening right now, and I can get into that a
little bit in my presentation.

With regard to \'09, I know that Dr. Cline has asked us to start
thinking about \'09 now because traditionally our request to the
Department is due in June, and then our request to OMB is due in
September, and then there are a lot of negotiations around the major
holidays, Thanksgiving and Christmas, and then of course we get into a
production mode, and then you have the budget going out in February. So
now is really the time to start talking about \'09. Then, of course, in
the middle of this process, after our budget goes to the Department and
before it goes to OMB, we have the House and Senate marking up the \'08
budget. So we look at what the \'08 markups are in the summer to
influence some of the decisions that may be made as the Department
submits its request to OMB, and then OMB looks at the projected or
reasonable outcomes. Sometimes we have a budget on October 1 and
sometimes we don\'t, and that also plays into their decisions.

DR. CLINE: Ken, I would expect that we will have a budget discussion
here, and I can tell now that you would be willing to share your
thoughts on that, which is the whole purpose of having an advisory
council, to be able to advise us on that process.

We don\'t have all the specifics in terms of that timeline, but it is
clear that we want input from multiple stakeholders, and the reason
we\'re starting that now is, as you know, that process is more labor
intensive and it takes more time to do that. So I want to make certain
that doesn\'t slow us down in doing what we need to do, and that we\'re
being as strategic and as informed as possible as we move forward.

MR. FAHA: Are there any other questions? Gwynneth?

MS. DIETER: Yes. In terms of the parity bill in the Senate and the one
the House is going to propose that actually you think will come to
nothing because of the disagreement, but what role does SAMHSA have in
that? Does SAMHSA have a role? Do you have a role?

MR. FAHA: Yes, we have a role. It\'s the role that the President gives
us, and that pretty much is we march in tune with what the President
wants. The President, as you may know, back in 2002 in Albuquerque, New
Mexico, he echoed his support for parity legislation, and as of
yesterday he\'s not wavered on that. He states that he is in support of
parity as long as it doesn\'t wind up being too costly and that it
doesn\'t result in limitations on access to care. So if you add mental
health benefits, you don\'t lose other kinds of benefits that may be
helpful to people.

The administration is currently looking at the Senate bill and will be
looking at the House bill so it can make its comments. But so far there
has been no administration position with regard to Senate bill 558,
which is the parity legislation.

MS. DIETER: So then if there is a comment by the administration, do you
have the opportunity to speak when these bills are coming up for votes
and so forth?

MR. FAHA: We always have an opportunity to speak about bills that come
up, but what we speak is always what the administration wants us to say.
Dr. Cline is going to be testifying on Monday out in Greentree,
Pennsylvania at a field hearing that is basically about parity, being
hosted by Congressman Tim Murphy and Patrick Kennedy and will echo a lot
of his personal and administration thoughts about the need for access to
care for mental health and substance abuse services. However, when it
comes down to taking a position with regard to the bill itself, we will
refrain from commenting about Section 1, Section 2, Section 3, and just
give the Presidential current position of the administration with regard
to the bill, which I just stated.

MS. DIETER: So you mean you don\'t comment on certain sections of the
specific bill, you just reiterate the position ‑‑

MR. FAHA: That\'s exactly what we\'re going to do on the 12th, because
to enter into a dialogue about the provisions means you\'re talking
about the bill when Dr. Cline has not been empowered to speak on behalf
of the administration. So what, in essence, we will do is leave it to
the White House to carry out that dialogue.

MS. DIETER: Could he be empowered to speak on behalf of the
administration?

MR. FAHA: He could be, but that would literally take the Domestic Policy
Council to make that decision to empower him. It\'s like any other
ladder. It goes from the DPC to the Secretary, from the Secretary to Dr.
Cline. That\'s how we got to the position of testifying on Monday.

MS. DIETER: So that does happen. I mean, I\'m not that familiar with
this. I\'m sorry.

MR. FAHA: It does happen, but more often than not, most of the stuff
that\'s being considered in Congress is of limited interest to the
Secretary, nevertheless to the Domestic Policy Council, and the less
interest it is to the Domestic Policy Council and the Secretary, then
the more latitude Dr. Cline has. The more important it becomes to the
Secretary and/or the Domestic Policy Council, then we have to bow to the
wishes of those people, and parity is one of those. The parity
legislation is one of those. I don\'t know if that thoroughly answers
your question.

MS. DIETER: Yes. It\'s an area I personally think is really important,
and it\'s been going on and on and never ‑‑ I mean, states have parity
rulings in some sense, but it\'s an issue that isn\'t resolved.

MR. FAHA: It certainly hasn\'t stopped us from talking about the need
for access to care and the fact that there are problems and limitations
in insurance. What we are limited in talking about is the actual fix
that Congress is putting together. We cannot talk on behalf of the
administration on that fix, other than to echo what it is they just
said.

MS. DIETER: But they\'re there talking about it.

MR. FAHA: They don\'t exactly call me up, or Dr. Cline, to say we\'re
going up to visit to talk about this, but yes, the Domestic Policy
Council is talking about this issue. Politically, to understand this,
right now there isn\'t much for them to have to worry about because
you\'ve got the divergence between the Senate and the House, so there is
a logjam that\'s caused. So there\'s no real political need for them to
enter into the fray. As it gets closer, then they will.

MS. DIETER: Okay. Thank you.

MS. HUFF: Also, I just might add that like Mental Health America and
other advocacy organizations, I believe they\'re holding briefings on
the hearings on the Hill. Am I right on that, Joe?

MR. FAHA: Yes.

MS. HUFF: So there\'s a lot of good advocacy work going on.

MR. FAHA: Yes, and I can attest to that. Barbara is absolutely correct.
There have been briefings given by Senator Kennedy and Senator
Domenici\'s staffs at which maybe 100 individuals representing every
mental health and substance abuse group that I certainly have known
about have attended, and they\'re all being very vocal about what\'s
going on in the bill.

DR. KIRK: I don\'t know whether this is a question appropriate for Joe
or for Daryl, but what seems to be the spirit in Congress relative to
block grants, as to whether block grants should be combined and so on? I
thought I saw something that Congressman Kennedy was oriented to, for
example, combining the mental health and substance abuse block grants,
but maybe I\'m wrong.

MR. FAHA: You\'re referring to a question he asked Dr. Cline at the
hearing. First of all, Congress has typically been very supportive of
block grants. I can\'t remember the last time that they were ever
reduced. The worst that seems to happen is that they\'re level funded,
but I can\'t recall either the SAPT or the CMHS being reduced in any one
year. So obviously they\'re very supportive of those programs.

With regard to your second question, there has been for some time, as
you know, a dialogue amongst mental health and substance abuse groups
about the opening of the SAPT to pay for mental health services, direct
mental health services, and I think that\'s what Congressman Kennedy was
referring to in his question, not so much about the combining. I don\'t
recall that he mentioned the combining of the two grants.

Thank you very much. I appreciate it.

MS. HUFF: Was there some conversation not about combining ‑‑ now this is
just a rumor. Was there some conversation about eliminating the block
grant?

MR. FAHA: Absolutely not. I\'ve never heard anyone say anything about
that, Barbara.

Again, thank you very much. I always enjoy this visit. Thank you.

DR. CLINE: Thank you, Joe.

At this point, Joe, you\'ve gotten us right back on schedule and in the
other direction, and we will take a 15‑minute break and reconvene at
11:00 sharp. Thank you.

(Recess.)

DR. CLINE: I\'d like to call the meeting back to order, please. Thank
you very much. I know we\'ll have a few other people who will still be
coming back into the room.

It\'s my pleasure now to turn the mike over to Ms. Daryl Kade, who is
the executive director of the SAMHSA National Advisory Council and is
also the associate administrator for the Office of Policy, Planning, and
Budget.

So, Ms. Kade, the floor is yours.

MS. KADE: Thank you. Due to the unusual budget situation this year,
I\'ll be talking about two budgets, \'07 and \'08. You have in your
handout or in your book some handouts on the 2007 budget. The first page
of the handout is what we call an APT or all‑purpose table. This is what
it looks like. I wanted to note that the joint resolution for \'07,
which was effective mid‑February, provided \$3.3 billion for SAMHSA,
which was slightly more than what we had in 2006. I would refer you to
the bottom line. If you\'re looking at this table, look at the third to
the last row. That\'s where you see the bottom line for SAMHSA. The
amount provided in the joint funding resolution was slightly more than
the 2007 President\'s budget, about \$66 million more, but somewhat less
than the summer House and Senate marks.

I wanted to also draw your attention to the next handout for \'07, which
looks like this, which identifies significant changes relative to the
2007 President\'s budget. I would point out that CMHS receives an
additional \$35 million. You can see the various increases, and I would
point out the largest increase was for the school violence program. CSAP
received an additional \$12.3 million, and the significant increase here
was for the SPF/SIG. CSAT received an increase of \$23.6 million, and
the two largest increases were for the PPW program and program
coordination.

I also wanted to point out some significant changes with regard to the
summer and the House Senate marks. In CSAT, I think the most notable
change was that ATR had been zeroed out in the summer, and the SAPT
block grant had been increased by \$75 million in the House and \$30
million in the Senate. However, under the joint resolution the block
grants were level funded, and we will be going ahead with the 2007
announcement for the ATR program for a new cohort, with a goal of \$25
million for treating people with methamphetamine addictions.

What you do not have in your package is a list of 2007 funding
announcements as a result of this budget. At this point we\'re reviewing
them. For CMHS there are over a dozen, I would say, funding
announcements, and a handful for CSAT. At this point, with the 2008
budget out, along with the 2007, a number of the programs, as you know,
have been eliminated in 2008, and a number of the programs have less
funding in 2008 than in 2007 to support the new grants in 2007. So at
this point there are ongoing discussions, especially with regard to CMHS
and the issues of multi‑year and one‑year funding announcements for
various programs that are funded in 2007, and with CSAT in terms of the
same issues, do we go for multi‑year funding if a program is no longer
continued in the 2008 budget, or indeed skip a new round of new grants.
That\'s an ongoing discussion within SAMHSA, and we\'ll get back to you.
If you want a list of announcements, we can get that to you as well.

As I mentioned earlier, an operating plan was submitted to the
Department last week in preparation for submission to OMB, and at this
point the operating plan assumes that we are in sync with the 2007
column in the 2008 budget, which includes all the specifics with regard
to the SLOA tables, which is the lining out of the programs in the
listing of Programs of Regional and National Significance. Again,
that\'s not a hard and fast rule. If we need to make changes, we\'ll
present those changes in a packet to the Department, and we will need to
negotiate them with OMB. To the extent that they affect CSAT and CSAP,
we\'ll probably need to negotiate with ONDCP as well.

So I\'m going to shift to the second attachment, which is 2008. I wanted
to make sure you knew that at the back of the package we do have a copy
of Dr. Cline\'s testimony from last week at the House hearing, which
included the three institutes. I also wanted to make sure that you saw
these SLOA tables. At the back of this section you have a summary of
listings for each PRNS program for each of the centers. So if you want
any specifics with regard to the reductions, with regard to the
eliminations, they\'re here specifically in these tables.

I wanted to just note some general specifics. There was a question
earlier about how various planning documents influence the decisions in
\'08. I would point out that all of our major programs or major
initiatives, although not increased and maybe slightly reduced, are
continued in this budget, and the block grants are level funded. So in
essence, although SAMHSA experienced a \$159 million reduction from the
base, most of our programs remain intact. Of the \$159 million
reduction, \$76 million was associated with CMHS, \$36 million for CSAP,
and \$46 million for CSAT. Again, if you look at the individual SLOA
tables, you will see that breakdown.

I also have in this section a handout that reflects the statements made
by the Secretary with regard to how difficult budget decisions were made
this year, not only in relationship to the various planning documents
that were mentioned before, but he had criteria that he used to make
difficult budget decisions. I would note bullet 3, looking for programs
that emphasize the delivery of direct services, not just replacing
infrastructure. I would also note the last two bullets, eliminate
programs whose purposes might be addressed in other places, that is to
say alternative sources of funding, and also looking for underperforming
programs, and then specifically programs where there is no measurable
way of determining whether they succeed or not. I think that gets back
to the earlier discussion with regard to the data strategy and NOMs and
how to communicate how effective or ineffective our programs are, or if
ineffective, changes and monitoring the effect of those changes on the
performance of those programs.

MR. STARK: Can I ask a question?

MS. KADE: Sure.

MR. STARK: Just a quick question. On those criteria for elimination, is
there any way, not necessarily today but at some point, of getting a
handle on which of those criteria were applied to the programs, or which
of the criteria are the criteria that caused the programs that are on
the list of eliminated programs to be eliminated? Like are there some
where there truly was a belief, the next to the last bullet, there truly
was a belief that some of those eliminated programs clearly could be
funded through other resources?

MS. KADE: I believe this is the type of analysis we\'re trying to do now
in preparation for \'09, to see where there were weaknesses in our
presentation and where we can strengthen that presentation and also deal
with gaps in funding.

MS. POWER: Daryl, I can just add that one of the things that we\'re
doing is going back and looking at that, and one of the examples that
was used in the budget presentation was the older Americans mental
health piece. I don\'t know if it was the Secretary or somebody who said
we know that there are services for older Americans that are funded by
CMS, we know there are services for older Americans that are funded by
HRSA, and so that was used as an example of one of the areas where the
Department said what are we doing? Now, our argument obviously would be
that specifically there are needs for older Americans from a mental
health perspective and from a behavioral perspective, and I think
that\'s what Daryl is getting at. We need to kind of be clear about the
ways in which we\'re working with those other agencies but there might
be some unique aspects to the program.

MS. HUFF: A couple of things that concern me. Bob Bernstein from Bazelon
Center for Mental Health and I offered a lot of volunteer support, all
volunteer support, to the consumer aging group. You could say that about
children, about everyone, because children are supported over in CMS
probably at a much greater level. So I don\'t want us to think that we
can eliminate a program because somebody else is funding some too. So
that concerns me because older adults are people just like children.
They just don\'t have the voice, and the organization that they formed
didn\'t make it because they were old and they just didn\'t have that
energy related to some of the things that needed to be done to keep an
organization going. So their money is kind of sitting in the
Federation\'s bank account right now on hold, and SAMHSA worked with us
on that, to get us to a place of just kind of hold on their consumer
organization.

But I think the thing that alarms me even more as we go through this in
those bullets is that ‑‑ Kathleen, are you there?

MS. VAUGHN: No, she\'s not. She must be on another line.

MS. HUFF: Okay, because Kathleen will remember, and maybe some of you
folks will, too, when they funded some of the suicide efforts, the
efforts around the issue of suicide, and we asked the question, the
council asked the question, if there was a strong evaluation piece with
this, because we felt like how will we know if putting a lot of money
into this, if we don\'t have a good evaluation with it, that we won\'t
know unless people have committed suicide or attempted suicide or
whatever.

Do you remember that when we asked that question? And Charlie said we
don\'t, we don\'t have what we really ought to have. So we don\'t have
that. So if we go back to these points here, that whole suicide
prevention thing could be unfunded if we don\'t have what we need to
prove that it\'s working.

Am I right on that, Terry? I mean, I say that just out of concern.
There\'s nothing we can do about it as a council, but I say that to you
as a concern that if we don\'t have a good evaluation component with
some of these things that we are funding, under this criteria we\'d lose
the program.

DR. CLINE: Well, consider your concern registered. There are two points
I would make in response. This does speak to the need for a data
strategy, and it speaks to the need for that level of accountability.
Our programs that do not have strong performance measures are
vulnerable, and they\'re vulnerable whether it\'s this year or next
year.

I mean, first of all, I think we\'re all in agreement that there will
never be enough money in our system. There will never be enough money to
address all the needs. So we want to do everything we can to get back to
making sure that we\'re funding programs that are most effective. One
way to demonstrate that is by having those performance measures and
those outcomes. So as other people chime in in terms of the budgeting
process and they see two programs and one has good outcome measures and
one doesn\'t, then the one that doesn\'t is vulnerable, and it\'s harder
for us to defend that particular program.

Certainly this was true for me at the state level, too. I loved it when
I could go up there and I had strong outcomes. I mean, it\'s just an
easier argument to make. So it behooves us to work aggressively to try
to get those types of measures.

Back to the earlier conversation and point about funding through other
agencies, first of all I\'m not of the belief that simply because the
money is there we can say it\'s already funded, so it\'s okay and we can
rest easy on that. But I think there is an opportunity for us, and
sometimes scarcity moves us toward that. The adage of necessity being
the mother of invention, we get more creative when resources are scarce.
The example that was given for older adults, if we look at that and the
hundreds of millions of dollars that are being spent across this country
in the overall President\'s budget, not just our budget but the overall
President\'s budget, hundreds of millions of dollars, very few of those
dollars are focused on behavioral health for older adults. So the
opportunity here, I think, is to drive us to say we don\'t have the
money in our budget or may not have the money in our budget to do that,
so part of the tradeoff is that we want to be certain that as those
dollars, as those programs, as those services are being delivered,
hundreds of millions of dollars, we want to be sure that behavioral
health has a seat at that table so those dollars are being leveraged in
some way to address our needs.

That\'s a big challenge. I think, again, that the Federal Executive
Steering Committee is a great opportunity to have all of those agencies
and departments at least talking about behavioral health and
transformation. That\'s one of the take‑home messages for me from that
whole initiative. It\'s not just about getting people to buy into our
agenda and support it but how can we get them to buy into it to such a
degree that they want to help transform their agenda and their budgets
to address these needs.

So I don\'t want to be superficial in terms of somehow thinking that
just because someone else is funding some of that with the big label of
older adults or children\'s services or any of those things, that
somehow that will automatically make that happen. I\'m saying there\'s
an opportunity to build on the work that has begun to get ourselves on
those agenda, and homelessness is another example. I mean, literally
there are hundreds of millions of dollars that are being spent on
homeless services in the President\'s budget. How much of that really
focused on behavioral health, whether it\'s substance abuse or mental
health services? Very little of that, and there\'s a risk of SAMHSA
being the only agency that\'s owning responsibility for those types of
services out of those hundreds of millions of dollars.

So the opportunity is how can we infuse it, again, into those other
agencies? It\'s not an easy task, and it\'s not going to happen in one
year or two years. It\'s going to take a long time to really get that
embedded.

Ken?

MR. STARK: Just as a quick comment, and I\'ll get off my shtick on this.

MS. HUFF: Me, too.

MR. STARK: But, Terry, since you\'re new in this position, I haven\'t
done this with you at the helm. It gets back to language and how we tend
to stigmatize ourselves. If we\'re clearly talking about trying to look
at mental health and alcohol and drugs on a par with physical health,
then we really need to, I believe, focus on the concept that we are part
of health when it comes to the human being. I hate the term \"behavioral
health\" because I truly believe that it stigmatizes mental health and
alcohol/drugs by using that term, seeming to give the perception that
mental health and alcohol/drugs are about behavior, not about physical
health and mental health. When I say \"mental health,\" I\'m not talking
about mental illness but a physiologic mental health issue.

So I really encourage us to try to think about not setting ourselves
aside from the health agenda by labeling ourselves behavioral health and
try to generalize and use the generic term that we are a health system,
mental health, alcohol and drugs, all part of this broader health
agenda. I think that behavioral health again just stigmatizes us. It
negates the physiologic, biologic, genetic predispositions that are part
of mental illness, as well as alcoholism and drug addiction. Even within
the physical health system, when they think about mental health and
alcohol/drugs, they use the term \"behavioral health,\" which then sets
us aside from their inner core in physical health. So just a shtick,
wanting to pay attention to how we use terminology that tends to
stigmatize ourselves, and I encourage us to get away from that term.

DR. CLINE: Thank you.

Dr. Gary, and then Dr. Kirk.

DR. GARY: Thank you very much. I was looking also at the guidelines that
were used for program elimination, and I wanted to ask if there was any
discussion given to programs that were eliminated based on these
particular guidelines. For example, if you look at grant activities that
have been essentially completed and no automatic renewal, I think at
first glance that sounds pretty solid, but in many instances where
grants are given and there\'s no renewal does not mean that there\'s not
the public health need for prevention, treatment and rehabilitation. If
we do not look at the second phase of what happens in the individuals\'
lives, then I could argue that that\'s money that was not well spent,
because sometimes after services are no longer available to people, they
again fall through the slats. Whatever we have invested up front,
there\'s no evidence for two or three years later. So even though a
program has run its course, it does not mean that the needs of the
individuals do not still exist and that we ourselves are not
participating in a subliminal kind of process, if you will, where we too
are creating health disparities.

So another way to look at this, I would think that if we would look at
the programs that have met these criteria, to the extent that they are
not being funded, could we look at them to see what populations are at
risk because they are not being funded? That would be number one.

Number two, then why weren\'t these programs evaluated to the extent
that there was feedback earlier about their non‑productivity or their
inability to meet the needs of individuals? I think that\'s back to your
idea about evaluation and having evidence base. So that could go on on a
yearly basis rather than when there\'s a budget crunch, because that was
not a good investment in the first place.

So I as a council member would be interested in those programs that will
not be funded and what happens to the human beings with regard to their
opportunities for resilience and for life in the community, because I
don\'t want us to lose any ground, especially in those areas that we
have invested in earlier.

DR. CLINE: I of course appreciate your commitment and your passion about
the issues. One of the overarching principles here was moving toward a
balanced budget by the year 2012. So that then puts the pressure on the
budget in terms of how will you actually get there, and these were
really guidelines. There were many programs that may have come to a
logical end, but that doesn\'t mean automatically that that program was
eliminated. So it wasn\'t an automatic process because that was coming
to the end of a grant cycle. That was basically the red flag that said,
well, we should really look at that, we should scrutinize that, instead
of just automatically renewing that.

DR. GARY: I think the second part is could that information be shared so
we can look at lessons learned from those programs that did not meet the
criteria so that we can protect, to the extent that we can, those
individuals who need our services. That\'s my point.

DR. CLINE: That is part of the discussion that we\'re having around how
can we better prepare ourselves for next year to make sure that our
programs and our people are not vulnerable.

DR. GARY: In other words, we don\'t want (inaudible). Just a short way
of saying this is that we in no way want to create vulnerabilities, set
the stage for vulnerabilities in people\'s lives. We want to make sure
that we do everything we can, but we do know that when services are
withdrawn, are not available for a variety of reasons, there is or can
be an exacerbation of conditions that lead to high mortality/morbidity
in people\'s lives.

DR. KIRK: A couple of comments. I\'ll make my comments and then I\'m
interested in finding out from you how can we help you on this.

One of the things that concerns me as I look at these numbers and as we
look at what it is we need to do ‑‑ and I appreciate, Dr. Cline, one of
your points, what I call trying to make sure mental health and addiction
issues are part of every agenda, as compared to being just our agenda.
One of the experiences we\'re having is that if you\'re talking about
true system transformation change, it\'s not just a matter of taking the
folks that we currently have in the service system, the staff and so on,
and doing more of the same, as much as it is to hit the infrastructure,
and I\'ll use a couple of examples.

One of them is that in Access to Recovery, we formed a partnership with
our judicial branch, probation, parole, prisons, and it set up a
framework in which I think something in the range of 40 percent of our
resources related to Access to Recovery made significant impact in our
whole criminal justice system. So Connecticut, in terms of its overall
approach, says we are not interested in building more prisons. We want
to make sure that we can keep people in the community, and so on, and
that has been supremely successful.

So, for example, something called technical violations, the rate of
technical violations, people just missing appointments and that kind of
stuff and being reincarcerated has been reduced to the range of 40
percent, and that was because the judicial branch has taken some of
their probation officers and parole officers and provided some training
for them to help them recognize mental health and addiction issues, but
also provide services. That, to me, is infrastructure. Yes, it\'s
services with infrastructure this other part of the service system.

As we sit here now, every 17 minutes there is a successful suicide in
this country. The largest proportion of those suicides, successful ones,
are in the senior population. I forget what the statistics are, I\'m
sure Kathryn knows this, but a very large percentage of those persons
were seen by a primary care physician within 30 days of the successful
suicide. Now, if I talk to my commissioner of public health, Dr. Galvin,
and he says my people do not know how to successfully screen for these
kinds of issues, that\'s an infrastructure issue.

So when you talk about mental health transformation or moving the
service system, what concerns me about the numbers is whether we\'re
going to move to a focus that we can\'t afford infrastructure changes
that will go back to your point about being part of a transformative
agenda, and we just need to keep throwing more money towards services.
That, to me, is what I call an acute care delivery system, and it\'s
crisis oriented, and crisis oriented types of systems are expensive. In
Connecticut we\'ll pay a thousand dollars a day for a person for acute
psych state, detox and so on. I\'m trying to get away from that and keep
people in the community.

So a long story short, I\'m interested in how much of what it is we have
here in the budget relates to what I would call infrastructure
development that would involve me helping my primary care docs in
Connecticut, helping people in the judicial system, helping people in
the child welfare system not to become specialists in this area but to
play off of a greater degree of understanding so that it\'s clear that
by partnering with us, they truly result in a transformed system.

I think the other point is just a question. Based upon this, are we
moving away from infrastructure development? And if so, what can we do
to help you either in terms of ‑‑ I looked at the book as to what our
ethics are and that kind of stuff, and I\'m not interested obviously in
getting us in trouble. How can we help you to continue to get across the
message that services are important, but if you don\'t pay attention to
these other things, it\'s just simply the same thing over and over
again. We never get there.

DR. CLINE: Rich?

MR. KOPANDA: To maybe just touch on a couple of these issues, we talked
about the evaluation components of some of our grants and whether we\'re
doing kind of a process evaluation that\'s done within the grant or a
cross‑site evaluation that tends to be very expensive. In fact, as
we\'ve discussed, many of the non‑service activities were not
prioritized in this budget. Unfortunately, in some cases, that included
our technical assistance and evaluation dollars. Technical assistance,
of course, is working to help grants to perform, and evaluation is
working to document that good performance.

So in terms of, Tom, your question in terms of how can we move toward
documenting the performance, I think taking our National Outcome
Measures, NOMs, and developing them to the point where all of our
programs, including our infrastructure programs, are reporting on NOMs
which can document how well the grants are performing serves us very
well. We\'re moving, of course, in that direction for the substance
abuse block grant for next year. We have done that in quite a few of our
CSAT programs, but not all, but it\'s very difficult to do in the
infrastructure area.

We were talking to our co‑SIG grantees just recently about the need to
develop our performance measures for infrastructure. It\'s a little bit
easier to do for the direct service delivery. But that helps us when we
go through a process like we\'re doing right now, the OMB PART process
with the Access to Recovery, where we do have pretty good performance
measures, probably as well as we have on any of our programs, but we
need to have that for basically all of our activities. To the extent
that you can work with us to develop those measures, that would be very
helpful.

DR. CLINE: Ken?

MR. STARK: Kind of keying off of what Tom had mentioned, that if we\'re
truly looking at systemic change and we\'re looking at trying to
maximize our dollars across multiple program areas, including the thing
that you talked about relative to looking at other programs, whether
that be looking at the CMS and their stakeholder systems, or as Tom
mentioned looking at the criminal justice system and their stakeholders,
if we\'re truly going to maximize resources and continue to be effective
at working with folks with mental illness, as well as with alcoholism
and other drug addictions and problems of alcohol and drug abuse, that
the whole leadership of SAMHSA around training some of those other
systems to be able to screen and recognize alcohol, drug and mental
health issues, and to see the value to their system of doing that and
the impact, the cost impacts ‑‑ and you know this from all your Oklahoma
stuff and doing the administrative database analyses across systems ‑‑
if we don\'t get these other systems committed to both recognizing
alcohol and drug issues and mental health issues early and being part of
helping those folks get stable, then we will continue to do nothing but
an acute care system, and that gets back to looking at programs not
unlike the Minority Fellowship Program of trying to identify folks and
training them in schools, and not just the students but also the
instructors, so that we get in the schools of psychology, in the schools
of nursing, in the schools of medicine, and in a number of these other
schools, this new group of professionals that are going to be coming
into the field as we all fade into the sunset, getting them trained to
at least recognize and do screening around alcohol, drug and mental
health issues.

It also goes in line for me to think about the contracts that SAMHSA has
with NCSL in trying to ensure that state legislators and their staffs
begin to recognize the impact of mental illness and alcohol and drug
addiction on their other systems within the state and the value of these
services.

So I hope that we truly do have, as we move forward, a balance of the
infrastructure things, as Tom referred to them, as well as the service
things, because, as you already said, there\'s never going to be enough
money, but there are resources in some of these other systems, and to
the extent that we can get those other systems trained to pay attention
to these issues, I think we can maximize some of those resources. But
that\'s going to take leadership from SAMHSA because those other systems
aren\'t necessarily going to recognize it on their own. So I hope this
leadership group that I know you guys have with the other federal
agencies continues to move forward and over time those other agencies
begin to put some requirements in their funding flows that go to states.

But in the end, it really is going to be the collaboration at the state
and the local level that\'s going to make this stuff work. You guys can
drive the policy. You can influence at that level. But whether it\'s
going to get initiated and implemented is going to be the states\'
responsibility and the locals\' responsibility. So I just want to be
sure that we don\'t throw the baby out with the bath water on this, that
everything goes to services and nothing goes to infrastructure and
policy change and the whole idea of collaboration.

DR. KIRK: Two quick comments. One of them is that I asked about the
sense of urgency to the issues that are important to us. I forget the
specifics, but there\'s a review of eight states looking at the life
expectancy of persons with serious mental illness, and currently it\'s
15 years less. That just screams for attention. Go back to Ken\'s point.
The relationship between their needs, the fact that they\'re living 15
years less than others. They\'re not dying of suicide, they\'re not
dying of drug overdoses. It\'s things related to obesity, cholesterol,
et cetera. So that\'s one point.

The second point is ‑‑ I forgot it. As my staff says, when I say I lost
my train of thought, they want to know is it a slow train?

(Laughter.)

DR. KIRK: I forget it. I\'m sorry.

MS. KITTRELL: I want to go back to what Tom and Ken are both saying
about infrastructure development. SAMHSA recognizes the importance of
that, and that\'s one of the reasons we have funded the Strategic
Prevention Framework State Incentive Grant Programs. I don\'t want you
to think we\'re just a one‑note agency, but this is very important for
infrastructure development. The federal government does not provide
direct services. States do not provide direct services. Communities do
that. So through the Strategic Prevention Framework, we are funding
states. We are working with states. We are training states. We have
prevention fellows, prevention fellows, in state systems working with
communities so that they can deliver effective services to be able to do
the screening.

As a part of the SPF/SIG planning process, we have to have more people
at the table other than just substance abuse treatment and prevention
people. We have mental health. We have education. We have criminal
justice. So we have a broad spectrum of people that impact children and
families. As I was talking with Barbara Huff earlier, when we did the
Starting Early, Starting Smart program together, we recognized that in
order to help the individual, you had to have a holistic approach. So we
are doing that with the SPF/SIG.

DR. GARY: I wanted to pick up on the theme that Ken and Tom and now you,
Rose, have brought up. If we look at, let\'s say, infrastructure
leadership, leadership is not only position but leadership is knowledge
and skills. One has to have knowledge and skills about leadership but
also knowledge and skills about what one is leading, which is mental
health and substance abuse. If we look at programs such as the Minority
Fellowship Program, which is directly tied to the President\'s New
Freedom Commission report that discusses cultural competency throughout
that document and many, many other documents, just suffice it to say
that, for example, in nursing, 3 million nurses in the United States and
only 13 American Indian nurses have Ph.D.s in anything, and 10 of those
13 American Indian nurses have gotten their doctorates through the
Minority Fellowship Program.

I make the case that there\'s no other agency that picks it up. The
Minority Fellowship Program is probably the most successful federally
funded program in the history of the United States. I would think that
if we would look at infrastructure, if we would look at service, and if
we would look at the populations who are most affected by substance
abuse and mental health, I don\'t have all the statistics in front of
me, but we know co‑occurring disorders and people who have to come in at
crises are primarily minority people and poor people. We know that
substance abuse, people who do not get care are primarily people of
color. We know that seclusion and restraints occur primarily with
Hispanic and African American young adult males. That history, that kind
of data has been in the literature now for about 50 years.

We know that children and families in foster care, children and families
who have no infrastructure are primarily people of color. We know that
the suicide rate of African American men has increased by 110 percent in
the last five years.

MS. SULLIVAN: Faye, excuse me. Which color? I know this is rude, but
when you say people of color ‑‑

DR. GARY: I\'m talking primarily about American Indians, people of
African descent, Hispanics, and to some degree Asians. That\'s the
nomenclature for people of color.

MS. SULLIVAN: All right.

DR. GARY: It\'s not rude at all. Ask me anything you\'d like.

MS. SULLIVAN: No, because when you say that, it\'s nice to be specific
when you say that.

DR. GARY: Thank you, ma\'am. Of course, we know HIV/AIDS, we know that
African American and Hispanic women are affected by HIV/AIDS more than
any, and we know that the prisons are filled with black men and now
Hispanics. We also know that the least represented groups in the
workforce are African Americans, Hispanics, and American Indians almost
don\'t exist there. There is not one doctorally prepared nurse who is
Alaska Native in the whole world, not one.

So we have some serious issues as we move any one of these agenda items
forward, and I would ask that we look very, very carefully at who is
providing the care, how that care gets provided, how that care gets
implemented, and if it makes any difference that one gets care if it\'s
not the right kind of care for that particular population‑based group of
people. So I think we really need to take a look at workforce.

DR. CLINE: Well, we are taking your message to heart, and there is a
full presentation on workforce development that is taking place
tomorrow. So you\'ll hear a lot about that, and there\'s been a lot of
work on that front.

DR. GARY: Good. Thank you.

MS. SULLIVAN: Dr. Cline, may I mention something?

DR. CLINE: Certainly.

MS. SULLIVAN: There\'s an elephant in the room here, and we\'ve danced
around this for years. Larry, I\'ve emailed you on this numerous times
at Veterans Affairs, but I think it\'s sitting right here, right in
front of us now, and it\'s an opportunity. It\'s now something that we
can look at as an opportunity because it\'s not only on the front page
of the Washington Post but it is now front and center in the front of
every American\'s mind, the disaster that\'s going on as far as the lack
of treatment for our veterans that have come back from Iraq and from
Afghanistan across this country.

I believe the number, Larry, and you can help me with this, is 62,000
who are suffering from post‑traumatic stress disorder. As you see that
as an issue that we can step into and just scream SAMHSA. I see now such
an opportunity for SAMHSA to step in, especially as former Senator Bob
Dole and former Secretary Donna Shalala are now heading up the group
that the President has put together to study what has gone on at Walter
Reed and what has gone on with the ailing within the Veterans
Administration as far as what has happened with the treatment of these
veterans.

For SAMHSA to be able to walk in, and possibly for Kathryn and for you,
Dr. Cline, to walk in and to say, hey, we are here, we can come in in
greater force than what you\'ve been able to do. We are here with
resources, and possibly also that we are able to get a bit of the budget
so that maybe we can get some resources as well, and maybe there is a
new partnership to be formed with the Veterans Administration.

We\'ve danced around this for years. We\'ve said, no, that\'s their
problem, they should deal with that. I think it\'s time for us ‑‑ on our
matrix, we don\'t see veterans, and it\'s always been Veterans Affairs,
Veterans Affairs. I think that that\'s something that we\'ve overlooked
for way too long, and I think the country is demanding that we do
something.

MS. POWER: Kathleen, this is Kathryn. Larry had to step out of the room
for a conference.

First of all, thank you very much for your comments, and I appreciate
your concern about this issue. A couple of things come to mind, and I
can reflect back on some of the activities that SAMHSA is actually
involved in.

First and foremost, as you know, last year we had the returning vets
conference, and subsequent to that the Administrator has created an
internal SAMHSA working group that is devoted to looking at the future
of SAMHSA\'s role in supporting veterans issues, and that is a very
active and very assertive outreach, and if Larry were here I\'m sure he
would say to the VA and to the Department of Defense that\'s being led
by Arnie Owens at SAMHSA, under Terry\'s direction, and many of the
folks across SAMHSA are sitting on that working group. We have done some
very deliberate reviews post‑conference to take a look at just where can
we build on our connections with our grantees, with the programs, with
the states, to make sure that mental health issues, mental illness,
substance abuse and addiction issues are front and center for us in
terms of that particular community.

Secondarily, I am the personal representative for SAMHSA on the DOD
Mental Health Task Force, which was created basically out of a piece of
legislation that Senator Boxer from your state created, and it was
created under former Secretary Rumsfeld, and now we report to the new
Defense Secretary Gates, and that report is going to be coming out
probably in April or May, and that is specifically composed of DOD
active‑duty military psychiatrists, family members, and I\'m the person
who represents the public health SAMHSA perspective, as well as being a
reserve officer.

Our task is to take a look at the current mental health and substance
use response system for three populations: the active‑duty military, the
returning vets that are involved in the VA system ‑‑ that is, that are
getting their care from the VA ‑‑ and their needs within the Reserve and
Guard community, which is very distinct from the active‑duty and from
the VA. It\'s been a very powerful experience. We\'ve done over 35 site
visits to military installations across the globe, and we are clearly
coming to the conclusions that you have elicited, and that is that it\'s
time for the military, for DOD and for VA, all of us, in SAMHSA, across
DHHS, everywhere, to bring the attention about behavioral health, with
apologies to Ken, about broadly the issues around mental health and
substance use and addictions and bring it to the forefront.

So we are very actively involved in those discussions. We are very
actively pursuing, with Terry\'s leadership, the federal partners
connection with both DOD and VA around specific areas, particularly
suicide prevention and particularly focused on that under our Federal
Action Agenda. So we resonate with your suggestion and your
recommendations and we are working, I think, very assertively to make
sure that these issues are paid attention to even though, as you know,
we are not the agency that is required by law to respond to or promote
those services. DOD and VA are the first line, and then we I think come
in as policy shapers and policy informers. The notion about a public
approach to mental health and substance abuse is very different when you
look at military medicine.

So all of that dialogue is going on and I really appreciate your
interest in it.

MS. SULLIVAN: Once again, Kathryn, I\'m just awed by the amount of work
you\'re able to do, and to do so handily. Congratulations and thank you
for putting that under your umbrella.

DR. CLINE: Thank you for raising that issue, as well.

We have just a few more minutes, and I know Ms. Kade has a couple of
points she would like to make before we close out for lunch.

MS. KADE: Very, very quickly, I did want to point out some of the very
positive features of this budget, that the 2008 budget does maintain
funding for the Presidential initiatives and priorities, including ATR,
the MTH SIG. It does maintain funding for other major activities,
including the Children\'s Mental Health Services, the PNA program, and
both block grants. It does maintain an overall level of funding for PRNS
at 95 percent, and there are increases for the SBIRT and drug court
programs in CSAT, and it does maintain funding for National Minority
AIDS Initiative activities.

Now, it does require the submission of NOMs for both block grants, we
think as part of the block grant application, and we\'re working with
OMB and the Department to clarify that. Obviously, we do have a \$159
million reduction. I\'ve included in your handout what I\'m sure you\'ve
already seen, which is the list of programs that are already reduced.
There are 18 programs that are eliminated, and that does not include the
additional programs for which there is reduced funding and thus not
enough funding to continue new awards from \'07 to \'08.

I did want to point out the 5 percent incentive/penalty for states
providing or not providing NOMs through their SAPT block grant. We\'ll
be working again with the states, as well as OMB and the Department, to
assure that states do comply. We\'ll be working on those criteria
together.

As a result of the \'08 budget, there are a number of programs that we
will be announcing in \'08. I would point out the handout that you have
in your packet. For CMHS we will go forward with youth violence and
youth suicide prevention, for CSAP National Minority AIDS Initiative,
for CSAT SBIRT as well as TCE general, AIDS as well as drug courts, and
again we\'ll be working with OMB and the Department to clarify what it
means to require the NOMs submission along with the block grants.

I think today we\'ve actually started a conversation on 2009. I would
point out that we did make commitments to OMB to provide a data strategy
to them by the summer, and I think the discussion about NOMs not only in
terms of individual client outcomes, which has been the focus, but also
infrastructure, may be things that we talk about in terms of identifying
action steps that we can proceed with even before the summer.

I don\'t think anyone has anymore questions? Barbara?

MS. HUFF: I see the amount. It says \"Children\'s Programs.\" What all
does that include? What was cut? What was eliminated? Not cut, but what
was eliminated in the way of children\'s programs?

MS. KADE: If you would look at this handout for CMHS, it is what we call
the Summary Listing of Activities, and you\'ll see the various deltas by
the programs. So if you have any questions about any of the programs,
the details are in these three center tables in your handout.

DR. CLINE: Ken?

MR. STARK: Mine\'s just a quick comment. As you\'re looking at 2009, I
would really encourage you to have discussions about the feasibility of
looking at SBIRT models and ATR models on the mental health side as
well, and particularly SBIRT given the fact that you\'ve got so many
individuals with mental illness who also show up at hospital emergency
rooms and what not. It gets to that whole issue of trying to do early
screening and interventions by engaging other systems where individuals
are showing up.

DR. CLINE: I\'ve just been reminded that we have one person who has
signed up for public comment. So if we could be patient for a bit in
case she\'s not here this afternoon, I\'d like to give her an
opportunity to go ahead and come up to the microphone to make her
comment. Marcie Granahan.

If there\'s anyone else who would like to make public comments, please
sign up on the sheet and do so this afternoon.

Is Marcie still here? Marcie, there\'s a mike right there for you.
Thanks.

MS. GRANAHAN: On behalf of the United States Psychiatric Rehabilitation
Association, I\'d like to thank SAMHSA for allowing me to present public
comment today, and I\'m very short. Thank you.

USPRA has been a long‑time supporter of SAMHSA and the Center for Mental
Health Services, as we both share similar missions to help facilitate
the recovery of people with mental illnesses. For those of you who
don\'t know, USPRA is a 501(c)(3) organization of psychiatric
rehabilitation agencies, practitioners, researchers, educators,
consumers, and interested individuals dedicated to promoting, supporting
and strengthening community‑oriented rehabilitation services and
resources for persons with psychiatric disability. We believe that, as a
government agency, SAMHSA is uniquely positioned to advance the
transformation of our nation\'s mental health system.

From its funding of progressive state programs to its investment in
identifying evidence‑based practices to anticipating future workforce
needs, SAMHSA and CMHS have been at the forefront of change. SAMHSA has
played a significant role in how society thinks about and cares for
individuals with psychiatric disabilities. However, there is still much
work to be done to realize the 10 fundamental components of recovery and
ultimately transform the mental health system. Reauthorization of
SAMHSA, and probably more importantly adequate funding for CMHS
programs, are essential. Although USPRA is pleased with the 2008 budget
that will continue to fund programs that are critical with the mental
health delivery system infrastructure, we\'re very concerned about the
\$78 million in funding cuts to the Programs of Regional and National
Significance, which also support the states in carrying out activities
that improve services for adults with psychiatric disabilities.

While admittedly difficult at times to measure, these programs have no
less an impact on transformation. In fact, the comparatively small
amount of resources spent on Programs of Regional and National
Significance deliver significantly higher yield in grassroots efforts to
transform the mental health system through training and technical
assistance. These programs speak directly to SAMHSA\'s fundamental
component of recovery that states \"Consumers have the authority to
choose from a range of options and to participate in all decisions,
including the allocation of resources, that will affect their lives and
are educated and supported in doing so.\"

Through knowledge dissemination and training, many of these programs
provide individuals with psychiatric disabilities a voice in the
delivery of mental health services. While not a direct recipient of CMHS
funding, USPRA has witnessed the benefit these programs provide.
Consumer and consumer‑supported technical assistance centers have
brought self‑directed tools such as WRAP, which is the Wellness Recovery
Action Plan, into the mainstream. The Rehabilitation Research and
Training Centers, also known as the RRTCs, have been instrumental to
mental health policies, programs and systems, as well as to the
development of innovative services, and have allowed for the mass
dissemination of mental health research. Many of these technical
assistance centers use USPRA, as well as other associations, as conduits
to ensure a trained and educated mental health workforce. The Statewide
Consumer Network Program provides support so that innovative delivery
services, such as Georgia\'s Peer Specialist Program, can flourish.
Elimination of programs such as these would be a terrible loss for the
entire mental health community.

USPRA understands the difficult and oftentimes unpopular decisions the
administration must make in presenting a realistic and balanced budget.
However, the extent of the cuts to SAMHSA, and specifically to CMHS, is
disappointing. USPRA hopes the administration will reconsider its
position on the Programs of Regional and National Significance and the
value that these programs bring.

Thank you very much for letting me speak today. I appreciate that.

DR. CLINE: Thank you for your comments.

At this time we will adjourn and reconvene at 1:45. Thank you.

Oh, one more comment from Daryl.

MS. KADE: Yes, just with regard to lunch. Lunch has been arranged at the
Sheraton Hotel, and a shuttle should be outside waiting for you now. See
you back here at 1:45.

(Whereupon, at 12:10 p.m., the meeting was recessed for lunch, to
reconvene at 1:45 p.m.)

[AFTERNOON SESSION]{.underline} (1:50 p.m.)

DR. CLINE: Welcome back, everyone. I hope you had an enjoyable lunch,
and I appreciate your presence back at the table to my council members,
and welcome back to our members of the audience as well.

At this point I am going to turn over the microphone to Dr. Kevin
Hennessey, who is our science to service coordinator in the Office of
Policy, Planning, and Budget, for his presentation on the National
Registry of Evidence‑Based Programs and Practices.

Kevin, the floor is yours.

DR. HENNESSEY: Thanks very much, Dr. Cline. I appreciate the council\'s
invitation to come and speak with you about SAMHSA\'s National Registry
of Evidence‑Based Programs and Practices.

Let me take you back to April 25, 2003, which was the date of my last
presentation to SAMHSA\'s council, and it was really a broader
presentation in terms of emphasizing SAMHSA\'s emerging science to
service initiative. In the course of that presentation, I made note of
the fact that SAMHSA was poised at that point to begin expansion of its
National Registry of Effective Programs to all SAMHSA domains, so mental
health treatment, mental health promotion and substance abuse treatment.
I am very pleased to say that a little less than four years later and
one name change later, here we are with the new National Registry of
Evidence‑Based Programs and Practices.

(Applause.)

DR. HENNESSEY: I was going to say there are probably a few council
members here today who weren\'t council members then, but I for one may
be the happiest person in the room for that blessed event. I am pleased
to report that it was a healthy delivery and the baby is poised for
tremendous growth and development in the months and years to come.

MS. HUFF: We hope without any mental health problems.

DR. HENNESSEY: Exactly.

(Laughter.)

DR. HENNESSEY: SAMHSA\'s vision for NREPP is that it becomes a leading
national resource for contemporary and reliable information on both the
scientific basis and the practicality of interventions to prevent and/or
treat mental and substance use disorders. NREPP really represents a
major activity within SAMHSA\'s science to service initiative, and it
has been reformulated as a decision support tool and a valuable
resource, we hope, for state and community‑based organizations seeking
to identify and select interventions to meet their needs, and you\'ll
hear that more of the emphasis really is on meeting the needs of these
states and localities. What it is not is a list of approved or
accredited programs or practices. I\'ll also have a bit more on that
later.

A little bit of the history of NREPP. It began in 1996, again as the
National Registry of Effective Prevention Programs. Between \'97 and
2003, the system was very active. It reviewed over 1,100 substance abuse
prevention programs. Over 150 of those programs, or about 15 percent or
so, were designated as either model, effective or promising programs,
and information on those programs was posted on the old NREPP website,
which was called Model Programs.

Again, back to that April 2003 date in which the decision was made to
expand NREPP to include all SAMHSA domains.

The new system. Part of the reason it has taken four years is that there
has been a tremendous amount of thought and effort given to how to
redesign the system to better suit the needs of particularly end users
of the systems, consumers, providers, purchasers of services. So we
began with a convening of several different kinds of review panels in
2003 in the various areas of expansion. We wanted to get their best
thinking at the time of how we should expand the registry to address the
needs in each of those expansion areas.

One of the strong recommendations that emerged from each of those panels
was that evidence should be rated at the level of outcomes targeted by a
particular intervention. The old NREPP system really was a global rating
and a global label of the intervention that this is a \"model
intervention.\" Even though perhaps it was modeled for achieving certain
outcomes, it may not have been modeled, or even promising, for achieving
some other outcomes. So the redesign of this system really is a much
more targeted effort to specify and be very clear and transparent about
what the intervention does accomplish and perhaps what it doesn\'t
accomplish.

We piloted ‑‑ \"we\" meaning the agency and the contractor ‑‑ different
criteria over this time and have redesigned the system, and we felt that
as we had this new system ready to launch that it actually would be very
important to begin to engage the public, that we thought we had it
right, but truly the true test of this was getting comments from the
public, people that were going to be using the system that were
influenced or impacted by the system. So in August 2005 we issued a
Federal Register notice saying here\'s what we think the system should
look like but, importantly, what do you think it should look like. We
did get a number of comments back, well over 100 comments to that
Federal Register notice.

Some of the recommendations emerging from that process, to make the
assessment of behavioral outcomes a priority, not to say that we\'re not
interested in changes in thought or changes in attitudes, changes in
risk and protective factors, but that the primary emphasis ‑‑ and again,
this is from the public comments ‑‑ the primary emphasis should be on
actual behavioral change outcomes, be they in individuals, in
communities, or in populations.

Another comment that was fairly consensus was to provide more importance
on the emphasis dimension that we now call readiness for dissemination.
It\'s one thing to have a strong evidence base for a particular program
that has been tested in randomized controlled trials or been tested in
various research‑based settings, but it\'s another thing for that
intervention to have been tested in generalized populations, to have the
kinds of materials and training and other ongoing support that\'s needed
to really take an intervention from a one‑site or several‑site
intervention to something that would be applicable statewide or
nationwide. So the public really did want information on how ready is
this intervention to be disseminated more broadly. We\'re trying to do
that with our new system.

They encouraged us to avoid a system that limits flexibility and
innovation, to develop a system that is fair to interventions with
limited funding, and I think that was born in many regards from the fact
that an unintended consequence of the old system was that purchasers
began to restrict their purchasing to only interventions that were
listed on the old NREPP system, and in some cases it was even to only
model interventions, and the reality is that while those interventions
in many cases were quite good, they were limited and there weren\'t
interventions to address all of the needs in all of the settings among
all of the populations. So we really did want to build with the new
system an opportunity to promote innovation and to encourage the
development of an evidence base for many interventions so that they had
an opportunity to move into the registry.

Other recommendations were to recognize that multiple streams of
evidence are important and that these multiple streams are really what
address stakeholder information needs; to establish policies that seek
to prevent the misuse of information on NREPP, again trying to protect
against that notion that NREPP was an exhaustive or comprehensive list
and you should feel comfortable in just selecting an intervention from
NREPP even if it doesn\'t quite meet your needs; and finally, providing
a summary rating system that reflects the continuous nature of evidence,
that somehow with the use of the labels under the old system, the
\"model,\" \"effective\" and \"promising\" programs, you lost a lot of
information in that process. Again, as I noted before, it might have
been a model for certain outcomes and perhaps not a model for others. So
we really have moved away from the labels in this new system.

What I\'d like to do now is actually move to the podium and give you
kind of a whirlwind tour of the new NREPP. We did launch the system last
week, on March 1, and are pleased with some of the initial feedback
we\'re getting from the system. So I\'m going to move to the podium.

Can everybody hear me if I speak up? Is it loud enough? Okay. I\'ll just
try to speak loudly into this mike.

I did want to publicly acknowledge the hard work and outstanding effort
of the NREPP contractor, Manila Consulting Group. Representing Manila
today are the project director, Gary Hill, and the deputy project
director, Anna Hodgson, if you guys can just stand up, because they have
done tremendous, tremendous work on this project ‑‑

(Applause.)

DR. HENNESSEY: ‑‑ leading a staff of extremely dedicated, talented and
incredibly responsive people. We\'ve thrown them lots of curve balls
over the years, including the fact that they\'ve now, I think, become
experts in helping us to issue Federal Register notices, because we had
three of them in the process. But they really have put in long hours,
and I think that we have lots to thank them for in terms of the
development of the website and the running of this system.

I do want to give you a whirlwind tour of the National Registry of
Evidence‑Based Programs and Practices. You can see that we\'re going
with a fairly in some ways bold website in terms of the colors, but more
importantly we tried to present it very clearly, not to have a lot of
information on any of the pages, because we know that people really want
to zero in on what the most relevant information is as quickly as
possible. People are busy. They want to have something that they can
easily access, that they can easily understand. So that\'s really what
we\'re trying to do here.

Let me click on the About page first to give you a little bit of context
about what NREPP is and, in some cases, what it\'s not. You can see the
second paragraph under \"What is NREPP?\" \"The purpose of the Registry
is to assist the public in identifying approaches to preventing and
treating mental and substance use disorders that can be scientifically
tested and that can be readily disseminated in the field. It\'s one way
that SAMHSA is working to improve access to information on tested
interventions and thereby reduce the lag time between the creation of
scientific knowledge and its practical application in the field.\"
Again, it\'s this translation of science to service or reducing the
research to practice gap that many reports, including the Institute of
Medicine\'s seminal report, \"Crossing the Quality Chasm,\" had
identified.

What we\'re really about at SAMHSA in many respects, or at least one of
our central missions, is trying to deliver on the services that have
been developed and tested through the National Institutes of Health and
other research bodies, to get those out and more broadly adopted in the
public. We hope that NREPP is one important way now that the public will
be able to get access to that information in timely ways.

What information does NREPP provide? Several important factors. One is
descriptive information about the intervention and its targeted outcome.
There are two rated dimensions. One is the quality of research, and that
is really the quality of the research behind the intervention, how
rigorous was the testing of the intervention in terms of achievement of
specific outcomes. So there\'s a rating in that regard, and then the
second rating is readiness for dissemination that I already talked
about.

You\'ll also see a list of studies and materials that were submitted for
the NREPP review, and finally contact information for the intervention
developer. We\'re encouraging the public to go directly to these
intervention developers. So we\'re providing full contact information
for them. We want to provide descriptive information in some of these
ratings, and then the public can make decisions on their own about what
interventions best meet their needs given their resources, their
organizational structures and various dynamics that they\'re facing. We
want them to have as much information as possible, and then they can go
right to the developer to learn more if they need to.

There\'s lots of discussion about what is evidence based, and I think
that the way we\'re really putting that in the context of NREPP is
really emphasizing that NREPP does not attempt to offer a single or
authoritative definition of evidence‑based practices. It\'s one way that
we\'re really operationalizing what an evidence‑based practice is. It
doesn\'t mean that there aren\'t other very valid and very important
ways of defining and implementing evidence‑based practices. The second
paragraph does capture it as well. We recognize that there is a wide
spectrum of possible definitions of evidence. With this in mind, the
agency has attempted to make the NREPP rating criteria and processes as
transparent as possible. This is really one of our guiding principles.
We want people to understand how NREPP is rating the interventions, and
so we\'re trying to be very transparent about that.

A few other contextual setting sorts of comments. Part of our education
of the field is really providing some important notes about what NREPP
is and what it\'s not, how it should be used and perhaps a caution or
two against how it should not be used. So we put this important note to
NREPP users. Let me go back just to show you. We make that a click off
the homepage, because we really do want people to hopefully go there as
one of the first things that they do.

In light of what we\'ve done with NREPP in terms of the redesign, we do
provide this information that we encourage NREPP users to carefully
weigh all information provided, that it\'s intended to serve as a
decision support tool, not as an authoritative list of effective
interventions. We don\'t really approve, recommend or endorse specific
interventions. That\'s up to the public to be the judge of that. Being
included in the registry doesn\'t mean that an intervention is
recommended or that it has been demonstrated to achieve good results in
all circumstances. Certainly, many of the outcomes are positive. That
doesn\'t mean that they\'re positive in all cases. That\'s a very
important distinction.

Finally in that paragraph, policymakers in particular should avoid
relying solely on NREPP ratings as a basis for funding or approving
interventions. That\'s a very important note, because in many cases
other registries are oftentimes used to limit the funding in decisions
that are made. So we want to make sure that we\'re very clear to the
public that NREPP is an important tool but, again, not an exclusive or
exhaustive list. You may want to go here to begin your search for
effective programs, but your search may or may not end here as a result.
Again, it\'s not a comprehensive list of interventions, but it is a good
place to start to look.

Let me go finally into if you\'re actually going to the system to find
an intervention. It\'s a searchable database, and it\'s searchable in
many cases by some key factors. You can see that it\'s searchable by
topics. It\'s also searchable by area of interest, searchable by the
type of study design, some of the population factors, age, race,
ethnicity, gender, setting, whether the materials are proprietary or
public. That\'s an important distinction in many cases for
community‑based organizations that are making decisions in some cases
with very limited funds. It may be a very important factor in whether or
not they choose a specific intervention, whether the materials are
proprietary or public.

At this point there are 25 interventions on the registry, but this is
poised for some pretty significant growth because we have over 200
interventions in the queue for review. Many of those are interventions
from the old NREPP system, but a number of them are expansion areas as
well. In response to the first period of an annual open submission
period, we got about 50 interventions in response to that. We anticipate
that that will be probably something that we do every year and that
we\'ll continue to populate the registry with a number of those
interventions. So at this point it looks like we\'ll be increasing the
numbers on the registry, probably 5 to 10 interventions per month that
we\'ll be adding. So it\'s a growing registry and it\'s something that
we\'re encouraging users to check back frequently.

You can do a keyword search. You can put in the name of an intervention,
the name of a program developer, a particular area, and interventions
will pop up. Let me just, for example, click on older adult
interventions. Again, you can use the check boxes as well. If I search,
it provides the quick overviews of the interventions. We\'re really in
Version 1.0 of NREPP, and like Microsoft we\'ll be coming out with 1.1,
doing some updates, things like that. One of the things we\'ll do is as
the search is conducted, we\'ll print across the top how many
interventions met that search criteria. So the end user will know right
away how many interventions are meeting their initial search
characteristics.

If I were to click on one of the interventions, you really get at the
heart of what NREPP is, and this is the program summary or intervention
summary. There is some descriptive information, the topics, the
populations, what the outcomes are, the abstract, settings, area of
interest, whether or not it\'s been replicated formally through
independent study, whether or not the information and materials are
proprietary or public domain, important information about cost, whether
or not the program has been adapted.

Moving down, adverse effects, again an evolution from the old NREPP.
It\'s important for the public to know whether or not the intervention
has any harmful side effects or whether or not there have been any
concerns that have been raised about the particular intervention.

The implementation history; again, this is really from the program
developer, but in many cases that\'s a very important feature because it
could be that an intervention has been implemented in two settings with
exposure to about 100 people, or it could be that it\'s been implemented
in 100 settings with exposure to over 2 million people. So that may be
important in weighing some of those decisions.

Again, moving down the page, you\'ll see outcomes, and there\'s a
description. Each outcome, each targeted outcome has a box associated
with it where there\'s a description of the outcome, what some of the
key findings are, the studies that measured that outcome, the research
design that was used to measure within that study, and then the quality
of research rating, which is again on that 0 to 4 scale.

Let me move down to a kind of summary table of the ratings. Again, these
are the quality of research ratings. It\'s really how strong, how
rigorous was the study design that evaluated whether or not these
outcomes were achieved by the intervention. So you can see the various
criteria across the top, the reliability, validity, fidelity move
across. Again, all of those are rated by independent, expertly trained
reviewers, and it yields the various scores for each outcome on the 0 to
4 scale.

The readiness for dissemination ratings again are done by experts as
well. The quality of research is scientific experts, people with not
only a knowledge of the content area but also expertise in statistics,
methodology, study design. The readiness for dissemination reviewers
I\'m pleased to say are people with expertise in implementation. So in
some cases they would be Ph.D.‑level researchers, and in some cases they
would actually be consumers and providers that have an expertise in
implementing particular interventions. So we\'re really engaging a
variety of stakeholders on the front end of this NREPP system. Again,
they produce ratings which reflect the quality of the implementation
materials, the training and support, the availability and the ongoing
nature of that, as well as quality assurance. Are there fidelity scales?
Are there other support sorts of materials that can help to kind of
assess in an ongoing or continuous way the quality of the intervention
and the quality of the implementation?

We provide some strengths and weaknesses in each of those dimension
areas. So there are strengths and weaknesses on the quality of research
and strengths and weaknesses on the readiness for dissemination. This is
really, I think, in many ways the most useful information in terms of
what the public may be most interested in, in helping them to make some
decisions about the interventions.

Moving on down in the intervention summary, the study demographics.
Again, people may want to know has this intervention ever been tested in
the population that I\'m most interested in. So this is a quick table
that would at least give you some basic information in that regard.

The studies and materials reviews. Remember that NREPP really is a
snapshot in time. It\'s a review that\'s conducted in a particular time
period, and so the NREPP reviewers have the benefit of all the
information that has preceded that, but we want to make sure that the
public understands that the review was conducted in November of 2006 and
it could be that additional information is available on that
intervention in 2007. So we actually do put that important note at the
top of each summary, that all information below was current as of the
date of review. To request more information or to see if new studies and
materials are available, please contact the program developer. Again,
we\'re seeing NREPP as an information tool, but we really do want to
begin to have NREPP begin to direct people to the program developers so
that if you\'re thinking about implementing that intervention, you go
right to the source.

The way you would go to the source is the fact that we provide the
contact information at the end of each program summary, so again
encouraging people in many ways to go directly to the program developers
to get the information.

That is kind of a quick summary of how you may find an intervention. Let
me just give you a little bit of an overview of a couple of the other
NREPP pages just so that if you\'re in a position of needing to talk
about NREPP or directing people to use of the system. The review process
is fairly straightforward. Again, it begins with an application.
There\'s an open submission period that is going to probably be tied to
the beginning of each federal fiscal year, what is now a four‑month open
submission period from October of the beginning of the federal fiscal
year to February, four months later.

Because each of SAMHSA\'s three centers is an important part of the
NREPP system, they are really the ones who are weighing in very
carefully about what kind of priority content areas they would like to
see move into the registry. So if there are particular areas that are in
need, if the center directors and the center staffs identify particular
gap areas where they would like to see more interventions come in and be
identified as evidence based and available to the public, they would
identify those areas.

Because I\'m seeing Kathryn, I\'ll pick on that area. Kathryn and her
staff identified several key areas last year for NREPP priority review,
and some of those areas were consumer‑ and family‑operated or consumer‑
and family‑run services, alternatives to seclusion and restraint,
diversion programs for individuals with serious mental illness or
children with SED, diversion programs from the criminal justice or
juvenile justice system, and I believe the fourth area was suicide
prevention programs for all ages. So some very targeted areas, and we
did actually receive some important submissions in some of those areas.
So far, the system is working well.

The process is that interventions submit during that open submission
period and some determinations are made about whether or not they meet
the minimum requirements of the NREPP system, and let me just highlight
what those three minimum requirements are. It\'s that the intervention
demonstrates one or more positive outcomes in mental health or substance
use behavior among individuals, communities or populations. The second
minimum requirement is that the intervention has been published in a
peer‑reviewed publication or documented in a comprehensive evaluation
report. Again, we\'re not saying that it has to be published, but it
certainly has to have some documentation associated with it.

And then finally, there is documentation in the area of manuals, process
guides, tools or other training materials, and that the documentation of
the intervention and its proper implementation is available to the
public to facilitate dissemination. Again, we\'re most interested in
interventions that have the kind of documentation where somebody in
Nebraska could pick up the phone and call somebody in, say, for example,
Oklahoma and say I\'m interested in implementing this intervention; what
kind of materials are available to me to do so with a high degree of
fidelity and a high likelihood of achieving similar successful outcomes?
So we do have certain minimum requirements associated with the NREPP.

Then on top of that are priority points, and that\'s really around study
design. If it\'s a more rigorous design, it gets an additional priority
point. Again, if it meets one of the content areas that the centers have
identified, it will get a second priority point.

So all of that information is put together and decisions are made about
which interventions are then invited for the full review. The
intervention developer works with someone called a review coordinator
employed by the contractor, and this is an expert who serves as a
liaison between the program developer and the actual expert reviewers.
They provide all the information that\'s needed to conduct those
reviews, and then they\'re very responsible at the end for developing
the intervention summaries and providing all the information that then
goes up on the website.

NREPP is a voluntary system, and so the part about submitting the
intervention is voluntary. The program developer has to decide to submit
the intervention. But the program developer also agrees to the posting
of that information after the review is completed. We\'re not posting
any information that the program developer hasn\'t provided us with a
signed consent that this is fine to post this information. Again, we\'re
trying to be a very voluntary and a very transparent system.

In terms of the process for moving forward, I had noted that we had over
200 in the queue, and so we anticipate getting through those
interventions in the next year or two and moving about 5 to 10 out per
year. We anticipate publishing a Federal Register notice with SAMHSA
priorities for review. We probably will do that every summer. We did the
first one last summer at the end of June, and we have a process
internally where we identify with the centers and their directors what
the priorities will be for the subsequent year and then publish that
information.

We\'re trying to make this a very consistent and predictable sort of
process, as well as a very transparent process.

At this point I wanted to make sure we have plenty of time for
questions. Again, thanks for your support, and I\'m glad to be standing
here four years later.

MS. POWER: I just had a sort of exploratory sort of question. When we
gave you the priorities last year, and you have a great memory because
you remembered them very well, we also had a lot of other programs like,
for example, the National Child Traumatic Stress Network, and they\'re
sort of poised and ready to continuously be creating new interventions
because they\'re a grantee and that\'s what they\'re supposed to be
doing. As those five or six or whatever priorities we gave you last
year, that will not inhibit folks from the National Child Traumatic
Stress Network who might want to have NREPP review this from submitting
that. Those are just simply guiding priorities for you and the staff to
take a look at whether this fits, because things like consumer programs
and consumer‑related services and peer services is sort of an emerging,
exploding field. So we\'re looking for interventions that are effective
in that, but that will probably be an ongoing priority given
transformation.

But there might be other programs specifically from this trauma network
that we funded over the last several years where they come up with new
interventions based on the science and based on the research. Though
trauma may not have been on my priority list, every year we\'ll have a
chance to look at that and say we\'d like you to consider some of these
emerging things, and hopefully that will reflect what we think is coming
out from some of the grantee programs that we\'re supporting.

Does that make sense?

DR. HENNESSEY: Absolutely. It really is striking a balance. The
challenge is striking a balance between wanting to bring new and
emerging areas into the registry and using the registry to really help
build the evidence base for particular areas like consumer and
family‑run services that I think we all see as so important, but with
areas that are already established, you continue to bring the new
programs and the programs that in many ways have been tested more widely
in some cases, you want to continue to populate the registry with those
programs. So I think part of the challenge that we face within SAMHSA
and the centers is making sure that we have a balanced portfolio every
year as we move forward.

The other caveat I would mention is that we also are limited by the
amount of resources, and these interventions and the whole process, as
you can see, is extraordinarily detailed, and with that comes a price
tag of between \$10,000 and \$20,000 per review. So the good news is
that it\'s very predictable in terms of what we can do. If we know that
on the front end if we put X number of dollars into the system it will
produce Y number of reviews, there\'s the ability to expand and
hopefully not contract, so I\'ll emphasize to expand the system as we
look to identify additional interventions.

Yes, Ken?

MR. STARK: I think it\'s a great tool and I applaud you all for doing
it.

One of the questions that I have is that given the fact that we\'re
going to always be wanting to add to the list with emerging and
promising practices, is there any sort of strategic alliance between
SAMHSA and the institutes, NIAAA and NIDA and NIMH, about looking at
some common priority areas where you\'ve got some emerging or promising
practices, and given the split of roles where SAMHSA is not supposed to
be doing research, that the institutes would focus some of their
resources around doing some research on some of these emerging and
promising practices so they can ultimately get on the list or prove that
they don\'t belong on the list?

DR. HENNESSEY: Excellent question. I would note, and Dr. Cline noted in
his testimony to Congress, that at this point even though it\'s a small
number of interventions on the registry, 25, two‑thirds of those
interventions were supported by NIH research, either initially or in an
ongoing kind of expansion sort of way, and we anticipate that that
percentage is going to be about the same or similar as we expand the
registry. So we\'re really identifying the interventions that NIH has
made investments in and bringing them forward hopefully in an
accelerated way to the public.

But in terms of those strategic alliances, it\'s very, very important
because I think that the registry ultimately will prove to be a very
useful tool not only to providers and consumers and purchasers but
researchers as well, because I think what it will clearly highlight,
particularly in those sections around whether or not there have been
adaptations or the implementation history, we all know that there are
certain interventions that really don\'t have a particularly strong
evidence base, or maybe it\'s more accurate to say a limited evidence
base from the standpoint of they\'ve been tested and proven to be very
efficacious in the initial research‑based interventions, but they
haven\'t been tested more widely, the effectiveness trials; in other
words, how well does it work outside of the lab or outside of this
tightly controlled research setting with Native American populations,
with Asian American populations, older, younger, whatever.

Having that be very transparent on this NREPP system actually could
provide leverage to the outside communities to say this intervention
looks great and it\'s getting some high scores or it looks like it could
be very effective, but we really don\'t know how well it works in these
other populations or in these other service settings. So in many ways,
the next logical step would be to maybe make some investments in some of
those additional areas.

MR. STARK: If I could do a follow‑up, I agree with everything you said,
that many of the interventions that have been funded by the institutes
do get on the list because they\'ve already got the research from the
institutes and they were driven from that arena. I\'m also referring,
though, to the other side, those that are practice based, meaning that
they\'ve already been developed, they\'re already working, and states
and communities already feel they\'re effective and even have some level
of documentation, but not the type of rigor that would come with an
institute‑funded study.

So I\'m hopeful that in these strategic alliances between SAMHSA and the
institutes, that the institutes can feel their way to fund not only new
interventions that they\'ve done in the lab, as you say, under those
conditions, but rather to identify emerging and promising practices that
were developed in the field, not in the lab setting, and that people do
believe they\'re effective but what they\'re missing is the rigor of an
institute‑funded study to validate their existence, because neither the
programs not the states, nor SAMHSA for that matter, given the role that
you\'re confined to, can fund those kinds of studies.

DR. HENNESSEY: There may be some alternative opportunities for some of
those things. I agree with you fully that we need to look at ways that
SAMHSA, even if it\'s not direct resources, ways that we can try to
facilitate partnerships so that some of these practice‑based
interventions have an opportunity to build their evidence base. It may
be through foundation support, it may be through state dollars. I know
state dollars are limited, but there may be some limited state dollars
for evaluations. I know that SAMHSA at one point, with our service to
science academies, was playing in that area a little bit, and perhaps
there can be some replications of those sorts of concepts by other
funders. I\'ve got to be careful what I say here.

MR. STARK: I understand. The reason I\'m laughing is because you are
being so careful and it sounds like there wasn\'t a whole lot of faith
that the institutes would jump on that idea and be willing to fund those
kinds of things. But then again, I think you\'re free to say that.

DR. HENNESSEY: I\'m a glass half full kind of guy, so I\'m going to
emphasize that we can do some strategic partnerships.

MR. STARK: Good.

MS. KADE: I would point out that this year we did have a hearing with
the institutes, and we\'re hopeful that the creation and growth of NREPP
will change and improve those dynamics, especially when the members want
to hear about the dynamics and the collaboration between the institutes
and SAMHSA.

MS. DIETER: You mentioned the priorities you used for the first 25
interventions. Are those our matrix priorities or are these priorities
within each area, and if so, what were they?

DR. HENNESSEY: Well, quite honestly, the 25 interventions that were part
of our initial launch were a combination of interventions that were
already model programs on the old NREPP and some that were interventions
in the expansion area. Perhaps the common denominator for those 25 was
that they responded very quickly to the invitation given to them to be
included in NREPP last summer, because again, we had 200 interventions,
many from the new system and then some new interventions that were
identified by the work of many of our center staff for interventions
that should be brought into NREPP, but we had so many interventions ‑‑
the contractor really reached out, and because of our tight time frame
in trying to launch the system, and because of all the information
that\'s needed to submit for a review, we really took those that
responded most quickly. So some of those are the old interventions and
some of those are expansion areas.

We ended up, of the 25, we actually have a fair amount of representation
across the domains. About half of them are mental health interventions,
and about half are substance abuse interventions. Within the substance
abuse, a few more prevention than treatment, but we\'re working hard to
elevate the substance abuse treatment interventions for priority review
as well.

The contractor agreed with me that the best advertisement for getting
additional interventions into the registry is to have a live website,
and just in the last week since we launched the website, they heard from
a number of the interventions that we hadn\'t heard from in the initial
invitation. They\'re saying, well, where am I in the queue? I really
want to be reviewed. So I think that\'s a good sign to us.

MS. DIETER: Have you gotten any calls from the field? I mean, I hadn\'t
thought too much about it. I think that\'s a really important question,
what Ken brought up, because as he said there are some practices that
have been tried and been successful that don\'t have any data, haven\'t
been written up anywhere, and that\'s one of our huge problems in mental
health and substance abuse, all this fragmentation all over the country
where we have no idea what\'s going on, no one is in touch with each
other. Maybe there\'s some sort of attempt on your part to offer ‑‑ I
don\'t know how you can really do this, to say if you have someone in
the field, that you have some way to do it, a short study, to give them
the technical support of actually performing a study to collect some of
the data that you might need before you can actually put it on board.

DR. HENNESSEY: Well, in thinking out loud a bit, one challenge that
could be posed particularly at the state level is if there are
interventions that are working well, perhaps within a state, but they
don\'t have a strong evidence base, perhaps there could be a decision
made at the state level by some of the funding agencies that we\'re
going to identify between three and five interventions a year, or maybe
it\'s only one or two interventions, but it\'s something that\'s working
well at the state level where we need to build the evidence base and
fund a more formal and a more rigorous evaluation of that intervention
through state and/or foundation dollars with a goal of perhaps moving
into the national registry. I don\'t think it should be the exclusive
goal of doing that sort of evaluation, but it could be an important
goal.

Another goal may be to fund a rigorous enough evaluation that it forms a
basis for pilot work where you would then go and get a larger National
Institutes of Health sort of grant. But if people think about it, there
are some different opportunities that might be available if people think
creatively. Again, some of it is a matter of priorities. There are
clearly going to be many, many dozens of interventions within each state
where people could make the case that they deserve the investment, but
maybe there are certain priorities that are established at the state
level, or even a county level, and some of those limited dollars could
go toward a rigorous evaluation that would build the evidence base and
move them toward systems like NREPP.

MS. DIETER: Yes, because it just occurs to me more and more after Ken\'s
comment that like anything, once you\'re a parent, you learn how to be a
parent. Once you\'re a treatment center, you learn how to treat clients.
I mean, a lot of it happens in the field, not because of a study or a
more contrived, creative response to a situation that ends up turning
out to be quite effective. I think there are some small places that are
doing some fairly neat things that nobody really necessarily knows
about. I shouldn\'t be taking so much time, but I\'m just thinking about
it. I mean, here\'s this national registry of evidence‑based, but how do
we promote more exchange of information about good practices?

DR. HENNESSEY: They\'re excellent comments, and I think what it
challenges me to think about is if something is occurring at the local
level, or even within a particular agency, and it\'s working well, the
challenge really not to just that agency but to the entire field is to
begin to document it in a way that it\'s replicable, because if it\'s
working well there, there are some secrets to success that maybe it can
work well in other places. But unless it\'s documented and evaluated,
there\'s really not that opportunity to replicate that in a successful
way. So I think the registry is a vehicle to help people begin to
identify that. But the step that needs to happen, or the many steps that
need to happen before that is to get some sort of partnership between
maybe a local evaluator or a university‑based evaluator in that state or
region to come in, and perhaps through an NIH grant or perhaps through
state or foundation funds, and to begin to document that more formally
so they can demonstrate those outcomes in a way that is potentially
replicable in other places, because I agree with you. I\'m a provider
myself through emergency room practices, and there are a lot of things
that go on that are great but don\'t necessarily have an evidence base.
You really do have to create that evidence base so that you can get it
out there more broadly.

MS. DIETER: Absolutely. Thank you.

DR. CLINE: Barbara?

MS. HUFF: I want to respond to you, Gwynneth. But first of all, I\'d
like to just thank you because I remember when you were here before and
I gave you a really rough time.

(Laughter.)

MS. HUFF: I bet you can\'t imagine that, can you?

(Laughter.)

MS. HUFF: About not having families involved. Do you remember that?

DR. HENNESSEY: I do.

MS. HUFF: And before I even got back home that day, because I still
lived out here, you had called Jane Adams, I think. I mean, you really
took it to heart, and I just wanted to say thank you for that and for
this work. I think it\'s absolutely evident that you\'ve listened to
people and done a really fine job. In fact, I think Trina Osher might
have been involved in this last review process.

DR. HENNESSEY: Yes, she was.

MS. HUFF: Another family member. I had to convince you that there were
family members who were also researchers that could be reviewers, but
that was at the beginning, and you\'re obviously a believer now. So
anyway, thank you. I appreciate that.

In response to your concern and questions, I for years thought that we
could move this system based on the fact that there were best and
promising practices out there, and I still believe there are, because
there are a lot of people who are never going to get into the
evidence‑based practices, probably, for whatever reason. I mean, it
costs money. I mean, there are lots of reasons. But this is one way, I
think, to begin to move practices to another level, and I think we have
to get real about the fact that ‑‑ and I think we\'re seeing it today
with the very things that are evidence of funding being cut, that there
may not be the evidence we need to say they\'re worthy of keeping.

So I think whether we like it or not, the handwriting is on the wall
that we\'re going to have to have data around things. I think, however,
that we ought to figure out a mechanism, sometime, some way, to collect
the information around best and promising practices. The Federation did
their conference this year on evidence‑based practice and practice‑based
evidence. The practice‑based evidence is more of what you\'re talking
about.

So there should be a way to collect it somehow, people who are doing
really good work in the field, and where families and consumers say we
like that work, whether it\'s evidence‑based or not, whether there\'s
the data around it, we believe it\'s helped our family, it\'s helped our
child. There ought to be a way to collect that, maybe in a little
different way. But right now, we\'re several steps ahead of where we
were several years ago, and I thank you for that. But your point is
really well taken.

MR. STARK: Let\'s see. I almost had a senior moment there. It came back.

The thing I was going to mention, and this is more of a philosophical
thing but it turns into a practical implementation thing, for the 17 and
a half years that I was with the alcohol and drug office in Washington
State, we struggled with all of this stuff around evidence‑based
practice and had talked with the institutes because many of the
evidence‑based practices were that, they had evidence based on a
practice, and we don\'t fund practices, we fund programs, and almost all
of our programs used a multitude of practices. The reason for that was
because the program served a multitude or a diversity of consumers,
whereas most of the evidence‑based practices were limited and narrow in
scope in terms of what they were evidence‑based for, some only for
African American males between the ages of 14 and 17, some for only
females, and thus and such, and our programs didn\'t differentiate that
way. Our programs served basically all comers.

So what we did is we decided to take the term \"EBP\" and apply it to
programs, and instead of calling them evidence‑based practices, we
called them evidence‑based programs, but we only called them that after
we had done the research, and we did a lot of research, although in the
beginning we weren\'t all that interested in publishing in a
peer‑reviewed journal, but over time we found that to have credibility
you needed to do that. So we did get about 20 to 25 articles published
on various prevention and treatment programs, not practices.

Now, I couldn\'t tell you for the life of me which practices within
those programs made them effective or not. I could only tell you that as
a total program, they were effective in the majority and that the
struggle with that as a state is, under the guise of this kind of
evidence‑based practice, that people want to come back to you and say,
well, what are the practices that make it effective, and that was
something we were hoping to be able to do in the next step, that we
didn\'t have everything manualized, for instance, we didn\'t have
everything documented, except the outcomes. We knew the programs were
working but we didn\'t know why, or why not in the case of the ones that
weren\'t working, and that truly would be the next step.

So I think we\'re all challenged here with a combination of how do we
document practice‑based evidence along with utilizing evidence‑based
practices in the context of a program that uses multiple practices to
serve multiple consumers. Big challenges.

DR. CLINE: Just to say as part of that, too, that there are multiple
goals in looking at that, and one of those might be to determine again
the effectiveness of this program versus that program in terms of
funding, but one of the challenges that I think we see here is that
collective practices within programs would be difficult in looking at
replicability. It would be very hard to replicate something if you
didn\'t know what made it successful. It\'s important to be able to say
it\'s successful, but then how can we really replicate and spread that
if we don\'t know the ingredients that made it successful? So depending
on your goal, and there could be multiple goals, the hope would be that
you could achieve many of these things at the same time, but many
challenges I would agree with.

MR. STARK: I would agree with that, Terry. The only thing I would say
back is that we did know the ingredients, but we didn\'t know which
ingredient made the difference because we didn\'t study it by
ingredient. We studied it in the context of the whole cake. But we did
know what the ingredients of the cake were.

DR. GARY: I just wanted to also thank you for such excellent work. That
certainly has great utility for many different stakeholders in America.
I guess the other part of the challenge is to make sure that individuals
know that this exists. I\'m talking about consumers, advocacy groups,
providers, as well as researchers.

My other comment is that I\'ve been in some discussions and meetings at
the federal level about requesting, perhaps even requiring, that
individuals who get federal monies provide a brief abstract, a brief
description of the program or the outcomes of their research or their
service program or whatever their research is that could be written at
the level where the consumers or the general lay stakeholder public
could understand it. Frequently right now, we know when we look at
peer‑reviewed journals that it\'s written in a language that we call
scientific writing, and it\'s difficult to decipher without having the
background for that kind of reading. I mean, even if you\'re good,
sometimes you miss the point.

So I\'m wondering if there is any discussion about having ‑‑ I guess the
issue is dissemination of information to a much broader audience through
several media. It could be newspapers, newsletters, the Internet, public
service announcements, so we can make this a living, breathing organism
for people, and improve and increase the utility of it so that we can
get the outcomes that we want, and also we can find out what programs
work for which particular groups and really have the data to
substantiate that. That\'s how we move the science forward, because I
think science informs practice, but practice also informs science.

DR. HENNESSEY: Absolutely, and a couple of thoughts in response. One is
that we have actively worked and are continuing to actively work to try
to achieve the right balance with the NREPP system in terms of providing
the information in an accurate and transparent way and an accessible
way, and yet maintaining truth to the interventions. We don\'t want to
oversimplify a finding and have that be misunderstood or misrepresented.
So part of the challenge is how do we represent the key findings within
each of these summaries in a way that\'s accessible to a variety of
audiences without needing a Ph.D. to understand it, but at the same time
realizing that we don\'t want to oversimplify it, the fear of
misrepresenting the findings of an intervention. So we\'re continuing to
struggle with that. I think we\'ve achieved somewhat of a balance, and
we\'ll be continually challenged as we move forward.

DR. GARY: I guess my observation from a policy perspective is that the
people who get the funds to do the interventions to do the research
should have that responsibility. I think that should be a basic part of
the requirement. We know that they all do abstracts. If you get research
funding, you have to have an abstract to go with your proposal, but
it\'s scientifically written. I\'m just suggesting that same information
be translated for a wider group of stakeholders.

DR. HENNESSEY: I think another thing that we\'re actually in development
with at this point is something that would take the accumulated body of
research in a particular area ‑‑ NREPP is really about identifying a
specific application of an intervention. So it\'s not
cognitive‑behavioral therapy for trauma. It\'s a specific application of
that that has a package and has implementation materials and training
materials. But there are those who are interested in just in general
what does the research say about the effectiveness of
cognitive‑behavioral therapy for trauma. So part of that is taking the
research that has accumulated primarily through systematic reviews, the
reviews that meet certain high standards, and translating that or at
least portraying that in a very accessible manner, almost in some ways a
journalistic manner, where there are key findings that are portrayed in
ways that are easily accessible to the public. That\'s a project that we
have in development currently, and I\'m happy to come back and talk
about that one. It\'s one of the other activities in our science to
service arena that I anticipate will probably take about another year or
so to fully develop.

But it\'s really taking that whole body of systematic reviews for
interventions that prevent or treat mental or addictive disorders and
getting that information and putting it into a database where it\'s very
accessible and you can drill down as far as you want. So if you really
just want the overall finding, you\'ll have that. If you want the
original study that was the basis for that finding, you can have that.
If you want additional SAMHSA resources that are related to that
particular type of intervention, you can get that through another web
click. So again, trying to design tools that are going to bring this
information to the public in an accelerated and yet accessible and
accurate fashion.

DR. CLINE: I think we have one more question we can take before we move
to the next session.

MS. DIETER: I wanted to apologize because when I asked my question
earlier I was so distracted by my thought that I forgot to say
congratulations and thank you for this work. I was here also when you
started, and I think I was so excited the other day when I got that
email and I popped it open, I think I mentioned to Terry right when we
first were talking, when I came in, how excited I was to see this, and
you\'ve done a great job.

DR. HENNESSEY: Thank you, but it\'s truly been a large team effort. I
have the privilege of sitting at the top of that effort.

MS. DIETER: Well, thank you.

DR. CLINE: That\'s a nice note to conclude on. Thank you very much. Dr.
Hennessey, thank you for all of your leadership and your work in this
area. Thank you.

DR. HENNESSEY: Thanks, Dr. Cline.

DR. CLINE: We will now move to a presentation from Dennis Romero, who is
the acting director for the Center for Substance Abuse Prevention.

Dennis, the floor is yours.

MR. ROMERO: Thank you very much. Dr. Cline and members of the National
Advisory Council, it is my pleasure to present to you a relatively large
sector of our prevention efforts, and that is the Strategic Prevention
Framework, and in this case the State Incentive Grants.

I apologize. I\'m trying to recover from a second cold. I\'m not
contagious.

Some of the discussions that took place with Dr. Hennessey really go in
line with what are the efforts of our SPF/SIG. As you probably already
know, SAMHSA\'s vision is a life in the community for everyone, and that
mission is guided by building resilience and facilitating recovery. That
is the hallmark of what we try to do throughout SAMHSA. The prevention
side of the SAMHSA is to create communities where people can have a life
in the community, and that quality of life is so important in that
process.

We do this through ensuring that healthy environments are at work and in
schools, that supportive communities and neighborhoods are supported,
and that drugs and crime are minimized or erased from the local
community. That\'s really the basis of what we\'re trying to accomplish
through the focus of prevention at CSAP. We truly believe that substance
abuse cannot be seen as a national epidemic but rather it is a series of
local epidemics, and we need to treat it as such, because in doing so we
can really tailor both the needs and the services in such a way that
they truly complement one another, as opposed to being given top‑down
information as to what you are going to be looking at.

In one word, the role of the federal government, the role of CSAP is to
support the communities and the states in this effort. We truly want to
support communities, states, tribal entities to ensure that they have
the necessary skills and tools to be effective as they try to address
this devastating issue which we call substance abuse. Every community
needs a comprehensive communitywide plan, and the reason is very simple.
Where change has to be measured is at the community level, not at the
state level, not at the regional level. It\'s at the community level.
It\'s where the rubber meets the road in my opinion, and that\'s where
we truly focus our prevention efforts through the SPF.

The SPF in a nutshell really is simply a planning tool, nothing more
than a planning tool to help galvanize the community to truly address
the problems that they foresee in their community, and I\'m going to
walk through these five steps very briefly, very quickly.

The first step is assessment. What do we mean by this? Simply that we
need to use data to help us drive our decisions. If data tells us that
there is a high prevalence of marijuana, then that might be the issue
that the community needs to address. But they will not know that. We
cannot use simple anecdotal information. But when we look at the data
that tells us through our epidemiological workgroups to tell us what is
driving the problems in our community. Once we\'ve identified and made
that assessment, we need to begin to explore capacity.

Through the capacity building will allow us to begin to form a planning
effort, and with that planning effort we will then begin to explore what
makes the most sense, knowing what the problems are, knowing what the
data are telling us about the problems in our community, what mechanisms
should we implement in the community to help us reduce, drive down the
problems that have been identified in our assessment phase.

So we then implement programs with fidelity in the hopes that the
program will truly address the problem that is so pervasive in our
community. When we\'ve gone through that phase, we then enter the phase
of the last step, which is the evaluation phase, and here it\'s very
simple. We evaluate how our program data in our community that drive
down the problem that we assessed in the assessment and capacity phases,
and if it just so happens that the evaluation comes back to report that
the problem still exists, then part of that evaluation component would
then be to revisit what other mechanisms, what other tools do we want to
implement and try the process again, or it just might mean that we need
to tweak what already is in place to make it more effective, and the
process continues.

Throughout this process, in order for this to be successful in any
community, at any level of the community, it requires that the key
stakeholders truly keep in mind at the forefront of their discussions,
keep in mind that cultural competency and sustainability have to be
paramount, truly the common denominators throughout every step of this
process. As a decisionmaking planning tool, you are not going to be
effective if you are not conscious of the cultural implications of your
community. You are not going to truly address the problems if you are
attempting to address a problem that does not fit with the community
that you are trying to work with. So we need to have sustainability and
cultural competence as key common denominators throughout this entire
planning process.

I am happy to say that this map represents where our Strategic
Prevention Framework State Incentive Grants are located throughout the
country. We currently have 42 SPF/SIGs across this nation, and of them,
it includes 34 states, 5 tribes, and 3 territories, and I am happy to
say that I had the privilege not too long ago, actually in mid to late
December, to be in Hawaii and be part of the kickoff celebration of the
SPF that Hawaii recently was awarded.

It has been said, first of all, that today\'s philosophies are
tomorrow\'s common sense. The SPF process, we are trying to bring a new
paradigm to the way in which we deal with substance abuse, no longer
using just anecdotal data, no longer just using what may seem to be the
compassionate approach to take, but rather we want to do that but we
want to make sure that we are successful in our approach, and therefore
it makes sense that we use data to help us drive our decisions, and we
are moving forward in that effort.

We started in 2004, as I said, and this year I was extremely proud to
report that we have five tribes and three territories already on the
road to SPF, as I call it sometimes.

That\'s a quick nutshell that I wanted to report. I did not really want
you to hear me, even though I know you were all just dying to hear me,
and I love to hear myself, frankly. But I think who you need to hear
from are from people who are truly making this operationalized, who
truly are successful in their own way, and there\'s no better way to do
that than to invite people who are where I call where the rubber meets
the road. But I would first like to introduce Michael Lowther, who is
the division director in the Center for Substance Abuse Prevention as
the director for the Division of State Programs.

Mike?

MR. LOWTHER: Very quickly, by way of introduction, let me just say that
there are 34 SPF/SIG grants. There are five tribes, three jurisdictions.
The grants, just so you\'ll understand the context of how it works, I
know Dr. Kirk that you know you have one in Connecticut, and you know
about the one in Washington. The grants are awarded to the governor or
the chief executive of the organization. They\'re five years in length.
Eighty‑five percent of the money has to go to communities for
infrastructure and/or services. So this is sort of the context. There
must be an advisory council that the governor appoints and chairs, and
that advisory council should be made up of agencies involved in drug
abuse, public health, public safety, communities, people from, if you
will, a coalition at the state level to try to provide guidance and
assistance to the implementation of the program.

They\'re required to have an epidemiological work group, and they\'re
required to do the five steps of the process that we\'ve described here.
That has to happen at the state level so that you build a state
prevention system. You transform a state prevention system into a system
that sees its goals, its role as serving communities in reducing
problems related to substance abuse, so that you really are about
building systems at the state level whose job it is to help communities,
whose job it is to reduce substance abuse, because as Dennis so
appropriately said, substance abuse is local.

That\'s the purpose of the grants, to provide the states with the
dollars to build the infrastructure at the state level and the community
level. That\'s the first goal. The second goal is to reduce problems
related to substance abuse, traffic deaths, emergency room visits,
overdoses, those kinds of things, and to reduce the onset and
progression of substance abuse, that is those patterns of use that drive
those problems. The notion is that if you use data and you find the
areas where it\'s the highest and you concentrate the resources, you can
do this work. You can drive it down. The prevention really does work.

So with that, let me say that it\'s a real pleasure to introduce our
real partners in the State of Kentucky. Connie Smith, who is the
director of the SPF/SIG project for the Commonwealth of Kentucky, is
here to talk about sort of the state level, and then her colleague,
Diane, who works at the community level, will also be involved and can
describe that, and you all can ask them some questions. But I wanted to
give you some context. And I would be remiss if I didn\'t acknowledge
Clarice Holden, who is a state project officer. She\'s the real federal
partner with Connie. So Kentucky\'s success is really about Clarice and
Connie and the folks at the local level.

Take it away.

MS. SMITH: Thank you very much. We were so excited when Clarice called.
I mean, I just didn\'t even know what to do, but I\'m so happy to be
here. What we\'d like to do is, first of all, just give you a little
overview of how we got where we are, and I\'ll talk about our state
grant, and then Diane is going to link that with her Drug‑Free
Communities because Diane is also one of our master trainers who is
involved with a county grant, and also she\'s Drug‑Free Communities,
Ohio County is. Then after that I just wanted to tell you a little bit
how the Strategic Prevention Framework has really changed Kentucky\'s
look at prevention and how we\'re looking at prevention. We are changing
it, and it is because of the framework, and we\'re pretty excited to do
that.

We have chosen the Commonwealth Alliance for Substance Abuse Prevention
to be our logo for the State of Kentucky. We have eight counties, and if
I say community or if I say county, they\'re interchangeable. We chose
to look at counties. Kentucky has 120 counties, so our communities are
the counties. The first thing we did was we had our epi work group look
at Kentucky as a whole, and they did all kinds of research and finally
identified Kentucky\'s ATOD priorities.

The second thing we did is we brought the results of the epi work group
to our strategic planning committee, and the strategic planning
committee then drilled down to identify the communities or the counties
that have the highest usage and consequences of state ATOD priorities.
So we started out looking at 120 counties, and then we began to drill
down.

After we looked at those counties that had the highest usage and
consequences, we began to drill down some more. At this level, at level
2, we identified that Kentucky really had five priorities that we needed
to look at. We needed to look at methamphetamine use, we needed to look
at inhalant use, we needed to look at prescription drug diversion, folks
that are sharing their drugs or selling their drugs. Also, obviously,
with Kentucky we looked at tobacco use, and then of course CSAP would
like us to look at underage drinking, so we did that. So those were the
five targets that we looked at.

What we did, then, to choose of these high counties which ones, because
we couldn\'t look at 19 and do a good job, we sent out a site review
team, and the site review team consisted of about five sub‑teams, and
they went to each of these counties that had these problems, and we had
a survey that we used, like a community norms survey. We talked to each
of these counties to look to see if that county had a coalition that
could support this project for the next five to seven years. We looked
to see which of these counties had low resources because we felt that
there might be high readiness and there might be a lot of substance
abuse problems in this county, but if they didn\'t have high resources
then they couldn\'t do anything about it. So we wanted to look at those
counties that did not have high resources.

What these site visit groups did was they interviewed all these
counties. They came back once again to the strategic planning committee
and they said out of the 19 counties that we looked at, we feel that
these counties should be considered as grantees. The strategic planning
committee then ‑‑ it took us almost all day. We talked about it and
talked about it and talked about it, and we drilled down to eight
counties that had the highest readiness, the highest use, and the lowest
resources. So that\'s how we ended up with our eight counties.

One of the things I\'d like very briefly to tell you because it\'s very,
very important to implementing this grant is that Kentucky is very
fortunate to have regional prevention centers. We have 14 regional
prevention centers that cover all 120 counties, which means that not
only are we looking at the SPF/SIG projects but we\'re also looking at
any other drug prevention project or drug abuse project in any county.
For example, if I were in Ohio County, I could go to the River Valley
Prevention Center and ask the folks there for help. If I were in
Franklin County, I could go to the Bluegrass Prevention Center and ask
for help. So there\'s always a person, a regional prevention center and
a regional prevention center director who is extremely familiar with
prevention that can help anyone in that county that needs assistance. So
overall, Kentucky does have regional prevention centers, and you\'ll see
in just a little bit how they really play an important part in our
SPF/SIG.

What this map attempts to show ‑‑ and we didn\'t know how to get rid of
the little lines, so just kind of pretend they\'re not there. I\'m okay
with prevention, but when it comes to clickers, I\'m really not very
good.

So let\'s just look at the yellow. The yellow are those counties that we
have given the awards to. Muhlenberg County and Ohio County, we\'re
looking to them to target methamphetamine. We have Monroe County and
Clay County. They\'re going to be looking at inhalants. We\'re looking
at Letcher County and Clinton County, and they are looking at
prescription drug diversion. We\'re looking at Owen County for underage
drinking, and we\'re looking at Owsley County for tobacco use and abuse.

One of the things I\'ll mention very briefly is that Kentucky has wet
and dry and moist counties, and when you produce a lot of bourbon, you
have to break it down into who is going to sell it and who isn\'t. But
anyway, wet counties are allowed to sell alcohol all over the county. In
dry counties you cannot sell alcohol, and moist counties you can
probably sell it in the cities but not outside the city limit. But, of
course, what you do is you go to the county line with the wet county and
you buy there.

Anyway, what I\'m trying to say is that Owen County, who we\'re
targeting for underage drinking, had the highest problem with underage
drinking, and they are a dry county. So that\'s going to be a challenge
for all of us on there.

Tying the communities and the state together using the SPF/SIG process.
Now that we have got those eight counties, we wanted to show you just a
little bit how our counties mirror our state plan. Each of our counties
or our communities were given a guide to do their strategic plan modeled
after the state\'s strategic plan. So each of our counties had to go
through the five steps of the Strategic Prevention Framework. We were
able to give them a good start. For example, we were able to give them a
good start on methamphetamine use using the KIP survey and using some
other bits of information, but it\'s going to be up to those counties to
drill in deeper. For example, some of our counties are going to the
coroner\'s, they\'re going to the emergency rooms, they\'re having focus
groups. So it\'s up to them on that first step to drill down into their
county to look at more of their needs assessment, and then they have to
also follow the next step and all five steps.

The state is helping each of our counties with step five. It\'s pretty
tough for folks to be able to do a good job of evaluation without some
help. So Regional Louisville, who are our partners, are one on one
helping each of these counties with their evaluations.

Our state agencies are also linked to the Strategic Planning Framework
through local affiliates. These counties are all expected to have
advisory councils or advisory boards. For example, we have what\'s
called home teams. So we have folks at the state level in the Department
of Education, in the Department of Juvenile Justice, Mental Health and
Substance Abuse, Family Resource and Youth Service Centers, and I
mentioned the Department of Education at the state level. But we also
have these folks at the community level. So we have the community folks
that are ‑‑ for example, the Department of Education. We have two people
who are at the state level, but at the Department of Education also in
our SIG communities, it has the board of education that\'s helping them.
So we\'re drilling down from the state to the community level.

We also have community project coordinators, meaning that in each of
these eight counties that are funded, we have a coordinator that must
have an office in that county. This person is in charge of keeping that
county in line. That\'s not a good way to use that. They\'re keeping the
county focused. They\'re charged with looking at the strategic plan of
each of those counties and helping those folks in the community
implement that plan effectively, and they are there five days a week.
They are there so that the county can reach them at any time. They\'re
also in charge of having board meetings and making sure that everything
is running as smoothly as possible with their logic models.

We also have master trainers. Master trainers are comprised of regional
prevention center directors or regional prevention center staff. These
folks have gone through a very intensive training that the state gave to
them on the five steps of the framework. This training lasted almost a
year, and each of our master trainers understand very thoroughly and
have presented the Strategic Prevention Framework to their counties, and
they work in conjunction with the project coordinators. Our project
couldn\'t be successful without the master trainers and the regional
prevention centers.

The communities are also required to do quarterly reports to us. In
other words, the county coordinators need to give us a quarterly report
on what they\'re doing as far as their strategic plan. Are they staying
with their logic model? Are they consistent with their timeline as we
have to report to CSAP?

We also have site visits. Our site visits are beginning next month and
our Frankfurt folks that are SPF folks, myself and our coordinator, will
be going to each of these eight counties and having a site visit, and
the site visits are not for the purpose of gotcha, you\'re doing this
wrong. The site visits are let\'s sit down now that we have a chance to
really talk and see what you\'re doing, see how we can help. So one of
our philosophies in Kentucky is that you can\'t stay in Frankfurt and
implement the SPF. You\'ve got to get down there with them, you\'ve got
to be a partner with them in each of these counties. So we really talk
to almost all of them at least weekly.

They have to have bi‑annual meetings of all granted counties. What
we\'re going to be doing is to bring them all to Frankfurt or bring them
all to Lexington or bring them all somewhere where they can all meet and
have all of our counties meeting at the same time where they can talk
with one another, they can dialogue with one another, we can talk about
common problems, we can talk about common successes, and we can just
exchange ideas. Instead of us exchanging ideas with them on a one to one
basis, they can also start exchanging ideas with one another. One of the
things we\'re also planning, I was also with the first incentive grant,
and one of the things they wanted was to open it up to community
members, too. So we\'re really excited that in May we\'re going to open
it up in a big room and the community members can come. So if I\'m a
community member from Clinton County, I can talk with someone else and
learn, with just the folks in the community and not worry about what\'s
going on as far as the logic model.

We just put \"TA is just a phone call away\" because we always, always
encourage that if the community coordinators or the master trainers are
having problems, we encourage them to call us, or if they just want to
sit and talk and tell us what\'s going on, we encourage that also.

The last slide is to talk to you about our funding streams. We\'d like
to just show you a little bit how our money is distributed in Kentucky.
We have the federal block grant money, and we have Prevention
Enhancement Sites. As of two days ago, the Prevention Enhancement Sites
are not three but they\'re five, so I\'m really excited about that. A
Prevention Enhancement Site is a site that\'s located in a regional
prevention center that really concentrates on one substance, and
they\'re open to any county in the state that would like to go to them
for help. We have a Prevention Enhancement Site that really focused on
alcohol. We have a Prevention Enhancement Site, the same site right now,
that is focusing on fetal alcohol spectrum disorder. We\'re having a
Prevention Enhancement Site that allows the faith‑based communities to
get in on prevention, to help with prevention. We have a Prevention
Enhancement Site that\'s going to be focusing on methamphetamine use and
abuse in the state, and finally we have one that\'s focusing on tobacco
use and abuse.

Once again, these are located in the regional prevention centers, but
they really are experts in these fields and anyone in the county is
welcome to go to them. Of course, our federal block grant also supports
all 14 of our regional prevention centers.

The SPF/SIG dollars, of course, go to the state. We have eight counties,
and we have some carryover funds this year, and what I\'m excited to do
is with part of our state dollars that are carryover that we didn\'t
use, what I would like to do, what we were planning on doing ‑‑ we
haven\'t gotten the RFP written, but we\'re hoping to take 25 new
counties at \$50,000 each, write a simple RFP, and these are counties
that are not funded already, and have them do a little RFP following the
Framework, saying what they would like to focus on, look at the
database, our data warehouse for example, and say we believe our county
has a problem with marijuana, the data warehouse says we do, and we have
a coalition that would like to follow the SPF/SIG process. So we would
like to give them \$50,000 to begin steps 1 and 2, counties that aren\'t
already funded.

So this is the way that we can build capacity with the state and get
that SPF out to the other counties that aren\'t funded through the
regular grant.

We also have some state general funds, and whenever we have some
leftover state general funds, we try to get those to the prevention
centers.

We have some tobacco settlement funds through the Office of Drug Control
Policy. The Agency for Substance Abuse Policy was one of our partners on
the ‑‑ excuse me. I\'m sorry. The train just left the station without
me. I guess that\'s my senior moment. Our strategic planning committee.
The Agency for Substance Abuse Policy is also in there, and they said,
well, you know, you had 19 counties, and you only funded eight, and we
feel that these counties that were so close need to have something
rather than just say sorry about your luck, you don\'t get anything. So
they came up with \$500,000, and they are giving nine more counties ‑‑
they\'re taking that money and dividing it between nine more counties to
also implement their framework in steps 1 and 2, basically. So we\'re
excited about that. They\'re also looking at their own strategic plan,
and their agencies are now looking at taking their strategic plan and
modeling it after the five steps of the framework.

Then, of course, we have our Safe and Drug‑Free Schools and Communities
funding that funds our early intervention program and our Champions for
a Drug‑Free Kentucky Coalitions.

Dianne?

MS. McFARLING: Thank you. It is a pleasure to be here today. Greetings
from Western Kentucky, particularly from the County of Ohio. We are
excited to have this opportunity to speak to you all and to share some
of the things that are going on in our region and the things that are
happening.

I wanted to start by showing just a basic organizational chart. I am a
part of the regional prevention center, a certified prevention
specialist, and also a master trainer for the SPF/SIG. So I was one of
those people who went through the extensive training that Connie was
talking about, and from the receiving end of it, it was very good for us
to have the opportunity to really learn even though it incorporated the
things that we had been using to a degree. But it was much more
intensive and much more results oriented than what we had been doing in
the past. So it was a very good opportunity that we had to do that.

When we look at the regional prevention centers, our scope, our roles
that we have follow basically the funding pattern that Connie just spoke
about. The early intervention program is a part of the Safe and
Drug‑Free Schools money. It\'s a program that\'s designed to work with
at‑risk youth who maybe have begun using but are not yet at the point of
addiction, to intervene early to show the risks and the consequences to
encourage them to make different choices in their lives. The referrals
to that program come through our district court system, court designated
workers, schools, a multitude of places that have opportunities to be
with these at‑risk youth.

The Prevention Enhancement Site, River Valley, is one of those RPCs that
just received the Prevention Enhancement Site for methamphetamine. Being
a part of Western Kentucky, it is a very heavy farming community. So
because we have the accessibility to the anhydrous ammonia and farmers
put those tanks on their properties, we have some issues with
methamphetamine. We have realized that over several years and have
worked to decrease the labs. We have decreased the labs. I would like to
say that we have decreased the problem, but we have found that now there
is coming a new way of importing the drugs from other countries. So
we\'re constantly faced with how we\'re going to approach this problem.

So that is what the Prevention Enhancement Site will do, particularly
for our seven counties, but the Prevention Enhancement Sites are for the
statewide community. So it will cover all 120 counties with regard to
methamphetamine. What we found is that things that happen on the west
end of the state have a tendency to move toward the east as well.

On the right‑hand side are the county coalitions, and these coalitions
are involved with policy advocacy. They\'re also involved with providing
an outlet for people to work to counter the problem and to deal with the
problem. I have listened to seven counties that currently my regional
prevention center operates, and this is by no means to say they operate
through us. We are there to provide technical assistance and help and
support for them.

We have the Champions for a Drug‑Free Kentucky. We have five counties
that have those grants and that work on encouraging science‑based
curriculum, encouraging strategies to use for community members to
combat the problems of all types of drugs, not just one specific drug.

We have three counties that we serve that are drug‑free communities:
Ohio, McLean and Hancock. Again, I serve the Ohio group, and they are
very committed, and you will see their names up there under everything
because they are really working hard to impact their community to make
it a safer place for youth and adults.

The third bullet down there is the Kentucky Agency for Substance Abuse
Policy that Connie spoke about. These are groups that we have in all
seven of our counties that work at looking at policy and how policy can
impact the use and the consequences and trying to look at system
policies, not just local law enforcement policies but school board
policies, workplace policies, and trying to impact those to reduce the
accessibility, provide information so that our community knows. Part of
what we do with the policy we cannot do unless we have the education
that goes along with it. Sometimes we try to enforce policies or
implement policies, but if you don\'t have the community support ‑‑ so
there is education that goes with that as well.

The SPF/SIG, we have one county, and that is Ohio. We are charged to
look at the methamphetamine problem that\'s there, and from the data
that we received from the state we know that we have a significant
problem with methamphetamine, and it is up to us now to have the initial
data that we received from the state, but then also to move and gather
new data and look at different ways to drill down, absolutely, as Connie
said, to really determine how significant the consequence data is.

So if we did a job description for prevention specialists, we might be
tempted to look at it from that fashion. But I would say that really the
fashion that we should look at it from is this fashion. The regional
prevention center serves as a part, and Together We Care is the name of
the county coalition in Ohio County. When they say together we care,
that is absolutely what they mean. They work together. They are hard
working. They are very committed to making these things work, and their
readiness certainly was noted when we did the readiness surveys. When
the site visit came for them, they were found to be up to the task to do
this.

They are a county that has over 1,500 square miles. They\'re the third
largest geographical region in our state but a much smaller population.
To cover that territory, they only have 18 law enforcement officers.
That is a big territory given the problems with farming and anhydrous
ammonia. There we have some problems.

Also, when we look at Together We Care, these are the 12 sectors that
support the Drug‑Free Communities, they are a drug‑free community or a
(inaudible) of their Drug‑Free Communities grant. They have these people
who are at the table. So when we looked at the diagram, we thought that
this was the perfect way to represent exactly what they did. You could
pull one of those circles out and you would still have a functioning
group. But I think the way that we assess readiness and abilities to
look at the problem is to say that all of these things are there and
working together we can address them much more rapidly and with more
effectiveness.

We look at all of the people that are at the table, and one of the
things about Ohio County, when they walk through the door, they check
personal agendas at the door. They do not carry what they want to get
accomplished to make them look good. They really are there to focus on
the needs of Ohio County and how that works.

So we are there with them. We provide technical assistance. I don\'t
really see that it\'s the regional prevention center and Ohio County. We
are one and the same. We serve other counties, and this would not be the
way that we see each and every county in our region, but this is
certainly the way we see Ohio County.

When we look at the bottom, we see the Drug‑Free Communities. They are a
recipient, again for five years. The Champions, they have consistently
been awarded Champions grants, and those are grants that they use to
implement science‑based curriculum in their schools and provide those
opportunities, Kentucky ASAP, and now the SPF/SIG. We have a
coordinator. We have completed our strategic plan. The strategic plan
was not just a document that we put together quickly. It was something
that really took about six to eight months, and we have truly
appreciated the support that we have had from the state. They have been
very beneficial. It was not just go out there and you do it. They have
been with us, working with us and in constant communication, and it has
been a tremendous help to us.

We are excited about the implementation stage, but we realize that the
implementation stage is not where it stops. The evaluation stage is not
where it stops. We are continually having to assess the needs. Again, as
the problem moves, then we have to adjust our strategies, and then also
as we move the needle, we need to adjust our strategies as well.

So that is a few words that we have to say from the regional prevention
centers and for this particular county. The Strategic Prevention
Framework is something that each of our counties are encouraged and
trained to use. We see this as the move of the future and a very good
move using the data and drilling down and helping everyone identify
exactly where they are and how they can build the capacity for their
communities. You can come up with a strategic plan, but if you do not
have the capacity to implement that strategic plan, it\'s a piece of
paper.

MS. SMITH: Very briefly, I just wanted to go over how the Strategic
Prevention Framework has really changed prevention in Kentucky. First of
all, we are working very, very hard to participate in the National
Outcome Measures. Our prevention data system we\'ve had for quite a
while, and some of the questions that are asked of the National Outcome
Measures we can already answer with our prevention data system. So we
continue to ask our counties that are funded by the SPF/SIG and the
regional prevention centers to enter data. Data is essential. We are
also applying this and also asking Regional Louisville, our evaluators,
to help us with the National Outcome Measures as well.

Each of our regional prevention centers are charged with having a
blueprint, what are you going to do this next year, and they give that
to the state and we look at them. The blueprints are also based on the
five steps of the Strategic Prevention Framework so that all regional
prevention centers are implementing this.

We mentioned the master trainers. The Agency for Substance Abuse Policy
is now having their own strategic plan around the framework, and
they\'re also helping us with funding those runner‑up counties that
didn\'t get the initial funding.

I mentioned the mini‑grants, the 25 mini‑grants of \$50,000 each. We\'re
also in the process that starts next week, Kentucky offers Prevention
Academy, and that is open to ‑‑ we\'re having to close it down because
there are so many people that want to do it, but Prevention Academy is
open to anyone in the field. We ask that the new staff that are employed
by the regional prevention centers to go to Prevention Academy. It\'s a
two‑week academy where, once again, each step of the framework is
taught. So anyone from the field can go, and also the folks from the
regional prevention centers can go. It\'s open to anyone who would like
to learn about the Strategic Prevention Framework. We\'re focusing on
that.

We have a data warehouse that Regional Louisville has constructed for
us, and that means that if I were in, for example, Ohio County, I could
go into the data warehouse, I could click on Ohio County and I could get
all kinds of information. Then from that I could do graphs, I could do
PowerPoints, I could do all kinds of presentations, and the work has
been done for me. That\'s when I mentioned those mini‑grants. What they
need to do is go into that data warehouse and say not that we think we
have a problem with marijuana, but the data warehouse with consequence
data shows us that we do. So we\'re making them use the data warehouse
also to begin their implementation.

We also use our state portion of the SPF dollars to offer trainings.
We\'re really excited that in the near future we\'re having a two‑day
cultural responsiveness or cultural competency training. We\'re
insisting on it. It\'s required for all of our community coordinators to
attend, and it\'s required for one other person from their coalition to
attend, but then we\'re opening it up to all the regional prevention
centers also. For anyone in the community who would like to come to
that, we\'re offering that.

Because of the SPF, our state is forming new linkages with other
agencies. We\'re looking at a system that looks at prescription drugs
that doctors record. For example, if Dianne were to get a prescription
for OxyContin, the doctor would enter that into the computer. When she
went to pick up her prescription for OxyContin, the pharmacist would
look and say yes, okay, it\'s not a false prescription. She indeed does
have a prescription. He would enter that he did give her that
prescription for OxyContin. If Dianne wanted to go to another county,
for example if she wanted to go clear to eastern Kentucky and try again
to get that prescription filled, then all they would have to do is go
into the computer and say sorry, Ms. McFarling, you have already filled
that prescription. So we\'re working with KASPER. I don\'t know if I can
remember what KASPER stands for, but I wrote it down and didn\'t realize
it. Kentucky All Schedule Prescription Electronic Reporting. So we\'re
trying to link with that, and we\'re very excited because we\'d like to
link that with Tennessee, because some of our folks in eastern Kentucky
are trying to go across the border to Tennessee to repeat their
prescription.

I think that that\'s all we have right now.

MR. ROMERO: Thank you, Connie and Dianne.

This is truly a wonderful example of prevention in practice,
operationalizing the impact that prevention can have in a community by
really galvanizing and certainly empowering the community to take the
lead on addressing problems. Again, thank you very much for presenting
today. You guys are awesome.

(Applause.)

DR. CLINE: Thank you, Connie. Thank you, Dianne.

We have some time for questions and comments from the council, and if
you wouldn\'t mind if you\'d stay at the table and be available for any
questions.

Dennis, I know you need to run, so feel free to do that. Thank you for
being here.

Mike, if you could stay, that would be great.

Ken?

MR. STARK: Great presentation. Thank you.

One of the things I wanted to ask you, having made the conversion myself
in terms of employment from working in the alcohol/drug field for a
long, long time and then shifting over to mental health through the
transformation grant, which is also a SIG grant but not a SPF/SIG,
although Washington State does have a SPF/SIG, have you seen in Kentucky
any buy‑in, if you will, at either the state level or the local level
from the folks in mental health around the prevention framework, given
the fact that there\'s so much interrelationship, as you all know, from
the prevention side between academic achievement, juvenile delinquency,
runaway, teen pregnancy, alcohol and drug use, that sort of thing?

MS. SMITH: Yes, we have. One of our home team leaders is a
representative from mental health and substance abuse, and they were
also part of the team that went around to interview these counties that
were potential grantees. What they learned is that there\'s a whole
other world out there. So our director is really pro‑SPF. We also have
folks on our strategic planning committee who are from the mental health
field, and on our advisory committee. So slowly but surely, yes, it\'s
taken on, and we\'re excited about that.

MR. STARK: I would just make a comment that I think it\'s another one of
those areas in terms of the whole framework that alcohol/drug prevention
is really something that can be a lot more generic than that and is
very, very appropriate for the mental health field. Obviously, we know
it\'s appropriate for the education field and some of the other arenas,
child welfare.

MS. SMITH: And our Office of Drug Control Policy is on there, too.

MS. McFARLING: I\'d also like to add that the regional prevention
centers are actually attached to the community mental health centers. So
my office actually sits in the community mental health.

DR. KIRK: Impressive process. Very good.

Let me ask a question from a SAMHSA point of view. The kinds of
approaches that are inherent in this effort, they\'re systemic, if you
will. From the experiences you\'ve had so far, what are the critical
components or bridge elements, if you will, that after the SPF/SIG is
over stay embedded, so the dollars stop but, frankly, the processes and
components that you\'ve built in have a lasting value that 10 years from
now someone says I don\'t remember what SPF/SIG was about but people
such as you can go back and see how that was an element? I think this
was a question, actually, for SAMHSA as a whole, for all of your grants,
how you build them in such a way that the effect doesn\'t end when the
dollars end but somehow they become embedded. So based upon your
experience at this point in time, what are the components, that
homegrown Kentucky flavor, that would stay in place over a period of
time?

MS. SMITH: One of the things that\'s really, really important is
sustainability. In the diagram you\'ve got sustainability in the center,
but what we ask our counties to do is to show sustainability for all
five steps. In other words, we\'ve got some folks who will help them
write grants, but money is only a part of sustainability. So hopefully
the folks will stay on board. What are you going to do to keep your
coalition going? What are you going to do to make sure that when the
money runs out, how are you going to continue with this?

So in partnership with the regional prevention center, they\'re doing
the SPF process. Their blueprints have been doing that. They\'ve been
modeled around that. So hopefully the name \"SPF\" might be gone, just
like we\'ve got KIP, and everyone associates that with the survey. So
the term \"SPF\" might be gone, but the process won\'t. So what we\'re
trying to do is get this process out and show them that each step relies
on the other and it works. Once you evaluate and once you see, you
either go on with what you\'ve been doing, you change what you\'ve been
doing, you modify what you\'ve been doing, but we keep the process
going. Hopefully with the regional prevention centers continuing to do
their blueprints around that, each of our counties is going to be more
and more adept at doing this process, and that\'s how we\'re going to
sustain.

MR. LOWTHER: I think at the practice level that\'s exactly right, that
it is about people learning how to solve problems, and it works when
they keep solving problems the way they\'ve learned how to solve them.
That\'s what the SPF process is. It\'s simply planning and about
executing it in the right order.

I think for the state, what it boils down to is figuring out what their
role is and supporting that ongoing process in communities so that the
state understands that there\'s going to be turnover in communities, so
we\'re going to continue to have to teach them assessments and how to do
them, that communities won\'t always understand what evidence‑based
means, and so we have to have a training system that will do that.
That\'s one of the glorious things about Kentucky, that they have
embraced it and they\'ve trained all the prevention centers to start
with the same language, all the time, over and over again. So as that
staff turns over, that won\'t change because it will be embedded inside
that training system, and they will be training the communities to think
that way about it.

The leadership at the state level, to continue to support and push the
idea that it should be a state coalition, that it should have all the
players at the table together at the state level is a critical piece.
The places where I\'ve seen this break down would be in states where
we\'ve gotten what you\'ve seen here in Kentucky going, but quite
frankly there will be a change in the governor, or there will be three
administrative heads change, or something different occurs and the folks
at the state level that have the authority and the ability to keep
things alive maybe for no reason ‑‑ not that they want it to be bad,
they just don\'t know, and so they don\'t support the continuation of
what\'s been going on, and things can die.

So I think at the state level it\'s about leadership and about
institutionalizing these ideas. If you can do that reasonably well and
embed it in the training structure, then the communities will embrace it
and use it, and they won\'t forget how to solve problems once they\'ve
learned how.

MR. AIONA: This sort of goes back to your question before about
practices and programs. I think the challenge for any number of us is
that based upon an experience such as this, do we learn from this what
might be called evidence‑based or experience‑informed system change?
What are the components that tie together so that it\'s not just a
matter of giving you money and so and so is not funded anymore? What are
the elements that give you evidence‑informed system change? Otherwise
the grant runs out and you have to figure out how to do another grant
application. I don\'t see that as getting us where it is we want to go.

MR. LOWTHER: I think you\'re absolutely right. I couldn\'t agree more.
When the grant runs out, you\'ve helped a few people and they\'re a
little bit better off for the time that you were there with them, but
you haven\'t changed anything permanently, and that has to be
institutionalized somehow at the state level and be appreciated, and
it\'s difficult.

DR. CLINE: Part of what happens with this is you\'re changing the way
you approach problems, you\'re changing the way you think about the work
you do and the challenges you face, and I think that\'s where that gets
embedded. You\'re actually changing the culture of how you approach
issues in your communities. In some ways there are a lot of similarities
with the NIATx problem, just that kind of process improvement, that kind
of plan/do/study/act kind of cycle. That is changing that culture and
approach, and it\'s not associated with any one specific problem. It can
be applied to everything you do. So I think that sustainability does get
embedded.

MR. LOWTHER: One of the things that\'s really different about this grant
is that we\'re not telling people what problems to solve. We\'re funding
them to solve the problems that they see. So we\'re not saying to
implement a program. We\'re saying figure out what\'s wrong and then
figure out what causes it, and then fund strategies that will drive that
change, rather than looking to the federal government to say, hey, go do
mentoring, or go do this, or go do that, because we don\'t know, we
don\'t live there.

MR. AIONA: If I can, I think this is a part of the discussion, and I can
talk offline maybe with you, but it seems like in your presentation ‑‑
by the way, very good presentation. It seems like a key element of this
whole thing is your regional prevention centers, and that was actually
created out of your block grants. Is that correct?

MS. SMITH: Yes.

MR. AIONA: So that means that the people in the regional prevention
centers are employed by the state, they\'re paid by the state?

MS. SMITH: They\'re paid through the block grant and they\'re using the
community mental health centers as the fiscal agents.

MR. AIONA: And that was started before you go this grant?

MS. SMITH: Oh, yes. They\'ve been in place for a long time. I couldn\'t
give you a date, but in the early \'90s, I believe, they were created.
Yes. We couldn\'t do it without them, and they\'ve done wonders for
prevention.

MR. AIONA: Do you know what percentage of your block grant is used for
these regional prevention centers?

MS. SMITH: I want to say it\'s the governor\'s portion. I wish I could
tell you, but I don\'t know. I\'ll be glad to find out and let you know,
but I don\'t know.

MR. AIONA: Thank you.

DR. CLINE: Any other questions or comments?

Dr. Gary?

DR. GARY: I wanted to thank you for certainly an insightful and
innovative way of looking at things. I can tell that you\'ve toiled for
long hours.

When I look at your relationships and collaborations, I wanted to ask
you if you would just talk with us a bit more about your notions of the
use of self‑help groups that are known to help to inculcate and change
the culture that Dr. Cline mentioned in communities, a very powerful
force in doing that. I\'m reminded of the research that comes from the
University of Vermont where they have a prevention research center and
they frequently write about self‑help groups and teaching people how to
do self‑help, which would include the consumers, parents, teachers,
organizations, et cetera. I would be interested in how is it that
you\'ve addressed that very important group of stakeholders, please.

MS. McFARLING: We have embraced that, actually. They have recently come
to the table, in Ohio County particularly. We did not have a lot of
self‑help groups that were there, but within the last six months they
are actively participating. Ohio County is also a recipient of the
Drug‑Free Mentoring Grant, and some of the mentoring counties that
they\'ve used have become very vital, and then Ohio County has also
embraced those. They are definitely at the table, and we could add
another circle for that collaboration and partnership.

They are vital, they\'re helpful, they provide a place in the community
for others who may need help to be able to access that.

MS. SMITH: Also, each regional prevention center has a library, and they
are charged with if someone with a self‑help group would like to learn
more about prevention or if they would like a prevention center to come
and speak with them or help them integrate it, the regional prevention
centers also are a resource for that as well.

DR. CLINE: Last question to Dr. Kirk.

DR. KIRK: On your graphic there, religious and fraternal organizations,
what are you finding in terms of how critical is the role that they\'re
playing? Coming from an Access to Recovery state, for example, we\'ve
found the faith communities, the spiritual communities to be really,
really important players in terms of getting messages out and access to
the system so that any number of folks ‑‑ my spouse may not go to our
doctor to tell that I have an alcohol/drug problem, but our spiritual
community, she may well go there. Can you talk a little bit more about
what you\'re finding as far as the role of the spiritual
community/fraternal organizations as critical to this prevention
framework?

MS. SMITH: We have known that the religious community is extremely
important. I guess we didn\'t have the right approach to get them on
board. With the Strategic Prevention Framework, we can show that right
in the church itself they can implement the framework, and in their own
little microcosm and macrocosm, they can do it.

Then I think we see that a lot of folks that maybe won\'t go to a county
meeting or won\'t join a coalition but are really strong in their faith
and in their church, when they see that implemented in their church and
they see what an important part prevention plays, they\'ll go ahead and
take part in it. In fact, now that we are implementing the framework and
we\'re seeing how important the church is, we have now got the
faith‑based PES. We\'ve got four in one county. We\'ve got 40 churches
right now that are interested in joining the coalition, and we need
their input. There are a lot of things that we can learn about
prevention, but we need the faith‑based input because it\'s a whole
other field out there that we\'ve not been able to reach. I believe they
are beginning to ‑‑ in fact, I know they are. They are beginning to take
part in it. So it\'s very important.

DR. CLINE: Great. Connie, Dianne, thank you very much for being here. We
enjoyed the presentation and we wish you the best of luck as you carry
on the work back home.

MS. SMITH: Thank you so much for having us.

DR. CLINE: Thank you.

(Applause.)

DR. CLINE: We will take a 15‑minute break and reconvene at five after
4:00. Thank you.

(Recess.)

DR. CLINE: We\'re going to jump right in here. We\'re into the home
stretch. We have saved one of our most engaging presenters for the last
up today, so everyone will be fully engaged with him and with us.

At this point I will turn it over to Rich Kopanda, who is the Center for
Substance Abuse Treatment deputy director.

Rich, the floor is yours. Thank you for being here.

MR. KOPANDA: Good afternoon. I understand the council actually asked for
this presentation on methamphetamine data. I\'m not sure you asked for
it at 4 o\'clock in the afternoon, and I do have quite a few slides, but
I\'m going to try to go through them very quickly and only point out one
or two of the highlights of each one.

I\'m not sure if you\'re like myself, but I sometimes get confused by
the various survey results that come out. We hear about the Household
Survey, and for us we have the Drug Abuse Warning Network, DAWN, and
then there\'s TEDS, and then there\'s Monitoring the Future. I tried to
look at our surveys, our information that we have here on
methamphetamines and put them together in some kind of logical order
such that we could compare, in this case, three: our National Survey on
Drug Use and Health through the Household Survey, which gives us
information on prevalence; our TEDS survey, which is a survey of the
state treatment providers, basically, that we receive from the states,
and that gives us information on admissions, basically, admissions into
treatment; and the data we have from our CSAT treatment programs, from
our discretionary programs or from all our programs, and to compare them
where we have data that are fairly comparable or similar from the three
programs.

TEDS and Household Survey data are from 2005. The discretionary program
data, the GPRA data you\'ll see on the slides, is as of December 31 of
last year. So I\'ll go through them fairly quickly and then leave some
time at the end for some questions.

First, prevalence and admission rates. This is Household Survey data.
What we see on methamphetamine and lifetime use, a statistically
significant decline between 2002 and 2005. We have a little over 10
million Americans who have used methamphetamines over the course of
their lifetime. There are declines also in past year use and past month
use. So in a given month we have slightly over 500,000 Americans using
methamphetamines. Also from the Household Survey, this is new initiates.
We see also a statistically significant decline in new initiates between
2002 and 2005, 299,000 to 192,000. That\'s on the left of this slide.
The age in years varies. We\'ll get to age a little bit later. So in
terms of overall prevalence and new initiates, we\'re seeing a decline
over the past four years.

This is TEDS treatment admission data where we don\'t see that kind of
decline. In fact, we\'ve been seeing an increase. You might have seen a
similar chart to this in terms of the Household Survey where we show how
it moves from west to east over the course of the past few years. Here
we have over 10 years between 1995 and 2005. We see the same with
respect to treatment, where it\'s particularly in the west, and I\'d
also note that we focus on the west a lot here because they look darker
and redder in our slides. But if you also look at the central part and
the eastern part of the country, you see the same trend. Now, it
doesn\'t get up to the same level as the western part, but what we\'re
seeing is that all states really are seeing many more methamphetamine
clients in their treatment system.

This is methamphetamine admissions from the TEDS data from 1995 to 2005,
once again the data that was shown by state in the other chart, a 172
percent increase. I\'d also note that that\'s about 8 percent of the
total treatment admissions. In this slide from the Household Survey, we
see methamphetamine as the primary drug of abuse is about 4.3 percent of
those who have a substance abuse problem. So while it\'s about 4.3
percent of those with a problem, it represents about 8 percent of those
in treatment. So what we see is a higher than expected treatment
utilization rate for those with methamphetamine as their primary drug,
and of course when you\'re addicted to meth, it has such significant
addictive properties that it\'s probably your primary drug of abuse.

Compared to all our discretionary programs in the second bullet, we have
a little over 9,500 of our clients from several of our discretionary
programs who report methamphetamine abuse when they enter into the
treatment in our programs. They represent about 5.2 percent of our
discretionary clients. This is a little bit higher than the 4.3 percent
that we see for the whole nation. This may be because we have some
dedicated methamphetamine programs, and it\'s about a 20 percent
increase, but it\'s fairly comparable.

The other thing about it is it\'s still a fairly small percentage in
terms of all of those using drugs. Methamphetamine is a small
percentage. On the other hand, those who use methamphetamine, of course,
create additional problems, as you know, environmental problems, family
problems, problems with law enforcement. So the problems that are
created by these clients are not necessarily proportional to the
percentage of those using drugs.

Where did those who use methamphetamine get their drugs? The third
column there, methamphetamine, you see it\'s a little bit different than
the others, fairly comparable in terms of the red and the yellow, that
is those who either bought it or got it free from a friend or relative,
which is about close to 80 percent. So for most of the drugs, they\'re
getting it from friends and relatives. What you see for methamphetamine,
though, is that none of the white, from a doctor, as you would expect,
and almost none bought on the Internet. You don\'t buy it on the
Internet as with other stimulants. So it\'s either coming from a friend
or relative or a drug dealer, pretty much.

With respect to age, if you look at the various cohorts in the Household
Survey, the 18‑ to 25‑year‑olds are the ones who have the highest
percentage use rate of their group. If you add the percentages up here,
you will not come to 4.3 percent because they\'re percentages of that
age group. But the highest percentage of the age group is in the 18‑ to
25‑year‑old range. Age 12 to 17 is about 0.7 percent, and 26 and older
is 0.3 percent, still relatively low percentages but highest in the 18‑
to 25‑year‑old group.

I tried to compare here several of the surveys. The Household Survey is
the first column. Monitoring the Future is a NIDA survey in the second
column. Youth Behavioral Survey, which is a CDC survey, is in the third
column. What you see is that the methamphetamine reduction in use is
approximately comparable among the three surveys. The Household Survey
comparison is from 2002 to 2005, so it\'s missing a year, if you will,
compared to the others, so the percentage there is a little bit greater.
But in all cases, the reduction in methamphetamine use is greater than
any of the other substances on here, including and especially alcohol
and cigarettes over the time period.

The treatment admissions by age differ from the utilization data. What
you see here is that if you take the 25‑ to 44‑year‑old group, the two
middle sets of bars, if you will, that\'s where you see the greatest
treatment admissions. If you remember, the other one was 17 to 25. So
it\'s about eight to twelve years after initiating use and using at your
peak period that you actually enter into treatment based on these TEDS
data.

The data from our group, from our CSAT treatment data, is basically
about the same. So more than half, about 60 percent of the clients, are
between 25 and 44 years old.

The demographics of the methamphetamine‑using population. Overall from
the TEDS data we see slightly over 50 percent male, slightly under 50
percent female. We think of it basically as about 50/50, which is a very
high percent of females, by the way, compared to many of the other drugs
of abuse. When you look at our CSAT data, it\'s about 60/40. So we have
more males than females in our CSAT program, and this is a very unusual
finding for us because CSAT programs generally, if you look across all
our discretionary programs, we have a much greater percentage women than
men when compared to treatment across the nation, compared to TEDS data,
our data. So it\'s different for the methamphetamine population. I\'ve
been trying to find out why that is. I thought maybe some of it was
because our drug program might be a higher percentage male, but I\'m not
really sure of that. More referrals to treatment ‑‑ I\'m not exactly
sure, but this is something we need to look at because it\'s unusual.

By race and ethnicity, we have ‑‑ and this is the TEDS data, national
data ‑‑ slightly over 70 percent white using methamphetamine. The second
group is about 18 percent Hispanic, and then very small use rates in the
other populations. From our CSAT data, I\'m not exactly sure why we
don\'t capture directly in the pie chart the Hispanic population
separately, but the white population is about comparable, almost 70
percent, comparable to the national population, and we have about 25
percent reported being Hispanic. So that is the second largest group,
but it\'s shown differently on this chart.

By referral source, the criminal justice DUI court referrals represent
nearly 50 percent of the total of those in treatment nationally for
using methamphetamine. Those who go into treatment by themselves as
individuals represent about 25 percent. So 75 percent are either going
into treatment on their own or being referred from the criminal justice
system in some way or another.

MS. HUFF: Richard, how is the (inaudible)?

MR. KOPANDA: They\'re from the criminal justice system drug courts or
they\'ve been picked up for some criminal activity and they\'ve gone
into treatment through that.

MR. AIONA: Can I ask a question?

MR. KOPANDA: Sure.

MR. AIONA: I just wanted to know from what age this is.

MR. KOPANDA: This is all ages.

MR. AIONA: All ages. Okay.

MR. KOPANDA: Let me show you the next slide. Here it is by age, okay? By
age it differs, and it changes at about age 30 or so. The young folks,
up through age 30, are predominantly being referred by the criminal
justice system. They\'re getting into trouble. They\'re getting into
trouble and they\'re being referred into treatment in that way. When
they start getting older, over about age 30, and they\'ve been using for
a while, because remember that they started using when they were
younger, then they start referring themselves to treatment, and they\'re
less likely to get into trouble and be referred to treatment in that
way, or compelled to treatment I should say. All the others are fairly
low, relatively speaking, and all stay about the same over the age
range.

By route of administration, as you\'d expect, methamphetamine is not
really taken on an oral basis by most people. I guess there are some.
It\'s either smoked, inhaled or injected, injection being second to
smoking.

By employment status, if you take the last two columns, those who are
unemployed and those who are not in the labor force, often forcibly not
employed, that\'s the majority of those who are going into
methamphetamine treatment. So they\'re basically not employed when they
go into treatment in some way or another.

By type of service, as you\'d expect, most are in outpatient or
intensive outpatient care ‑‑ i.e., ambulatory care. For the last two
columns it\'s kind of interesting, because for long‑term residential,
while the numbers are not high, percentage‑wise many more of those in
treatment for methamphetamine are in long‑term residential than all
admissions, which is the yellow, and only half of those are in detox in
all admissions. So in that respect, they\'re slightly different than the
general population of those in treatment.

MR. STARK: Question on that?

MR. KOPANDA: Sure.

MR. STARK: Do you have any data or any belief that one of the reasons
why you see so many of them in long‑term treatment is because of the
fallacy, the myth that was out there where a lot of research was
misinterpreted and people believed they needed longer‑term treatment, so
a lot of folks are being pushed in that direction via the criminal
justice contacts?

MR. KOPANDA: That\'s a possibility. I personally don\'t know that to be
a fact, though. Wes would probably know that better than I would, but
that\'s definitely a possibility. I mean, if you talk to anyone about
methamphetamine abuse, they\'ll say oh, yes, you\'ve got to get them
into treatment forever. It doesn\'t appear to be the case based on our
experience with the matrix treatment and other kinds of treatment
programs.

MR. STARK: And it didn\'t appear to be the case in Washington State with
the research that we did, either.

MR. KOPANDA: The outcomes, just very briefly.

Oh, yes?

DR. KIRK: Go back to the previous slide.

MR. KOPANDA: This one, or this one here?

DR. KIRK: That one. Tell me what, when you say long‑term residential,
the yellow is all admissions?

MR. KOPANDA: All admissions into TEDS. This is the TEDS data that we get
from almost all the states and almost all the treatment capacity. So if
you add up to 100 percent all the treatment, basically we look at it as
all the treatment in the nation, basically. The percentage there would
be, say, 18 percent, and there would be 14 percent for methamphetamine.

MR. STARK: If you can cross‑reference that particular chart with your
referral to treatment criteria, you might be able to get some sense of
whether the majority of those who are in long‑term treatment were the
ones referred by the criminal justice system.

MR. KOPANDA: Oh, yes. We should be able to do that because they\'re both
from the TEDS data, too.

Okay, just very briefly on the outcomes from our programs. This is a
list of our programs where we have a fairly high number, a reasonable
number of those who are in treatment for methamphetamine, Targeted
Capacity Expansion generally speaking, and also some of the programs we
initiated which were targeted to methamphetamine, the Drug Courts
Program, Access to Recovery, which of course is open to all but some say
it\'s focused more on methamphetamine than others. Those are
discretionary programs. But as I mentioned, any discretionary program,
different data than I\'m showing here, come from all discretionary
programs, even some others where the rates of referral to
methamphetamine treatment may be fairly low.

We also address methamphetamines through our substance abuse block
grant, of course, our states do. We have a collaboration with ACF on
their child welfare program. It\'s a \$40 million program that\'s being
started this year to focus on child welfare with meth families that are
using methamphetamines.

We supported the governors summits in many states to address
methamphetamine. We have begun some collaborations to address American
Indian and Alaska Native meth use, and TIP 33 ‑‑ I\'m not sure if it\'s
33 or 32 ‑‑ addresses stimulant use disorder, and it\'s very helpful for
methamphetamine.

If you take all of our discretionary programs and you look at the
outcome in terms of six‑month follow‑up use rates, you see a 54 percent
decline in the use of methamphetamine. This is a very excellent outcome,
we think. You\'ll see the numbers. Remember I mentioned over 9,000
before? This is significantly lower. That\'s because we don\'t have
six‑month follow‑up data on all of the clients from all of our programs.
But for those we do, we see a 54 percent reduction.

Some of the other NOMs that we collect with respect to those in
methamphetamine treatment in our programs. Once again, 3,000 versus the
9,000 total, but we see increases in all these areas, improvements I
should say. The rate of change here is basically improvement in all
these areas, improvements in employment, housing. The housing, 5.9
percent. It\'s hard to get improvements in housing sometimes, but I\'m
not sure if that might reflect the fact that many meth users had housing
before they went into treatment. In other words, they\'re not
necessarily a homeless population.

Arrests and involvement with the criminal justice system and social
connectedness as we now define it ‑‑ we\'re still working on that as a
NOMs measure, but we do have something we use now in our programs.

Yes, Ken?

MR. STARK: Well, there are states, as you know, that do report private
pay clients on TEDS as well. So that whole employment thing and housing
thing could be skewed by the fact that it is such a broad range of
consumers, unless you only with this chart looked at those who are poor,
like at 200 percent of poverty level and below, or whatever.

MR. KOPANDA: Well, this is not TEDS. This is from our programs, CSAT
programs now.

MR. STARK: Oh, it is only ‑‑

MR. KOPANDA: This is only our CSAT programs.

MR. STARK: But even them, each state does differ in terms of where they
have the cutoff of who you can serve.

MR. KOPANDA: Well, that\'s true. This is from our discretionary
programs, so this is a compilation of ATR grantees, methamphetamine TCE
grantees, drug court grantees.

MR. STARK: Then I would actually argue that that\'s even more so,
because some of the grantee programs don\'t differentiate between people
who are poor and people who have money when they fund them through the
discretionary grants.

MR. KOPANDA: That\'s true.

MR. STARK: So unless you segregate that out by income level, you\'re
going to get some things that ‑‑ it will underreport the positive issues
around employment, although that one looks good, and housing, because a
high number of those folks may have already had good housing and good
employment from day 1.

MR. KOPANDA: That\'s true, that\'s true.

DR. GARY: Thank you. I wanted to ask a quick question about employment.
That\'s a quite impressive figure, and I noticed in a previous slide
that individuals who are employed are less likely to be users.

MR. KOPANDA: Yes.

DR. GARY: Is there any particular focus in the treatment program that
helps with employment, any special training to help with employment,
attaining employment, how to act when employed, et cetera, et cetera?

MR. KOPANDA: I would say generally not in our strict treatment programs,
like our Targeted Capacity Expansion. What we have in our grant focuses
on the treatment aspect of that, unless the grantee provides that kind
of service on their own. However, one of our big emphases now is on
recovery support services. The RCSP program is basically not in these
data because they don\'t provide treatment, but the Access to Recovery
program, for example, Connecticut, they probably don\'t have a high
methamphetamine use rate, but should any of the ATR programs where they
do focus on recovery support services, which can include, depending on
what a state wants to do, employment services, that would be included
here. So it\'s kind of hard to say. We have kind of a mixed bag of
programs. We\'ll have to look at it individually, but that would be
something we would want to look at in terms of emphasizing our recovery
support services, how much better outcomes do we get if we don\'t just
provide treatment, which is what we have traditionally done, but if we
also add recovery support services to that.

DR. GARY: Absolutely. I was just wondering if it happened
serendipitously or if you programmed for it. Then again, another way to
look at it is if it were not a part of the treatment package, if it
were, how much more positive outcome could you get?

MR. KOPANDA: I would say some, but that would be a guess right now.

DR. GARY: Plus they\'d be paying into the tax base and be productive
people.

MR. KOPANDA: That\'s a very good point.

Last slide here. I didn\'t want to go through all of our communications
material and everything, but we do have some new tools that have come
out recently, including what we use for our earlier methamphetamine
treatment program, the matrix intensive outpatient treatment that was
very successful in our treatment. We do now have that available for
anyone\'s use. So people can access that through these and have that
tool available for them, and that\'s pretty much it.

So any other questions?

DR. CLINE: I have one question for you, Rich. You presented a lot of
data, a lot of information. I think it shows how rich the data system
actually is, and I\'m sure there are a lot of questions that people may
be mulling around.

What couple of take‑home messages, when you present all that data, what
couple of big themes, big‑ticket items would you like us to pay
attention to or that were interesting to you? What are a couple of
take‑home messages from that data?

MR. KOPANDA: Methamphetamine use seems to be declining. I didn\'t really
get into the issues here because it has to do also with everything from
the lack of availability to Sudafed to enforcement efforts and shutting
down the labs and such, but it does appear on a national basis to be
declining. It doesn\'t necessarily mean that in Hawaii or any individual
state, or Kentucky, that it is declining, or in local areas, but
nationally it is declining.

Treatment is not. Treatment is going up. But as we see, there\'s kind of
a lag. I would expect treatment to continue to go up for a little bit
and then start to decline in concert with the decline of the prevalence
rate. Hopefully we can continue that. We have available the tools now to
provide, as Ken was saying, effective treatment. We know how treatment
can be effective. I think, as Faye was saying, we need to start
analyzing the various components of this data, like employment and
looking at it in terms of providing more recovery support services in
association with our treatment services, in particular recovery support
services that you might say are indicated for the kind of problem that
you\'re seeing.

We have a lot of data. This is just a piece of our data. We need to also
do a better job, I think, within SAMHSA and CSAT of analyzing the data
we have and using it to help mold our programs as we look to the future.

MR. AIONA: I have a question. Do you have any data on the effect of
methamphetamine on brain development, long‑term, short‑term, or just
brain intervention, if that\'s the right way to phrase it?

MR. KOPANDA: We have a lot of slides on that that we\'ve gotten from
Rick Ralston from California. We\'ve worked very closely with him. He
has an excellent presentation. We\'ll be glad to send it to you. It
includes very graphic slides.

MR. AIONA: Can you give me a real brief summary on it? What are the
findings up to this point, if they have anything definitive? Because I
know it\'s the early stage and it takes a while to get to any type of ‑‑

MR. KOPANDA: Well, what he shows is that with continued use,
methamphetamine has distinct and definite harmful effects on the brain.
It actually changes your brain chemistry. Those effects, though, are
reversible. It takes a while. I\'m not sure how long it takes, but they
are reversible with treatment and with abstinence. Then there are other
associated effects, like meth mouth, and other kinds of things. But once
you get to that addictive phase, you\'re almost compelled to continue
your addiction unless you get some kind of help. That\'s what I\'ve
taken away from that. We talked before about whether this is a
behavioral problem. It\'s really not behavioral. It\'s physiological
after a while, and you need help to reverse those physiological changes
to get to the point where you can heal yourself.

DR. CLINE: Ken?

MR. STARK: NIDA has a lot of slides, too, and you can get those on their
website around the brain changes. But one of the things that has always
fascinated me is that when they, \"they\" meaning NIDA and their
researchers, first started coming out with those slides, what they would
initially say is that it causes a lot of brain damage, and I continually
questioned that. What does that mean? I mean, I know there are brain
changes, and if you\'re making the words \"brain change\" synonymous
with damage, then I want to know what kind of functional impairment is
caused by methamphetamine. I mean, we all can see the dental stuff.
That\'s real clear. We can all see how one looks like they\'ve aged 10
or 20 years when they haven\'t slept in weeks and they haven\'t eaten
and that sort of thing. Chris, you can see that in a person who has
chronic alcoholism, too, when they first go into detox if they\'ve been
living on the streets for years. They can age 10 years in a matter of a
year.

But what I finally came to realize, and we went through this with crack
cocaine with the crack epidemic in 1988‑\'89, that there was a lot of
hype initially about this brain damage that was going to be permanent.
Just like with crack cocaine, what we\'ve discovered, at least thus far,
is that although there may be certain brain changes that might be very,
very long term, that relative to functionality nobody has been able to
demonstrate yet that this is irreversible brain damage that results in
functional impairments that are irreversible, and most of the
impairments that they\'ve identified, from what I can see, are things
like short‑term memory and things around coordination initially. But
then again, I remember seeing brain slides on even chronic marijuana
users where you\'ve had effects on short‑term memory and on the ability
to walk a straight line, just like with alcohol.

So I think there\'s a lot we don\'t know, but I do know there\'s a lot
of hype, a ton of hype about this being the most addictive drug there
ever was and the most damaging. I don\'t want to downplay how damaging
it is, but we heard the same rhetoric with crack cocaine in the \'80s,
and if you go back, god knows how far back, we heard the same thing with
reefer madness about marijuana; not to say there aren\'t serious issues
here, but bottom line is that it\'s not as devastating and permanent as
the hype might tell people.

DR. CLINE: Other comments or questions for Rich?

(No response.)

DR. CLINE: Rich, thank you very much. Appreciate that. That was a great
presentation, and you went through that at lightning speed. Thank you.

(Applause.)

DR. CLINE: For the last request of the day, I have one more request in
terms of advice from you with the advisory council. Given that I\'m new
at this task and new to this advisory council, part of what I would like
‑‑ and this was also triggered by the presentation with the National
Strategic Prevention Framework ‑‑ is to use just a few minutes to get
some feedback from you about the process of this meeting, this
particular meeting, focused on things that you thought went well with
this meeting, in one minute or two minutes. I\'m going to go around the
room and ask if everyone would just quickly say what they liked about
the meeting or what they thought could actually improve this meeting,
and that will be important feedback from me. You have kind of a relative
basis given your experiences with this particular format, and this is a
structure that I\'ve used many times in other meetings, and it helps
keep our meetings focused and also helps that continuous quality
improvement model stay alive in the meeting. Hopefully it won\'t feel
too touchy‑feely for the group, but it\'s also something that\'s widely
used in a lot of business communities and other communities that are
focused on quality improvement.

So I\'m going to actually start. I normally would not start, but with
the hope of kind of modeling a little bit, I\'ll put in one cautionary
note. It\'s not a last opportunity to make a speech. It\'s not a last
opportunity to make the point that you hoped that somebody would get and
they never did get at the last part of the day, but to really focus on
the process of this particular meeting, what you liked and didn\'t like.
So I\'m going to jump right in there, and we\'ll move quickly with this,
and then I\'m going to go around this way.

I found the discussion around the budget very helpful, really helpful
for me, and having the feedback from you and being able to hear what was
really a dialogue between council members very helpful. In the
afternoon, every single presentation I enjoyed and I thought they were
all very rich. I probably found it less helpful to have so many
presentations because that took away from conversation and dialogue. I
found myself needing to say \"last question, last comment.\" So I felt
like I was cutting the conversation short a little bit, and I would
wonder about that balance, having more time for conversation and less
time for presentation.

Daryl?

MS. KADE: I thought the change in dynamics in terms of inviting Q&As
during the presentation as opposed to waiting until afterwards resulted
in a much richer discussion.

MS. HUFF: I really liked it. I liked everything about it. I liked the
richness of the discussion around budget, too, but that\'s just because
I had some questions I needed to have answered. So I appreciate your
willingness to not be defensive about it when we kind of really
approached it in a straightforward sort of way, because you easily could
have been, especially your first meeting.

I felt very listened to in the sense that I told you on the phone when
you called me that I really did like the idea of bringing in people from
the field to have some SAMHSA input into subject matter and for them to
bring in people who kind of backed up good programming.

Anyway, I was really impressed that that was heard, because I think
several of us have said it over time, that we really like that style.
Thank you.

MR. STARK: I think this is probably one of the meetings where I\'ve seen
more engagement than many of the other meetings. In a number of the
other meetings I felt more talked at than talked with, and I thought
this one truly did give an opportunity for much more dialogue. I agree
that the mix of presentations with the dialogue and the opportunity to
ask questions not necessarily at the end of the presentation but during
it added a lot, because some of us are having senior moments and we\'ll
forget by the end of the presentation.

MS. HUFF: Almost all of us.

MR. STARK: Hey, you weren\'t the only one. It happened to me, too.

(Laughter.)

MR. STARK: The other thing I would mention, if I can stall just a second
because I\'m already having that senior moment I just mentioned, is that
I liked the diversity of the topics that we had today. I think it\'s
really important for us all to get a better understanding of the budget
process and the limitations, and also seeing timelines and how we can
fit in to giving SAMHSA input to truly be able to say that we had some
opportunity to try to influence, if you will, the priorities. It may be
that it\'s too late for 2007, it\'s too late for 2008, maybe we\'ve got
to be talking about 2009 right now to be able to give you the input to
feel like we had that opportunity, and I think I heard that mentioned
earlier today, that that\'s a discussion that\'s already going to go on.
But I liked it, I thought it was good, but not too many presentations,
because then it\'s like you said, you\'re going to have to end up
cutting us off, because the minute we get warmed up, it\'s time to cut
us off.

MS. KITTRELL: Well, I enjoyed the interactive dialogue as well, and to
find out from you some of the things you\'re interested in, like the
veterans initiative, mental health transformation, really transforming
the field through the leadership, some of the things that you talked
about this morning, cultural competency. It\'s important to know your
thoughts as well as our thoughts.

I\'ll yield the rest of my time to the gentleman from ‑‑ where are you
from, Larry?

DR. LEHMANN: From the VA.

MS. KITTRELL: I\'m yielding the rest of my time to you.

DR. LEHMANN: This is not my good ear.

I thought this was very useful in terms of the fact that what I tend to
get from these meetings is sort of picking up what other organizations
and groups are doing and how that applies to some of the things that
we\'re doing in VA, and also what\'s going on within the non‑VA
community that we can tap into. As a result, even though I\'m not a
substance abuse person, it was very interesting to see the process of
how, for example, the funds from the grants were being used and the
issues that were being raised and how they were addressing them in terms
of the idea of how you sustain an evidence‑based practice, which for me
is really what the afternoon was about, evidence‑based practice. It\'s
very, very important for us.

So it was quite useful, and it was the combination of the presentations
and the discussion. I think it\'s very, very useful, though, as an
organization or as an advisory committee to see some of the fruits of
SAMHSA\'s investments. I think that\'s extremely useful, because it\'s
quite reinforcing, quite frankly, to see the good that\'s being done
from the investments that come down from on high.

MR. KOPANDA: Well, at the risk of repeating what others have said, I
agree with the comments that you all have made. In particular for me,
the interest and engagement of the council members, all the council
members were engaged, jumped in and gave us comments on a number of
different subjects. That\'s what I really enjoy most about this meeting,
and I think it has been actually a greater involvement than I\'ve seen
sometimes, and maybe it\'s because of the nature of the mix of the
presentations and discussion.

MS. DIETER: I thought it went really well, too, in the two points which
have already been stated. I think the format of having the questions and
having a dialogue during it has been extremely helpful for the first
reason that we might forget, but also people carry on. I mean, Tom has
been able to emphasize something. Now I\'m just thinking about all the
time in terms of the systems change. I mean, because he\'s able to
insert, it comes up at different times under different topics, and I can
see how it relates to each one. I think that\'s really helpful.

I also agree that having a program visit had the same effect last time.
It is wonderful to see the benefits of what\'s happening, but I think
even more importantly it stimulates also other questions and thoughts
about what to do with that, what further needs to be done here. We have
all this great information. You know, it just stimulates a lot of other
questions, conversations, thoughts on not just our part but everyone at
SAMHSA. So I thought it went really well.

MS. POWER: In the three‑plus years that I\'ve been at SAMHSA, I\'ve had
the privilege of working with this council as member, and also have my
own CMHS council. So it\'s interesting to see that process and this
process and sort of compare and contrast, and one of the things that
happened for the CMHS council was they basically demanded that this kind
of process go on, that there be much more interchange, that there be
less presentations, that there be much more dialogue relative to an
investment in the process. From my perspective today, because all of the
people around this table I\'ve really worked with over the last three
years and have watched my relationship with them and your relationship
with us grow together, we really are fortunate that this is a mature and
highly sophisticated group of people who are ready and willing and able
to step in and make comments and ask questions. So I think that\'s an
advantage, Terry, that you\'ve exploited, which I think is good.

The other thing that I observed is that at the end of our day and a half
when we meet, or at the end of our two days of council, we found that we
needed to go back and remember with our brains what were the nuggets
that we came up with during the conversation. We learned we had to sort
of capture those in a parking lot somewhere. So when Ken says I think we
should do a mental health ESPIRT kind of thing in \'09, we ought to
capture that somewhere, and then that becomes the basis of the closing
discussion tomorrow, when everybody can kind of reconnect with some of
those ideas thematically. So that was a process that we\'ve used, and I
think that may be helpful, Terry.

DR. CLINE: We actually have that in place, and the staff has done an
incredible job. I was already presented with a sheet that has all of
those nuggets, which is very impressive when you look at it. You say how
in the world did you capture all of that? So it\'s an amazing job. One
option was to do that today, and I thought just to help inform the
process a little bit tomorrow we would save that parking lot and do that
tomorrow, and actually I\'ll probably start with that in the morning
just to connect today with tomorrow. Thank you.

DR. GARY: I always feel that I\'m very fortunate to be here to meet
colleagues who share the same passion that I do and who work hard every
day to assure that everyone will have a life in the community.

I enjoy very much looking at the cutting‑edge kinds of activities that
SAMHSA is doing. For example, we learned today about the evidence‑based
data and the interventions. To tell you the truth, I had not checked the
website to see that. I enjoyed the dialogue, but we could spend a whole
lot more time talking about how that one program could impact mental
health services utilization throughout the United States, a variety of
ways, in universities and community mental health centers, self‑help
groups. I would love to have that kind of dialogue and that kind of
sharing here so that we could look at new and creative ways to do that.

I know I enjoyed the discussion, and if we had more time I think there
would be even more discussion and more nuggets of wisdom. One such
nugget of wisdom would be if we could have discussions, predictive
discussions, so we could predict what we need to do and how we could
plan to do that, I think that would be very helpful for SAMHSA.
Otherwise I think we\'re always looking at the downstream rather than
looking at the upstream, and to take some time to prepare what I would
call concept papers that would relate to these specific kinds of areas
on our matrix that we would want to take a look at, and how that might
also drive budget, how program can drive budget and how numbers drive
budget, and how we can come to some kind of agreement on that.

But I truly enjoyed the discussion, and I\'m glad I had the opportunity
to learn so much from my colleagues.

DR. KIRK: I thought the diversity of the topics today, I didn\'t find it
too long, but let me tell you part of what I was thinking. I think
you\'ve already anticipated how to make use of this.

How do we take what we talked about today and all the give and take in
terms of discussion, maybe in your roundtable discussion tomorrow?
What\'s the opportunity for strategic thinking, not based upon projects
but how some of this stuff ties together? I don\'t know whether you\'re
comfortable with this, but from SAMHSA\'s point of view, what are the
hard questions, if you will, or the challenges that you\'re looking at
that you\'re comfortable talking about besides how much money?

I mean, you all go through your discussions internally about how to do
this, how to do that. So what I would think the opportunity is for,
because I like the diversity and the give and take, but how do we take
this? You asked Rich a question before. When we walk out of here
tomorrow, what are the lessons learned, if you will, that will be of
benefit to you as well as from the strategic thinking that we might have
for a half hour, 45 minutes, would serve to be of benefit to you? And
furthermore, as a council member, as I go back to my day job, as I think
about things, as I see things that go on in my day job that I say why
don\'t I send that to Terry Cline? We talked about that at the last
session, and this might be of help to him.

You can only bring in so many programs, bring in the local programs, but
it happens at the state level, it happens at the program level, and I
think people such as us, particularly within the states, we can bring
back to you things that are going on in an individual state not in a
formal presentation as much as to tie things together that we have
talked about here. So it\'s tying one session to another.

I think the other piece, and I should have thought about it before when
Daryl was giving the budget piece, one of the things I heard today is
that so many of the things that are important for mental health,
substance abuse prevention, all the components, are not necessarily
within SAMHSA itself, like housing and employment and these other kinds
of things. I\'d be interested in hearing from you ‑‑ I presume you do
something like this ‑‑ how do the budgets for these other federal
agencies go generally that are likely to have an impact on some of these
recovery support services and essential components? Housing, for
example, is critical to so much of this. The employment stuff is so
critical to this. Did HUD or whatever the agency is, did they take some
heavy hits so that when we talk about services critical to the people ‑‑
yes, the things that are unique to SAMHSA are important, but some of
these other things that any number of these folks talked about, in many
ways they\'re more important than me getting an outpatient appointment.
Do these other federal agencies take hits such that the service system,
if you will, out there, that there are going to be breaks that we should
be aware of?

I think the final comment I\'d like to make is that I think in the
conversation today and hopefully tomorrow, that you walk out of here
with the impression and some suggestions to us as to how we can help
SAMHSA. So it\'s not sitting here and doing dog and pony shows, go back
and nothing changes. How can we be of assistance to you within all the
ground rules for council members? Any number of us in states, we have
these councils, and sometimes, frankly, they\'re more trouble than
they\'re worth. I don\'t want me or others to be more trouble than it\'s
worth to you. How do we provide some assistance to you, and what comfort
level would you have in saying I need some thinking about this and this?
We\'re not struggling with it, but we\'re at that stage of our thinking.
So the \'09 budget may be one of the pieces. So you could say, okay,
that\'s what we\'re going to concentrate on.

But all in all, I think it was very, very helpful, but I would look
forward to that strategic discussion tomorrow. You know, you sat here
for all day, you listened to these things, and can you identify what you
see as the strategic questions or observations you could make from
listening to that so that it\'s not projects but the larger picture?

MR. AIONA: I agree with Tom on what he said. I guess maybe I\'ll say it
in a different way, but we are an advisory group, and so I look at our
role much like I as a leader in the state government would put together
a task force, or whatever you want to call it, to give me advice on
something that we may be undergoing, some project we may be undertaking
and making changes to or developing or implementing. So likewise with
us, I would feel great to walk away from here knowing that I came with a
purpose to help you and SAMHSA, and we walked away and we did a better
job of it.

I think you had a great discussion today because you had topics that
people really were engaged with. It was interesting topics that everyone
could engage with and had expertise in. You can see that you\'ve got a
great diversity of ‑‑ if you want to call it experts here in this room
on this council. So I would just echo what Tom said and just say that
today was a great meeting, it really was. Thanks.

MS. VAUGHN: Several things. I like the idea that we went out to council
and asked them what were they interested in hearing about. So the agenda
is a mix of what you wanted and what we thought you would be interested
in because it was an emerging issue, and then some of the things that
you asked to be on the agenda at previous meetings. So I really liked
that effort on both of our parts.

I also like the idea of the handout presentations. We\'re calling these,
in a sense, your homework. We gave you your books last night. We hope to
get the information to you earlier. That\'s putting more pressure on me,
but so you\'ll be able to read the material and then you\'ll come to the
meetings with a better understanding of where we are with regard to
these particular issues.

The other part is a logistical issue. I like the idea that you\'re at
the Sheraton, which we have the transportation back and forth and we\'ve
made it available, and they\'re very flexible with getting you here and
moving you out.

One other thing. We talked about the grantees coming here. I would be
interested in hearing tomorrow whether or not you\'re interested in
maybe an onsite/offsite visit of a grantee.

So those are the things that came up for me.

DR. CLINE: Well, thank you all very much. That was extremely helpful,
and I appreciate your candor and that spirit of contribution in being
here, and your service to SAMHSA and to the country.

So with that, we will adjourn and reconvene at 9 o\'clock tomorrow
morning. Thank you.

(Whereupon, at 5:08 p.m., the meeting was recessed, to reconvene at 9:00
a.m. on Thursday, March 8, 2007.)