U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

IMPROVING SUBSTANCE ABUSE TREATMENT: THE NATIONAL TREATMENT PLAN INITIATIVE

Changing the Conversation

NOVEMBER 2000
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

Changing the Conversation

NOVEMBER 2000

Panel Reports, Public

Hearings, and Participant

Acknowledgements

Improving Substance Abuse Treatment: 

The National Treatment Plan Initiative
Acknowledgements

The National Treatment Plan (NTP) Initiative is conducted under the general auspices of the Substance Abuse and Mental Health

Services Administration (SAMHSA), Center for Substance Abuse Treatment (CSAT), and the CSAT National Advisory Council. At its

meeting on May 12, 2000, the National Advisory Council formally recommended “Changing the Conversation, Improving Substance

Abuse Treatment: The National Treatment Plan Initiative,” to CSAT for its consideration and implementation as appropriate.

NTP reports are developed under the supervision of Dr. H. Westley Clark, Director; Dr. Camille T. Barry, Deputy Director;

Donna M. Cotter, NTP Coordinator; and Dr. Mady Chalk, Director, Office of Managed Care. This report is based on the detailed

review and recommendations of five expert panels that were convened by CSAT, and that deliberated from April 1999 through

February 2000, with assistance from numerous CSAT staff. Representatives of the five panels and a steering group of field leaders

formed an editorial review board for the report. The Lewin Group, led by Leslie J. Scallet, Project Director, and Dianne S. Faup,

Project Manager, provided staff support to CSAT and to the panels.

The opinions expressed herein are the views of the panel members and do not necessarily reflect the official position of CSAT or 

any other part of the U.S. Department of Health and Human Services (DHHS).
Changing the Conversation

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THE NATIONAL TREATMENT PLAN INITIATIVE

Table of Contents

PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

SECTION I: PANEL REPORTS

PANEL I: CLOSING THE TREATMENT GAP

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

II. DEFINING THE TREATMENT GAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

A. Societal, Organizational, and Individual Barriers to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .9

B. Access and Inter-System Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

C. Resource Allocation and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

D. Quality Care and Outcomes Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

IV. THEMES FROM THE PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

V. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

PANEL II: REDUCING STIGMA AND CHANGING ATTITUDES

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

II. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

A. Definitions of Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

B. Individual Experiences with Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

C. National Efforts to Reduce or Prevent Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D. Public Opinion Research on Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

E. Formal Approaches to Reducing Stigma and Changing Attitudes . . . . . . . . . . . . . . . . . . . . . . . .46

F. Previous Recommendations Addressing the Reduction of Stigma and Change in Attitudes . . . . .48

III. THEMES FROM THE PUBLIC HEARINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

IV. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

V. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

VI. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Changing the Conversation

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THE NATIONAL TREATMENT PLAN INITIATIVE

PANEL III: IMPROVING AND STRENGTHENING TREATMENT SYSTEMS

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

II. PROFILE OF THE CURRENT TREATMENT SYSTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

A. Facilities and Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

B. The Client Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

C. Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

D. Effectiveness of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

E. Role of Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

III. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

A. Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

B. Financing and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

C. Management and Business Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

IV. THEMES FROM THE PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

V. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

VIII. APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

PANEL IV: CONNECTING SERVICES AND RESEARCH

I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

II. BACKGROUND AND UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

A. Current Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

B. Why We Need A System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

III. THEMES FROM THE PUBLIC HEARINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

IV. RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

V. DISCUSSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

A. The CSR System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

B. Proposed Vision of Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

C. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121
iii

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

PANEL V: ADDRESSING WORKFORCE ISSUES

I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

II. BACKGROUND AND UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

A. Prevalent Problems for the Substance Abuse Treatment Workforce . . . . . . . . . . . . . . . . . . . . . .134

B. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137

III. RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

IV. DISCUSSIONS: OPPORTUNITIES FOR THE FUTURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

A. Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

B. Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

C. Supply, Demand, and Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157

D. Factors to Consider in Moving Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158

V. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

VI. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

VII. GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

SECTION II: PUBLIC HEARING SUMMARIES

I. OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

II. HEARING SUMMARIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

A. Arlington, VA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 

B. Hartford, CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177

C. Chicago, IL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

D. Washington, DC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188

E. Portland, OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192

F. Tampa, FL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198

III. WRITTEN TESTIMONY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
SECTION III: PARTICIPANT ACKNOWLEDGEMENTS

I. CSAT NATIONAL ADVISORY COUNCIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

II. NTP LEADERSHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

III. PANEL PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

IV. PANEL MEETING SPEAKERS AND CONTRIBUTORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

V. PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

VI. NTP CONTRACTORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

iv
Changing the Conversation

v

THE NATIONAL TREATMENT PLAN INITIATIVE

Preface

The Center for Substance Abuse Treatment (CSAT) began the National Treatment Plan Initiative

(NTP) in the fall of 1998, to provide an opportunity for the field to reach a working consensus on

how best to improve substance abuse treatment, and then to pursue action to effect needed change.

The NTP is not designed to create a traditional “national plan” to be published and cited. Rather, it

was intended to provide a common starting point, to engage people throughout the field in a collaborative effort, and to recommend the types of guidelines and actions that over time can help to

make effective substance abuse treatment available to all who need it.

Changing the Conversation is the first product of the NTP Initiative. It was developed through

extensive examination of relevant research and past reports, consultation and discussion among

experts reflecting a broad cross-section of opinion and experience throughout the field, and active

solicitation of public comment. Expert panels met between April 1999 and February 2000.

CSAT encouraged public comment through field publications and a dedicated web site, and 

convened public hearings from July through November 1999 to ensure that community 

perspectives were incorporated.

This volume, Changing the Conversation: Panel Reports, Public Hearings, and Participants, contains

the full panel reports, summaries of the public hearings, and lists of all contributors. The companion volume, Changing the Conversation: The National Treatment Plan Initiative to Improve Substance

Abuse Treatment, presents a set of guidelines and recommendations drawn from the work of the five

(5) panels and the many additional individuals who participated in the hearings and submitted

comments. It represents the collective vision of the participants in the NTP over the past eighteen

months. The Substance Abuse and Mental Health Services Administration (SAMHSA), CSAT and

the participants regard this as the beginning of a long-term effort that will engage the attention 

and energy of people throughout the country.

Changing the Conversation

vii

PANEL REPORTS

THE NATIONAL TREATMENT PLAN INITIATIVE

Section I: Panel Reports

Changing the Conversation

Report of Panel I: 

Closing the Treatment Gap

1

THE NATIONAL TREATMENT PLAN INITIATIVE

REPORT OF PANEL I

REPORT OF PANEL I

Changing the Conversation

3

Table of Contents

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

II. DEFINING THE TREATMENT GAP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

III. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

A. Societal, Organizational, and Individual Barriers to Treatment . . . . . . . . . . . . . . . . . . . . . . . . . .9

B. Access and Inter-System Linkages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9

C. Resource Allocation and Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

D. Quality Care and Outcomes Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

IV. THEMES FROM THE PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

V. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

THE NATIONAL TREATMENT PLAN INITIATIVE
4

Changing the Conversation

I. Executive Summary

Panel members focused on identifying ways to close the “gap” in alcohol and drug treatment,

defined as the difference between individuals requiring treatment and those receiving treatment.

This report discusses a number of underlying issues surrounding the treatment gap and proposed

recommendations for filling the gap.

Substance abuse and dependence is a “biopsychosocial” disorder, which means that the nature of the

disorder is influenced by a combination of biological, medical, psychological, emotional, social, and

environmental factors. The disorder is progressive, chronic, and relapsing. Often, substance abuse

dominates an individual’s life, with a profoundly negative impact on the individual and those

around him or her.

Substance abuse disorders afflict approximately 13 million individuals. Of those 13 million individuals, only about 3 million are receiving treatment, leaving approximately 10 million people stranded

in the treatment gap. To fill this gap, the Panel strongly recommends a “no wrong door” strategy to

assure effective and appropriate care for all individuals in need of treatment, regardless of demographic or other factors that might impede their access to care. The Panel considered approaches

that would reflect the needs and concerns of all individuals who might use the substance abuse system or other overlapping systems. They sought to understand the factors that impact individuals

and their families and friends.

Although it is now well established that treatment is effective to counter substance abuse, the Panel

identified significant barriers to treatment: societal, organizational, and individual factors; access to

appropriate treatment; the use and allocation of resources and adequate financing of programs and

services; and issues surrounding the quality of care and treatment outcomes.

To address these barriers, the panel developed recommendations in three areas: Access and interState linkages; resource allocation and financing; and quality care and outcome measures.

ACCESS AND INTER-SYSTEM LINKAGES emphasizes the benefit of multiple systems working

together to ensure that appropriate, effective care is available to all individuals in need of treatment.

1. Develop a plan to create a nationwide expectation for alcohol and drug treatment such that no

matter where in the human services, health, or justice system an individual appears, his or her

alcohol or drug problem will be appropriately identified, assessed, referred, or treated.

RESOURCE ALLOCATION AND FINANCING focuses on improving public and private insurance benefit packages, increasing the resources in the system, and using system resources more effectively.

THE NATIONAL TREATMENT PLAN INITIATIVE
5

2. Increase total resources available for substance abuse treatment (i.e., Federal, State, local, and

private) in order to reduce associated health, economic, and social costs.

3. Develop a standard insurance benefit for substance abuse treatment that provides for a full 

continuum of appropriate and continuing care to meet the needs of persons with substance

abuse disorders.

4. Provide sustained support to increase State and local capacity to identify, assess, determine, and

monitor need for treatment at the local/community level.

5. Organizations and payors that want to engage in delivery of services for substance abuse screening, assessment, and/or treatment should: (1) use evidence-based treatment protocols; and 

(2) continuously monitor quality of care (structure, process, and/or outcomes) using common

methods and measures adopted by the field through a consensual process. This should apply to

both public and private providers and payors, operating in the substance abuse, primary health,

social service/welfare, justice, education, or other fields.

QUALITY CARE AND OUTCOMES MEASURES centers on improving the quality and appropriateness

of care provided and creating an ongoing monitoring process for maintaining a high level of care.

6. Define and help support processes to reach cross-system consensus on evidence-based 

standards for quality of care and practices that apply to all systems and payors.

7. Facilitate cross-system consensus on critical data elements to measure quality of care and 

treatment outcomes.

Viewed collectively, these recommendations provide the strategic base to ensure that those in need

of treatment actually receive treatment, that sufficient public and private resources are available and

appropriately employed to deliver the “quantity” (frequency, duration, intensity) of treatment, and

that the types and levels of care needed are available.

II. Defining the Treatment Gap

Substance abuse and dependence is a complex disorder, with associated biological, psychological,

and social causes and effects. Historically, this disorder has been treated as a social problem while

the psychological and biologic aspects largely have been ignored. However, the deterioration of

functionality within each of these aspects of the disorder requires that treatment and intervention

address the entire biopsychosocial continuum. In addition, substance abuse and dependence is a

chronic, relapsing illness. Although many of the symptoms and associated illnesses require that a

client receive specialized or acute care, these systems might not be prepared to treat the chronic 

elements of the illness.

REPORT OF PANEL I
6

Changing the Conversation

In this report, people with alcohol and drug abuse disorders are defined as individuals who meet

diagnostic criteria for receiving treatment whether the nature of their presenting symptoms is biological, social, or psychological. These individuals have progressed to the point where they require

intervention and treatment. However, given the social aspects of this disorder, the ramifications and

possibly the causes of substance abuse extend beyond the individual experiencing the problem to

affect those around him or her, as well. Thus, it is also important to address the treatment needs of

family and friends closely affected by this disorder.

Many organizations and agencies have published estimates of the number of people experiencing

problems with drugs and/or alcohol in the United States. Across studies, the findings consistently

demonstrate that there are more individuals in need of treatment than can be accommodated by the

system. In most reports, alcohol and drug abuse are studied separately. The Office of National

Drug Control Policy (ONDCP) focuses on drug problems, and many of its findings are cited in this

report. The National Institute of Health (NIH) focuses on alcohol and drug abuse in two separate

institutes, the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol

Abuse and Alcoholism (NIAAA). The separate statistical representation of alcohol and drug use

means that attempts to combine the numbers provide only rough estimates because double counting may occur. The fact is that approximately half of people with drug problems also suffer from

alcohol disorders. The disparity in survey methodologies and access to data also produces many of

the numeric differences. Nonetheless, the numbers presented below paint a broad picture of the size

of the treatment gap.

According to the ONDCP’s 1999 National Drug Control Strategy, there are approximately 4 million

chronic drug users in the United States. This closely aligns with the 1998 National Household Survey

on Drug Abuse, which found that 4.1 million people were in need of drug treatment. The NIAAA

report, Improving the Delivery of Alcohol Treatment and Prevention Services, estimates that there are

14 million alcohol abusers, whereas the 1998 National Household Survey on Drug Abuse finds

approximately 9.7 million people in need of alcohol treatment. Regardless of the source, a conservative estimate of those in need of substance abuse treatment is between 13 and 16 million people.

In contrast, both the 1997 Institute of Medicine (IOM) report, Managing Managed Care, and the

1998 National Household Survey conclude that approximately 3 million people receive care for alcohol or drugs in one year. Although, as previously stated, neither the estimates of those in need nor

the estimates of those in treatment are all inclusive, the picture remains the same — more than 10

million people who need treatment each year are not receiving it.

THE NATIONAL TREATMENT PLAN INITIATIVE
7

To move toward closing the treatment gap, a clear understanding of how treatment is defined is necessary. Panel members agreed that for this report, treatment would be defined as follows:

“Treatment refers to the broad range of [primary and supportive] services — including identification, brief intervention, assessment, diagnosis, counseling, medical services, psychiatric services,

psychological services, social services, and follow-up, provided for persons with alcohol [and/or

other drug] problems. The overall goal of treatment is to reduce or eliminate the use of alcohol

[and/or other drugs] as a contributing factor to physical, psychological, and social dysfunction and

to arrest, retard, or reverse the progress of any associated problems” (IOM, 1990a).

It is becoming increasingly evident that treatment is effective in addressing substance abuse. For

example, the ONDCP 1995 National Drug Control Strategy stated that “studies and statistics indicate that the fastest and most cost effective way to reduce the demand for illicit drugs is to treat

chronic hard core drug users.” The ONDCP used this empirical evidence to buttress its plan for

more effective use of available Federal treatment grant funds to move individuals into treatment and

the increased use of justice system resources to treat chronic users under their authority. Other

studies have also supported this view.

“Research has shown that drug abuse treatment is both effective and cost effective in reducing not

only drug consumption but also the associated health and social consequences. . . .Treatment gains

are typically found in reduced intravenous and other drug use, reduced criminality, and enhanced

health and productivity” (IOM, 1996).

REPORT OF PANEL I
8

Changing the Conversation

III. Understanding the Problem

The next step is to understand what factors are contributing to the gap and interfering with effective

treatment. The Panel separated the treatment gap into four main discussion areas: Societal,

Organizational, and Individual Barriers to Treatment; Access and Inter-System Linkages;

Financing/Resource Allocation; and Quality Care and Outcomes Measures (see Figure I.1).

Figure I.1 Major Access Barriers in Substance Abuse Treatment

THE NATIONAL TREATMENT PLAN INITIATIVE

Financing/Resource Allocation

Quality Care and 

Outcomes Measures

Access/Inter-System Linkages

UNTREATED

Substance 

Abusers

More than 10 Million

TREATED

Substance

Abusers

Approximately 

3 Million

Societal, Organizational

and Individual Barriers to

Treatment

• General Denial 

• Stigma
9

A. SOCIETAL , ORGANIZATIONAL, AND INDIVIDUAL BARRIERS TO TREATMENT

There are many reasons why individuals fail to get treatment, including stigma associated with the

disorder; cost of treatment; unavailability of support services, such as child-care or transportation;

and failure of systems to effectively identify individuals and direct them into treatment.

These issues intensify for individuals categorized as “special” populations. The treatment system

often does not provide well for population groups such as women, children and adolescents, the

aging and disabled, ethnic groups, and rural populations. Historically, programs have been aimed at

men; thus, there are a limited number of women- or juvenile-oriented programs. Because access

issues due to pregnancy and child-care are prevalent within these groups, the result is impaired

access to care. Gender and age are not the only barriers; ethnic and racial differences frequently 

prevent individuals from accessing treatment due to language or other cultural barriers.

Furthermore, geography poses a problem in many rural areas because an insufficient number 

of programs are spread across different regions. These scattered programs pose problems for 

accessibility (e.g., long travel times or lack of transportation), especially for individuals in need of

on-going care. Location of care, type of care available, hours of operation, and other program characteristics often limit client access to care. In addition to these barriers, some individuals who have

access to treatment do not choose to use it. Many people fail to accept the magnitude of their specific problem, or have a fear of the public perception associated with treatment. Their “denial”

increases the importance of rigorous screening across systems and facilitating access to treatment 

for resistant individuals.

B. ACCESS AND INTER-SYSTEM LINKAGES

Because of the nature of the disorder, individuals in need of treatment might appear in various settings, including healthcare, the justice system, mental health, welfare and social services, and juvenile

or educational systems. Often they are not effectively screened and diagnosed to facilitate movement into treatment. Different systems function independently, often failing to use inter-system

linkages that could increase the number of individuals able to receive treatment as well as the

resources available for treatment.

Additionally, the lack of cohesive interaction among systems interferes with the ability of the 

treatment system to provide a high quality continuum of care. The disconnection between overlapping systems does not foster effective identification and maximization of the resources (financial 

or otherwise) available across systems. The development of an interactive system that matches 

care to need, regardless of point of entry, is crucial to establishing inter-system linkages and 

improving success.

REPORT OF PANEL I
10

Changing the Conversation

A recent study (Weisner, 1999) of new admissions of weekly drug users across population and community agency systems shows the prevalence of drug users located in other systems (see Figure I.2).

Figure I.2 Distribution of Drug Users Across Health, 

Social Service, Justice, and Other Sectors of the Community

The justice system poses one of the greatest challenges for improving access. One study estimates

that approximately 1.4 million or 80 percent of the people who are incarcerated have a history of

alcohol and/or drug abuse (Culpepper Foundation, 1998). Furthermore, many of the incarcerated

individuals who are in need of treatment do not have access to treatment. A report from Join

Together (1996) indicates that only seven percent to15 percent of incarcerated persons receive treatment. Additionally, the problem extends beyond the walls of the correctional facility. Substance

abuse is equally a problem among juvenile justice populations and parole and probation populations and can also be an issue in civil proceedings. In a 1995 survey of adults on probation, nearly

70 percent reported past drug use, and 32 percent admitted to illegal drug use in the month before

their arrest (Bureau of Justice Statistics, 1997).

Inability to effectively deal with persons in need of treatment is not limited to the justice system.

For instance, studies show that primary and urgent care physicians treat a substantial number of

THE NATIONAL TREATMENT PLAN INITIATIVE

Source: Weisner (1999)

100%

80%

60%

40%

20%

0%

General 

Population 

(3069)

HMO

Primary

(314)

Public 

Primary

Health

(394)

Welfare

(621)

Mental 

Health

(406)

Jail

(1147)

Drug

Treatment

(307)

Alcohol

Treatment

(381)

5.5% 3.5%

12.7%

27.1%

43.6%

27.1%

83.0%

52.8%

Percent of Clients

Presenting with 

Drug Problems
11

individuals in need of substance abuse treatment (Join Together, 1998). Often health care providers

are unable to identify the treatment needs of their patients and are not linked into the appropriate

system to effectively guide patients into treatment.

The inter-system disconnect is also common between the mental health and substance abuse treatment systems. A joint report by the National Association of State Alcohol and Drug Abuse Directors

(NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD )

indicates that there are 10 million persons with at least one co-occurring mental health and substance

abuse-related disorder. Patients with mental, drug, or alcohol disorders appear in both systems and

often are missed or misdiagnosed (NASMHPD and NASADAD, 1999). Additionally, differences in

insurance coverage and differences in funding mechanisms between systems fuel the disconnect

between systems because diagnoses might not be covered from one payor to another.

There is also a substantial disconnect between the social service system and the substance abuse

treatment system. In the welfare system, caseworkers have limited clinical training and few standards for screening and assessing individuals who might be in need of treatment. This lack of training makes it difficult to identify patients who are in need of treatment, and nearly impossible to

ensure that they are referred into treatment (IOM, 1997a; National Association of Alcohol and Drug

Abuse Counselors [NAADAC], 1998).

Inter-system issues that contribute to the treatment gap are not limited to the inability of systems 

to identify and move individuals toward appropriate treatment. They also include the difficulty associated with transferring patient-specific information from one system to another. For systems to

interface effectively, they must share relevant data. Currently systems with overlapping clients often

do not exchange data. These systems frequently lack updated information systems, standard reporting requirements, and consistent and clear communication processes. The lack of collaboration and

communication between systems can be attributed to the territorial nature of some agencies and 

systems, whereas in other cases, conflicting or different organizational missions make collaboration,

even for the greater good, more difficult.

Another challenge associated with the effects of substance abuse that systems must address is the

impact of the problem on those not directly involved. Treatment tends to focus on the individual

experiencing problems and not on the families, friends, and others affected by the disorder who are

not actively involved in substance abuse. The Panel believes that the ability to work with children

and family members of the client is critical and must be considered by all systems interacting with

persons experiencing problems with alcohol or other drugs.

REPORT OF PANEL I
12

Changing the Conversation

C. RESOURCE ALLOCATION AND FINANCING

Resources as defined in this context include the financial, infrastructure, and other resources that

support and sustain the provision of substance abuse treatment. The adequacy of resources

addresses the amount of resources currently available in the system, and the effective use of

resources addresses the ability to use and deliver better results with limited funds. These financing

and resource allocation issues directly determine the ability of an individual to access treatment.

Despite the many factors that contribute to the gap, the Panel agrees with many in the field that

inadequate funding for substance abuse treatment is a major part of the problem. Over the last

decade, spending on substance abuse prevention and treatment has increased, albeit more slowly

than overall health spending, to an estimated annual total of $12.6 billion in 1996 (McKusick, Mark,

King, Harwood, Buck, Dilonardo, and Genuardi, 1998). Of this amount, public spending is estimated at $7.6 billion (McKusick, et al., 1998). The public spending includes dollars from Medicaid and

Medicare, as well as other Federal funds from the Department of Defense, the Department of

Veterans Administration, the Department of Justice, and the Substance Abuse Prevention and

Treatment (SAPT) Block Grant. The SAPT Block Grant provides Federal support to addiction 

prevention and treatment services nationally through State and local governments. Private spending includes individual out-of-pocket payment, insurance, and other nonpublic sources, and 

is estimated at $4.7 billion (McKusick, et al., 1998).

One of the main reasons for the higher outlay in public spending is the frequently limited coverage

of substance abuse treatment by private insurers. Although “70 percent of drug users are employed

and most have private health insurance, 20 percent of public treatment funds were spent on people

with private health insurance in 1993, due to limitations on their policy” (ONDCP, 1999b). In the

view of the Panel, private insurers should serve as the primary source of coverage, with public insurance serving as the safety net.

Despite the $12.6 billion spent on substance abuse treatment, the system possesses limited

resources. Several issues have an impact on the effective allocation of resources. Because financing

is not based on the effectiveness of programs, inefficient allocation and use of resources is common. Clients often enter treatment based on the geographic and financial factors that affect their

ability to access care. An individual’s course of treatment frequently is decided based on the program to which he or she has access rather than on his or her specific needs. Often a patient’s gender, culture, or other individual factors are not considered in the treatment plan. Thus, the needs

of special populations such as women, children, and minorities who require additional or different

services might not be addressed.

Not only are treatment resources limited, but eligibility requirements associated with different

Federal funding streams are often inconsistent, making funding somewhat inflexible. The Panel

THE NATIONAL TREATMENT PLAN INITIATIVE
13

believes that the stringency of these requirements enables ineffective methods for allocating

resources.

The Institution for Mental Disease (IMD) exclusion in Medicaid can be one such hindrance to treatment. The IMD exclusion, unless otherwise amended by a waiver, prohibits inpatient or residential

settings with more than 16 beds from using Medicaid dollars to cover that care. Through statutory

language and regulations promulgated by the Health Care Financing Administration (HCFA), no

residential facility that has more than 16 beds may receive reimbursement for alcohol and drug

treatment. However, effective financing and treatment for substance abuse and dependence requires

the flexibility to use residential care when needed.

Other issues related to resources that are affecting the treatment system — such as low resources 

relative to the number of clients treated, low wages, erosion of dollars per client, staff burnout, and

other provider issues — make it difficult to provide a full continuum of appropriate care. Further

exacerbating the gap is the poor condition of many structural facilities and the lack of resources

available to maintain or improve existing facilities or to build new ones (see Panel III Report).

D. QUALITY CARE AND OUTCOMES MEASURES

Substance abuse treatment lacks generally accepted standards of care and quality improvement protocols. Because care is frequently defined differently across different payors and providers, the care

provided might vary for the same diagnosis, making some courses of treatment ineffective. This

variation is compounded by cost reduction strategies of third-party payors that might affect clinical

decisions and drive treatment decisions. This situation often leads to the provision of care that does

not match the specific needs of the individual, and results in less effective treatment.

The lack of basic standards can also result in overuse and underuse of treatment. The Panel believes

that specific areas without generally accepted standards include screening and assessment and quality assurance. In a system in which the point of entry determines the type of treatment received,

the result of inconsistent screening and assessment approaches can be treatment that does not meet

individual needs. To provide effective care, the standards must be structured so that providers 

can identify the level of care necessary and match it with the correct provider possessing both the

resources and availability to treat the individual at the appropriate level of care. Currently the 

system does not require a set of standards across all types of providers within the system; until 

that is the norm, system inefficiencies that result in lower quality of care will persist.

In many cases, people experiencing problems with alcohol and/or drugs do not have access to the

appropriate level of care, and the care they do receive may fall short of their needs. A continuum of

care should include prevention, intervention, assessment, treatment, and maintenance. The general

unavailability of an adequate continuum of care is evident in the limited funding available for brief

REPORT OF PANEL I
14

Changing the Conversation

interventions, where the purpose is to screen and provide quick therapeutic interventions. Further,

the full continuum of care should include services needed by families and others affected by an individual’s substance abuse disorder.

IV. Themes from the Public Hearings

To ensure the incorporation of community perspectives in this effort, the Center for Substance

Abuse Treatment (CSAT) held six public hearings across the nation. More than 400 testimonies

were heard from individuals from 31 States and included representatives from the recovery community, State and local agencies, treatment providers, educators, and researchers.

Considerable testimony was presented around the need for an increase in funding to support the

improvement of treatment. These areas included: (1) services to individuals with co-occurring 

disorders, (2) treatment facilities (e.g., residential, long-term, women, youth, and hearing impaired

settings), and (3) wraparound services for clients and their families (e.g., education programs, independent living skills, vocational training). Additionally, the need for integration with other systems

such as primary care, child welfare, justice, and social services was often identified as critical.

Other testimonies expressed a need for:

• The development of a continuum of care;

• Parity for substance abuse treatment services;

• The system to be better equipped to address the diverse needs of its clients; and

• The consideration of treatment as an alternative to incarceration for non-violent offenders.

Panel members used the issues raised during the public hearings both to guide and to supplement

their areas of discussion.

THE NATIONAL TREATMENT PLAN INITIATIVE
15

V. Recommendations

To address these problems, Panel members developed a series of recommendations focusing 

on three areas: inter-system relationships, resource allocation, and quality care and 

outcome measures.

A. ACCESS AND INTER-SYSTEM LINKAGES

1. Develop a plan to create a nationwide expectation for alcohol and drug treatment such that no

matter where in the human services, health, or justice system an individual appears, his or her

alcohol or drug problem will be appropriately identified, assessed, referred, or treated.

This recommendation calls for a “no wrong door” approach to effective treatment. It requires that

there be access to treatment through all systems, regardless of point of entry, and that any treatment

provided meets specific standards of quality. Due to the nature of substance abuse disorders, individuals may present in many different venues. The goal for each system is to be able to refer clients

or provide effective treatment. Development of inter-system collaboration to maximize available

services and resources is critical to provision of effective treatment. Because it is impossible for all

systems to provide comprehensive effective treatment services, creation of integrated identification,

screening, referral, and care management processes is essential to successful treatment outcomes.

Panel members believe that there are three main strategies for the implementation of this 

recommendation: (1) CSAT should serve as the lead agency for developing the plan; (2) CSAT

should support the development of standards for treatment for those agencies outside the substance

abuse treatment system, provide technical assistance, facilitate intergovernmental links, and coordinate with the ONDCP and the Substance Abuse and Mental Health Services Administration

(SAMHSA) to promote implementation; and (3) protocols for providing evidence-based treatment

may be attached to State and local funding streams to ensure effective treatment, regardless 

of point of entry.

Discussion

The negative impact that substance abuse has on health, crime, employment, education, and 

every other facet of life speaks directly to the benefits of providing treatment to those experiencing

problems with alcohol or drugs. Treatment has been shown, among other things, to significantly

lower drug and alcohol use, lower healthcare costs, reduce crime, and increase productivity. Thus,

ensuring that the client experiencing problems with alcohol or other drugs receives treatment will

help that individual recover from his or her disorder and also produce results for all of these systems.

REPORT OF PANEL I
16

Changing the Conversation

The concept of maximizing access to allow for the effective provision of substance abuse treatment

is not new. The Panel reviewed a wide variety of reports and studies that emphasize the importance

of cross-system cooperation, and recognized that some progress has been made. Over the past several years, drug courts, health systems, schools, and social services programs have worked with the

substance abuse system to place individuals in treatment. However, the Panel found that efforts

have not been enough to overcome the competing forces that hinder access. For that reason, the

Panel recommends a specific plan and shared standards of treatment.

The Panel strongly believes that to assist individuals in entering effective treatment, all systems must

share a common approach to identifying the problem, assessing the nature of the problem, and

determining the most appropriate treatment. To determine the most appropriate treatment plan, it

is crucial that individuals conducting the screening understand the wide spectrum of options available. For this to happen, information must flow across systems.

For the no wrong door approach to be effective, each system must assume an appropriate level of

responsibility for individuals or patients experiencing problems with alcohol or other drugs. These

systems must ensure that their clients have access to and receive treatment. This requires that

providers in systems interfacing with substance abuse problems be trained, at a minimum, in the

identification of those in need of treatment. Because not all systems are able to provide treatment,

there should be explicit limits on what each system is expected to do with regard to substance abuse

treatment. These expectations should not exceed the responsibilities of each system; however, there

should be an expectation that other systems will serve as a bridge to move clients from their agency

to the substance abuse treatment system, when necessary.

At a minimum, all systems providing services to people experiencing problems with alcohol or 

other drugs should be able identify these problems; however, some systems can and should directly

provide some level of treatment. The effectiveness of this treatment is paramount; thus, treatment

must be held to specific standards, regardless of whether that treatment occurs within the specialty

treatment system or outside it. Standards for effective treatment are discussed further in

Recommendation Six.

A number of past recommendations have focused on specific systems that overlap with the treatment system. For example, a Join Together panel found that “a significant factor in ensuring access

to substance abuse treatment is its integration into health and mental health care systems.

Screening for, assessing, and intervening in substance abuse should be part of general medical and

mental health practice” (1998). The IOM has called for the integration of primary care, mental

health, and substance abuse treatment systems (IOM, 1996).

THE NATIONAL TREATMENT PLAN INITIATIVE
17

“Primary care and the alcohol and drug treatment systems have distinct areas of expertise, and better linkage and integration are desirable. It is important to recognize that treatment for alcohol and

drug abuse is, in itself, a cost-containment measure, since early prevention in alcohol and drug

problems may prevent the need for treating more costly medical complications. . . . NAADAC now

recommends that alcoholism and drug addiction treatment be fully recognized and integrated into

the medical, healthcare and public health systems” (NAADAC, 1999).

The large number of people who suffer from co-occurring disorders, substance abuse/dependence,

and mental illness creates a need for coordination between these treatment systems, which should

range from informal consultation to formal collaboration to service integration, depending on

severity of illness (NASMHPD and NASADAD, 1999).

As noted above, the justice system poses a significant inter-system issue for the substance abuse

treatment system, and several reports advocate expansion of comprehensive drug and alcohol treatment for individuals who are incarcerated (Legal Action Center, 1993; American Society of

Addiction Medicine [ASAM], 1994).

Several reports have recommended that overlapping systems share information to ensure comprehensive care. For example, the Department of Health and Human Services (DHHS) called for a 

lead agency, such as an “interagency coordinating body” to take responsibility for linking human

services providers together, and later expanded the recommendation to include the sharing of

information on values and perspectives by providers in overlapping systems to collaborate 

effectively (DHHS, 1991, 1996).

B. RESOURCE ALLOCATION AND FINANCING

2. Increase total resources available for substance abuse treatment (i.e., Federal, State, local, and

private) to reduce associated health, economic, and social costs.

The goal of the treatment plan must include the more effective allocation of current resources as

well as new resources to make more effective treatment accessible to a larger number of people who

experience and are affected by problems with alcohol or drugs. The Panel feels strongly that the 

substance abuse treatment system does not currently possess sufficient resources to provide effective

treatment for all who need and seek treatment and, therefore, strongly recommends that additional

resources be put into the system. The recommendation charges Federal, State, and private entities

with seeking additional resources from new sources and more efficiently using existing resources

through the redefinition of funding boundaries.

To implement this recommendation, additional funding mechanisms must be sought, or existing

resources must be made more readily available. This will require looking to government funds not

REPORT OF PANEL I
18

Changing the Conversation

usually tapped for substance abuse treatment, to private sources, and across systems to access 

additional financial resources. To maximize the use of current funding streams, additional flexibility is critical so that resources can be used across different social service systems to meet treatment

needs. For example, by increasing the benefits provided in the private sector (see previous recommendation) through parity and comprehensive coverage packages, the financial burden on public

programs might be alleviated, making more resources for medically indigent patients available 

within the public system. However, the Panel notes the importance of assuring that an increase in

resources in one sector is not followed by a decrease in resources in another; otherwise, the need 

for additional resources will never be met.

One of the major problems with financing care is that the restrictions and inconsistencies existing

across systems and programs hinder the effective use of resources. Various systems have different

eligibility requirements as well as multiple approaches for serving certain populations; this often

results in the provision of inconsistent types and levels of care. The IMD exclusion is a leading

example of how the restrictions associated with funding streams can create barriers to treatment.

It is important to note that the eligibility requirements, which make funding streams rigid, were

developed primarily to counteract the inadequacy of care available for particular populations.

Thus, providing adequate care for all populations will eliminate the need for such requirements.

Decreasing resources and improving allocation can achieve the goal of increasing the flexibility 

of funding streams, expanding resources for treatment and providing more effective 

treatment to more people.

Discussion

This recommendation is based on clear evidence that substance abuse treatment contributes to

recovery, helping individuals to improve health outcomes and reduce alcohol and drug use and

other undesirable activities. As a result of treatment, there are significant economic benefits to communities, employers, and the patients, and their families. Prior recommendations have advocated

increasing Block Grant resources to bolster the substance abuse treatment system, reallocating funds

from interdiction and incarceration to treatment programs for justice populations, and increasing

excise taxes for alcohol and tobacco. An IOM panel recommended an expansion of the public tier

and suggested focusing additional resources on increasing capacity and improving the quality of

services, facilities, and staff skills (ASAM, 1995; IOM, 1990b; Join Together, 1993; Legal Action

Center, 1993; NAADAC, 1986).

“The balance of resources devoted to combating these problems should be shifted from a 

predominance of law enforcement to a greater emphasis on treatment and prevention programs, as

well as programs to ameliorate those social factors that exacerbate drug dependence and its related

problems” (ASAM, 1994).

THE NATIONAL TREATMENT PLAN INITIATIVE
19

The Panel identified the need for additional resources to bolster the treatment system but did not

specifically recommend the sources. There was consensus, however, that other systems must also

assume responsibility for funding, that there exist other funding streams that can be tapped to

enrich the service delivery mechanism either for direct clinical services or other associated services.

Therefore, this recommendation targets those systems that interface with substance abuse treatment

in addition to entities and stakeholders who can best determine how to increase resources and make

them more flexible. These include legislators, third-party payors, State agencies, and communitybased organizations dealing with multiple funding streams. CSAT may work toward the goal of

this recommendation by using the Block Grant mechanism to make funding more coordinated and

flexible. It is important to note that for systems to benefit from flexible funding streams, different

systems must collaborate and be accountable for identifying and providing treatment to clients with

substance abuse problems.

3. Develop a standard insurance benefit for substance abuse treatment that provides for a 

full continuum of appropriate and continuing care to meet the needs of persons with 

substance abuse disorders.

The Panel recommends establishing comprehensive benefit packages to move toward closing the

treatment gap. The concept of parity, although not explicitly stated, is encompassed in this recommendation. Parity is the equal treatment by insurers and other payors of substance abuse treatment

in a manner that is consistent with the treatment of other medical conditions. Equal treatment with

other medical conditions is critical to the success of a mandated comprehensive insurance benefit

package. The goal of this recommendation is to establish a comprehensive insurance benefit on par

with benefits for other chronic illnesses, thus allowing for a full continuum of care.

Discussion

Current insurance benefit packages, both public and private, typically do not adequately cover substance abuse treatment. Many private and public (Medicaid and Medicare) insurance packages do not

cover specific services, are for a limited number of units of service with annual or lifetime caps, or

support limited or no continuing care. Further, the private sector takes no responsibility for those

who cannot afford treatment when insurance coverage is exhausted, forcing the use of public funds for

individuals with private insurance. Public resources, such as Medicaid and State substance abuse treatment systems that were originally intended to serve as a safety net, instead have become the primary

insurance option for many individuals in need of treatment. Additionally, government insurance

packages (specifically Medicaid) generally do not provide comprehensive treatment. For example,

under the IMD Exclusion criteria, people experiencing alcohol or other drug problems may not be

treated in a residential or inpatient setting with more than 16 beds. Such limited and often inconsistent coverage leads to inappropriate and insufficient care with less than positive outcomes.

REPORT OF PANEL I
20

Changing the Conversation

The standard benefit endorsed by this recommendation is also aimed at ensuring coverage based on

treatment needs rather than on economic feasibility. The Panel feels that given a certain diagnosis,

there is an ethical responsibility to ensure that the client is offered services accordingly. Specifically,

the provision of services should be based on clinical appropriateness and not on the allowances of

an insurance plan. Furthermore, the standard benefit should be designed such that there is no conflict between the clinically appropriate strategy and the allowances of the insurance plan.

Implementation of this recommendation will address inappropriate cost shifting that now occurs

between the private and public sectors in the substance abuse treatment system, eroding the quality

of care and effectiveness of treatment. This proposal will create a system where the private and public sectors work collectively to ensure that all individuals receive appropriate comprehensive care.

By providing coverage for a full continuum of care, standard insurance benefits will allow people

experiencing problems with alcohol or drugs to gain access to the appropriate level of care and continuing care as they progress through treatment.

NIDA recently developed a guide, Principles of Drug Addiction Treatment, that lists 13 principles 

of effective treatment, including the necessity of multiple episodes of care, readily available treatment, treatment matched to individual needs, treatment of adequate length, and treatment that

addresses multiple needs, not just drug use. These and the other principles in this guide must be

considered in the development of a standard insurance package designed to ensure access to 

a full continuum of care.

Several IOM committees have made previous recommendations regarding insurance coverage for

substance abuse treatment. Parity between coverage for substance abuse and dependence and other

illnesses has been the focus of many of these recommendations (IOM, 1990a, 1990b). However, recommendations have also focused on coverage for the full continuum of care, mandating employer

investment in benefit packages that include coverage for behavioral health problems, monitoring

private insurers and managed care plans, and altering Medicaid to address substance abuse treatment needs (IOM, 1990b, 1996, 1997b). Panels convened by many other organizations have recommended parity coverage that better coordinates public and private resources (ASAM, 1992; Join

Together, 1993, 1998; NAADAC, 1988, 1999).

The Panel suggests that CSAT should work with others to facilitate the implementation of this recommendation. For the recommendation to be successful, treatment professionals and organizations, such as the Health Insurance Association of America (HIAA), HCFA, and other third-party

payors, must work together and promote the improvement of coverage options. In addition, the

Block Grant and the provision of other funds from the Federal government should have the input of

family members and people in recovery to better serve people experiencing problems with alcohol

or other drugs. CSAT should facilitate efforts by the recovery community and other organizations

to develop a standard benefit that is complete and outlines a full continuum of care.

THE NATIONAL TREATMENT PLAN INITIATIVE
21

4. Provide sustained support to increase State and local capacity to identify, assess, determine,

and monitor need for treatment at the local/community level.

The Panel supports the devolution of planning for treatment from Federal to State and local levels

to enhance State and local capacity to conduct planning, surveillance, and resource allocation to

meet the specific needs of a geographic region. Although treatment need can be assessed most

effectively at State or local levels, states and localities often lack the necessary resources to monitor

treatment need and subsequently treatment services. As a result, people experiencing problems with

alcohol or drugs cannot gain access to appropriate care because their community is not sufficiently

equipped to meet the treatment needs of its residents. The ultimate goal of this recommendation is

to combat this phenomenon by providing sustained support to monitor treatment need.

Discussion

Currently CSAT is shifting funding from the State Needs Assessment Program to use of the National

Household Survey on Drug Abuse (NHSDA), which has become more comprehensive. The idea is

that the data from the NHSDA can be used to help determine the level of funding for substance

abuse treatment that should be allocated to each State. However, the Panel believes such data allow

only for comparisons between States and do not provide enough information to assess treatment

need to better allocate resources at the State, community, or local levels. To this end, States will 

continue to need support for determining treatment need within their borders.

Panelists also believe that it is important to examine the data currently being collected. Such data

collection should be based on scientifically valid sampling and collection techniques to obtain a 

better picture of community need. The current markers of substance abuse and treatment need

must also be expanded. Typically, the level of substance abuse-related crime is seen as the primary

indicator of substance abuse; however, there are many health consequences of substance abuse that

also indicate prevalence and need for treatment. Prevalence of hepatitis, HIV, cirrhosis, and other

associated illnesses must be treated as markers of substance abuse and treatment need.

Previous recommendations primarily have addressed the means by which communities might better

assess and meet residents’ treatment needs. In 1990, an IOM panel suggested adopting common

prevalence indicators to assess treatment need across geographic areas; expanding support of

health services research programs that currently investigate financing policy issues to provide sufficient data for resource allocation; and establishing and funding a full continuum of care in all

communities (IOM, 1990a).

This IOM panel concluded that, with a minimal level of funding, research committees could provide

the necessary data for planners and policymakers to use in the decision-making process for allocation of resources and choices among competing modalities and settings. They further suggested

REPORT OF PANEL I
22

Changing the Conversation

that State agencies be required to submit plans that analyze the conjunctions and mismatches

among the most current epidemiological information and known treatment capabilities; it also 

recommended that States be required to propose annual spending patterns that reflect this 

information (IOM, 1990a).

The Robert Wood Johnson Foundation’s report, Fighting Back Initiatives, provides an excellent

example of potential impact and benefits of community surveillance. In this initiative, a total of

14 communities engaged (or are currently engaging) in an effort to address substance abuse problems through a coordinated effort between public, private, and volunteer organizations. These communities work to identify and monitor indicators of substance abuse to reduce alcohol and drug

abuse and associated effects.

Certain data are important to make sound policy decisions. States and localities do not have the

resources to obtain and analyze data to accurately assess treatment needs and allocate resources

accordingly. To obtain these data, the Panel suggests collaborative funding through a partnership

among the ONDCP, the Centers for Disease Control (CDC), NIDA, NIAAA, and CSAT.

5. Organizations and payors that want to engage in delivery of services for substance abuse screening, assessment, and/or treatment should: (1) use evidence-based treatment protocols; and 

(2) continuously monitor quality of care (structure, process, and/or outcomes) using common

methods and measures adopted by the field through a consensual process. This should apply to

both public and private providers and payors operating in the substance abuse, primary health,

social service/welfare, justice, education, or other fields.

In the alcohol and drug treatment system, reimbursement generally is not tied (or is weakly tied) to

meeting specific quality or treatment standards. The goal of this recommendation is to tie the reimbursement eligibility to use of evidence-based practices rather than to cost reduction strategies.

The recommendation calls for specific types of reimbursement to be contingent on meeting certain

quality and treatment criteria. It would build a stronger framework for accountability in substance

abuse treatment if each provider controlled its ability to determine its level of reimbursement.

To be reimbursed for substance abuse treatment, providers would have to meet a set of previously

defined standards. Coordination with the CSAT Practice Research Collaborative programs and the

NIDA and NIAAA Research to Practice efforts will facilitate increased awareness and implementation of such evidence-based practices (see Panel IV Report).

This recommendation calls for the development of a series of tools to monitor quality in an ongoing

manner. Quality would be monitored based on both process and outcome data that would be continuously collected. Such standards must be promulgated through a consensual field-wide process.

When the tools have been developed, it will be important that they be updated regularly with the

evidence gained in the ongoing monitoring process.

THE NATIONAL TREATMENT PLAN INITIATIVE
23

Discussion

The Panel’s recommendation is based on a commitment, to be made by both provider and payor

organizations, to use evidence-based treatment practices. After developing the treatment strategies

providers must adopt them, while payors must uphold and adhere to these strategies in their reimbursement decisions. Payors should be monitored to ensure that payment patterns reflect a continued commitment to funding evidence-based treatment, while providers should be monitored to

ensured continued use of this treatment.

Some prior recommendations have touched on the development of accountability mechanisms that

would directly link quality to reimbursement. ASAM supports the use of ongoing treatment 

evaluations and case management, cost benefit, and outcome studies as an integral part of ongoing

evaluation of all substance use disorder services (ASAM, 1993). An IOM panel recommended the

linkage of outcomes research, performance standards, and accreditation to clinical practice guidelines (IOM, 1997b). Another panel recommended an expansion of the Federal government’s services research effort to establish the cost effectiveness of alternative strategies and models for treating

alcohol problems, and noted that studies of treatment effectiveness should not be undertaken without a consideration of the comparative cost effectiveness question (IOM, 1990a).

C. QUALITY CARE AND OUTCOMES MEASURES

6. Define and help support processes to reach cross-system consensus on evidence-based 

standards for quality of care and practices that apply to all systems and payors.

Currently the system lacks consensus on standards necessary to ensure that treatment plans are 

consistent and appropriate, regardless of where the individual enters the system. The lack of consistency across the substance abuse treatment system and other overlapping systems negatively impacts

the quality of the care provided.

This recommendation is aimed at addressing the need for agreed upon evidence-based standards

regarding the quality of substance abuse treatment. The goal is to achieve consensus on new or

existing standards and to assure that treatment strategies are consistent across providers, payors,

and systems and based on evidence-based practices. It calls for the development of standards to

guide substance abuse treatment, including practice protocols that are based on scientific and other

practice-related evidence. Standards relating to screening and assessment and quality measurement

are inherent in the development of cross-system standards for substance abuse treatment.

A key element of this recommendation is that the standards describing how to deliver all kinds of

substance abuse treatment across all systems of care must be further developed. A continuum of

care includes education; prevention; screening and assessment; brief intervention and treatment

REPORT OF PANEL I
24

Changing the Conversation

determined by client need, severity of addiction, and co-occurring health problems; and maintenance care. The successful implementation of standards can improve communication and treatment planning across systems.

Discussion

As funding per client has decreased, the substance abuse treatment system often has had to 

attempt to provide more effective treatment with the same or reduced amounts of resources. These

conditions make the establishment of minimum standards crucial. In this time of health cost containment, it is both necessary and possible to have better guidance for how treatment dollars will 

be used. A failure to accurately diagnose and match an individual to the appropriate treatment program is likely to compromise the success of the treatment, which in turn reduces cost effectiveness.

Because substance abuse disorders have a high rate of associated problems, ensuring that the treatment plan is the most appropriate plan available should reduce costs associated with the care and

minimize the possibility of repeat treatment. The Panel believes that establishing system standards

will lead to the provision of more coordinated appropriate care in a cost-effective manner so that

the system can deliver more effective treatment with the same level of resources.

There are a number of guidelines and protocols available; however, these previous and ongoing initiatives fall short of what the Panel recommends because there is no coordination or consistent use

of one protocol or standard, and not all of these standards are evidence-based. For example, ASAM

has taken the lead role in the development of practice guidelines; however, without agreement from

HCFA, primary care, or the justice system, these guidelines will be used inconsistently.

Lacking a consensus on standards, managed care and other third-party payors create their own standards for treatment. Reimbursement decisions, then, are based on these often idiosyncratic clinical

protocols, not necessarily on those that would best meet patient needs. Some managed care organizations (MCOs) develop artificial barriers to access and deny or delay treatment. These practices

must be curtailed. The development of treatment standards adhered to by both payors and

providers would make these practices more difficult to continue.

Concern about quality of care has sparked numerous recommendations over the years. For example, a 1998 recommendation from an IOM panel stated that:

“CSAT, in collaboration with State substance abuse authorities, professional organizations,

and consumer organizations in the addiction field should continue the development of evidencebased treatment recommendations (including considerations of short- and long-term outcomes) 

for use by clinicians of all disciplines involved in the treatment of drug and alcohol use disorders”

(IOM, 1998).

THE NATIONAL TREATMENT PLAN INITIATIVE
25

This supported a 1997 IOM report, Managing Managed Care, suggesting that the development of

clinical practice guidelines be linked to outcomes research, performance standards, and accreditation, noting that performance measures must be relevant to treatment processes and outcomes. A

previous recommendation had called for government agencies to conduct studies on the relationship between treatment approaches and patient needs (IOM, 1996). Other recommendations have

called for “national, uniform performance standards [that are] applied equally to public and private

organizations and systems” and “manageable, measurable and meaningful” performance measures

(NASADAD and the American Managed Behavioral Healthcare Association [AMBHA], 1998).

The panel also recognizes that a number of important initiatives have responded to these recommendations including CSAT’s Treatment Improvement Protocols (TIPs) and Technical Assistance

Publication Series (TAPS). Additionally, the Joint Commission on Accreditation of Health Care

Organizations (JCAHO) and the Commission on Accreditation of Rehabilitation Facilities (CARF)

have worked on accreditation standards for methadone clinics. NIDA has developed a researchbased guide, Principles of Drug Addiction Treatment, which lists 13 principles of effective drug treatment. The American Psychiatric Association (APA) and ASAM also have developed treatment

guidelines. ASAM, in particular, has developed patient placement criteria to ensure that patients are

matched to the appropriate level of care (ASAM, 1996). The Panel’s recommendation builds on and

extends this important work.

For this recommendation to be successfully implemented, many different groups must participate,

from government and private provider and payor organizations to research and teaching 

institutions. The Panel feels that CSAT could assist with the implementation of this recommendation by facilitating discussions and focus groups on this issue. Further, the Panel notes that 

CSAT should consider using the Block Grant as a vehicle to promote the development and use of

evidence-based standards.

7. Facilitate cross-system consensus on critical data elements to measure quality of care 

and treatment outcomes.

This recommendation seeks to expand the inter-system linkages previously discussed by identifying

outcome-specific data elements that can accurately capture the quality of care provided. Although

the effective use of assessment tools on intake is crucial, the focus of this recommendation is assessment during and after treatment with an emphasis on treatment outcomes. The charge of this recommendation is to develop a common set of data elements to measure and ultimately improve

treatment outcomes and enhance the quality of care.

This recommendation also calls for the development of assessment mechanisms that are uniform,

ongoing, and evolving and will account for case mix variances across providers. Such mechanisms

should be multidimensional and appropriate to specific settings and populations. A complete 

REPORT OF PANEL I
26

Changing the Conversation

measurement system should address structure, process, and outcomes. To implement this 

recommendation, CSAT can, in collaboration with others, fund the development and testing of

these data elements.

Discussion

This recommendation is necessary to measure quality consistently. The rising pressure from public

and third-party payors for more accountability for treatment and treatment outcomes is also an 

indicator of the need for ways to measure quality. In the course of developing standard tools for

screening and assessment and quality measurement, it is crucial to gain consensus from providers

and others involved in substance abuse treatment across the country. Consensus must ensure that the

tools are broad enough to account for particular demographic and other differences across settings.

It is widely accepted that there must be performance measurement and treatment outcome measurements for substance abuse treatment (ONDCP, 1999a). These concepts emphasize the need for

tools to monitor treatment and outcomes and predicate the effectiveness of the tools on their ability

to take into account ethnic and other population specific criteria.

Prior recommendations have addressed the importance of accounting for population characteristics,

monitoring quality of care, assessing the effectiveness of varying treatment mechanisms, and the 

use of consistent data and instrumentation (ASAM, 1996, 1993; NAADAC, 1992; NASADAD and

AMBHA, 1998). Plans that serve distinct populations should measure and evaluate the needs of

those groups through reviews of research literature, consumer surveys, and other appropriate 

mechanisms (IOM, 1997b). The same report also recommended that public and private purchasers,

consumers, providers, practitioners, behavioral healthcare plans, and accreditation organizations

continue to monitor and assess the quality of care.

A key element of monitoring is the determination of the length and intensity of treatment. For

example, a 1998 IOM report recommended that CSAT and NIDA develop mechanisms to enable

State policy makers to monitor service delivery in community-based treatment programs to determine if consumers receive services demonstrated as effective and to ascertain if the treatment dosage

and intensity are sufficient to be effective.

THE NATIONAL TREATMENT PLAN INITIATIVE
27

VI. Selected Bibliography

The sources listed reflect those used by the panel members based on the data current at that time.

Subsequent sources were not incorporated into the individual reports, but may be in the companion

report, Changing the Conversation, Improving Substance Abuse Treatment: The National Treatment

Plan Initiative.

American Society of Addiction Medicine, Patient Placement Criteria for the Treatment of SubstanceRelated Disorders (ASAM PPC-2), 2nd ed. (Chevy Chase, MD: The Society, 1996).

———, Public Policy Statement, Parity in Benefit Coverage (Chevy Chase, MD, ASAM, 1997)

Online, <http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, Federal Funding for Addiction Prevention, Treatment and

Rehabilitation. (Chevy Chase, MD, ASAM, 1995) Online, <http://www.asam.org/ppol/

pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, National Drug Policy (Chevy Chase, MD, ASAM, 1994) Online,

<http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, Persons with Alcohol and Other Drug Problems and Criminal Justice

System (Chevy Chase, MD, ASAM, 1994) Online, <http://www.asam.org/ppol/

pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, Core Benefit for Primary Care and Specialty Treatment and

Prevention of Alcohol, Nicotine and Drug Abuse and Dependence (Chevy Chase, MD, ASAM,

1993) Online, <http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, Addiction Medicine and Health Insurance Reform, (Chevy Chase,

MD, ASAM, 1992) Online, <http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999

American Society of Addiction Medicine and American Managed Behavioral Healthcare

Association, Public Policy Statement, Federal Funding for Addiction Prevention, Treatment,

and Rehabilitation (Chevy Chase, MD: ASAM/AMBHA, 1995) Online,

<http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

Bureau of Justice Statistics, “Characteristics of Adults on Probation, 1995,” NCJ 1164267, 1997,

Online, <http://www.ojp.usdoj.gov/bjs/>, Aug. 1999.

Center for Substance Abuse Treatment, Funding Resource Guide for Substance Abuse Programs, TAPS

No. 9 (Rockville, MD: DHHS, 1994).

REPORT OF PANEL I
28

Changing the Conversation

Culpepper Foundation and Robert Wood Johnson Foundation, Behind Bars: Substance Abuse and

America’s Prison Population (New York: The National Center on Addiction and Substance

Abuse at Columbia University, 1998).

Department of Health and Human Services, Comprehensive Case Management for Substance Abuse

Treatment, TIP No. 27 (Rockville, MD: DHHS, 1998).

———, Treatment Drug Courts: Integrating Substance Abuse with Legal Case Processing, TIP No. 23

(Rockville, MD: DHHS, 1996).

———, Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the

Justice System, TIP No. 21 (Rockville, MD: DHHS, 1995).

———, Coordination of Alcohol, Drug Abuse and Mental Health Services, TAPS No. 4 (Rockville,

MD: DHHS, 1991).

Dunn, C. W. and R. Ries, “Linking Substance Abuse Services with General Medical Care - Integrated

Brief Interventions with Hospitalized Patients,” American Journal of Drug and Alcohol Abuse

23(1), 1997. pp. 1–13.

General Accounting Office, Drug Abuse Treatment: Data Limitations Affect the Accuracy of

National and State Estimates of Need, Report No. GAO/HHS-98-229 (Washington, D.C.:

GAO/HHS, 1998).

Herman, M. and M. Gourevitch, “Integrating Primary Care and Methadone Maintenance

Treatment: Implementation Issues,” Journal of Addictive Diseases 16(1), 1997. pp. 91–102.

Institute of Medicine, Bridging the Gap between Practice and Research: Forging Partnerships with

Community-Based Drug and Alcohol Treatment (Washington, D.C.: National Academy 

Press, 1998).

———, Dispelling the Myths about Addiction: Strategies to Increase Understanding and Strengthen

Research (Washington, D.C.: National Academy Press, 1997a).

———, Managing Managed Care: Quality Improvement in Behavioral Health (Washington, D.C.:

National Academy Press, 1997b).

———, Pathways of Addiction: Opportunities in Drug Abuse Research (Washington, D.C.: National

Academy Press, 1996).

———, Broadening the Base of Treatment for Alcohol Problems (Washington, D.C.: National

Academy Press, 1990a).

THE NATIONAL TREATMENT PLAN INITIATIVE
29

———, Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and

Private Drug Treatment Systems Volume 1 (Washington, D.C.: National Academy Press,

1990b).

Join Together, Treatment for Addiction: Advancing the Common Good (Boston: Join Together,

1998) Online, <http://www.jointogether.org/sa/files/pdf/jtadvanc.pdf>, Aug. 1999.

———, Fixing a Failing System: How the Criminal Justice System Should Work with Communities to

Reduce Substance Abuse (Boston: Join Together, 1996) Online,

<http://www.jointogether.org/sa/>, Aug. 1999.

———, Health Reform for Communities (Boston: Join Together, 1993).

Legal Action Center, Blueprint for a New and Effective National Drug and Alcohol Strategy, Rev. ed.

(New York: LAC, 1993).

Levin, S.M and T. Pierce, The KOBA Institute: New Directions in Health Care Linkage, The U.S.

Monograph of Linking Primary Care, HIV/AIDS, Mental Health, and Substance Abuse

Treatment (Rockville, MD: DHHS/SAMHSA, 1997).

McKusick, D., T.L. Mark, E. King, R. Harwood, J.A. Buck, J. Dilonardo, and J.S. Genuardi, “Spending

for Mental Health and Substance Abuse Treatment, 1996,” Health Affairs 17(5), Sept./Oct.

1998. pp. 147–57.

National Association of Alcohol and Drug Abuse Counselors, Position Paper, Parity for Alcohol and

Drug Addiction Treatment (Arlington, VA: NAADAC, 1999) Online,

<http://www.naadac.org/0397pos.htm>, Aug. 1999.

———, Position Paper, Integrating Alcohol and Drug Abuse Treatment into the Medical and Public

Health System (Arlington, VA: NAADAC, 1998) Online,

<http://www.naadac.org/0498pos.htm>, Aug. 1999.

———, Position Paper, Managed Care and Public Sector Agencies (Arlington, VA: NAADAC, 1996)

Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Women’s Issues in Chemical Dependency (Arlington, VA: NAADAC, 1992)

Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Treatment on Demand (Arlington, VA: NAADAC, 1990) Online,

<http://www.naadac.org/pstnst.htm>, Aug. 1999.

REPORT OF PANEL I
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Changing the Conversation

———, Position Paper, Accessibility of Treatment by Certified Alcohol and Drug Abuse Counselors

(Arlington, VA: NAADAC, 1988) Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Equalizing of Excise Tax on Beer, Wine, and Distilled Spirits (Arlington, VA:

NAADAC, 1986) Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

National Association of State Alcohol and Drug Abuse Directors and American Managed Behavioral

Healthcare Association, Public Substance Abuse and Managed Behavioral Healthcare, 1998,

Online, <http://www.nasadad.org>, Aug. 1999.

National Association of State Mental Health Program Directors and National Association of State

Alcohol and Drug Abuse Directors, National Dialogue on Co-Occurring Mental Health and

Substance Abuse Disorders, 1999, Online,

<http://www.nasadad.org/national_dialogue_on.htm>, Aug. 1999.

National Institute on Alcohol Abuse and Alcoholism, Subcommittee on Health Services Research,

National Advisory Council on Alcohol Abuse and Alcoholism, Executive Summary,

Improving the Delivery of Alcohol Treatment and Prevention Services, NIH Publication No. 97-

4224 (Bethesda, MD: NIAAA/NIH/DHHS, 1997).

Office of National Drug Control Policy, The National Drug Control Strategy, 1999 (Washington,

D.C.: ONDCP, 1999a).

———, “Parity for Substance Abuse,” Memo, 1999b.

———, Treatment Protocol Effectiveness Study (Washington, D.C.: ONDCP, 1996).

———, The National Drug Control Strategy, 1995 (Washington, D.C.: ONDCP, 1995).

Pikoff, Howard B., Treatment Effectiveness Handbook (Buffalo, NY: Data for Decisions, 1996).

Sciacca, K. and C. M. Thompson, “Program Development and Integrated Treatment across Systems

for Dual Diagnoses: Mental Illness, Drug Addiction, and Alcoholism,” Journal of the Mental

Health Association 23(3), 1996. pp. 288–97.

Substance Abuse and Mental Health Services Administration, Office of Applied Studies, Summary 

of findings from 1998 National Household Survey on Drug Abuse, 1998, Online,

<http://www.samhsa.gov/oas/nhsda/98summhtml/toc.htm>, Aug. 1999.

Weisner, C., “The Distribution of Drug Users Across Health, Social Service, Criminal Justice and

Other Sectors of the Community.” Report presented at the second panel meeting of Domain

I: Closing the Treatment Gap, Tyson’s Corner, VA, July 1999.

THE NATIONAL TREATMENT PLAN INITIATIVE
31

VII. Participants PANEL MEMBERS

Henrick J. Harwood (Chair)

Vice President

The Lewin Group

Falls Church, VA

Steven P. Amos, D.Crim.

Deputy Director

Office of Justice Programs

Corrections Program Office

Washington, DC

Mary Lou Andersen

Consultant

Health Resources Services Administration 

Bethesda, MD

James F. Callahan, D.P.A.

Executive Vice President and CEO

American Society of Addiction Medicine 

Chevy Chase, MD

John Coppola

Executive Director

Alcoholism and Substance Abuse

Providers of New York State

Albany, NY

Marc Galanter, M.D.

Department of Psychiatry

NYU Medical Center

Division of Alcohol and Drug Abuse

New York, NY

The Honorable Richard S. Gebelein

Associate Judge

Delaware Superior Court

Daniel L. Hermann Courthouse

Wilmington, DE

Suzanne Gelber, Ph.D.

President 

SGR Health, Ltd.

Berkeley, CA

Irma Gonzales

Consultant

Sieta del Nortè

Community Development Corporation 

Embudo, NM

Janice Ford Griffin

Deputy Director

Join Together

Boston, MA

Michael Harle, M.H.S.

President and Executive Director

Gaudenzia, Inc.

Norristown, PA

Jerome H. Jaffe, M.D.

Clinical Professor of Psychiatry

University of Maryland

Towson, MD

Nolan E. Jones, Ph.D.

Group Director

Human Resources Group

National Governors Association

Washington, DC

David C. Lewis, M.D.

Director

Center for Alcohol and Addiction Studies

Brown University

Providence, RI

Gloria J. Merk

Deputy Director

Program Operations Division

Alcohol and Drug Programs

State of California

Sacramento, CA

Constance Pechura, Ph.D.

Senior Program Officer

Robert Wood Johnson Foundation

Princeton, NJ

The Honorable Toddy Puller

Legislator

State of Virginia

Mt. Vernon, VA

REPORT OF PANEL I
32

Changing the Conversation

Mayra Rodriguez-Howard, M.S.W.

Director

Bureau of Substance Abuse Services

Massachusetts Department of Public Health

Boston, MA

Ian M. Shaffer, M.D., M.M.M.

Executive Vice President

Quality and Outcome Strategies

ValueOptions 

Falls Church, VA

Ronald Simeone, Ph.D.

Simeone Associates, Inc.

Albany, NY

Richard Spence, Ph.D.

Director of Research 

Texas Commission on Alcohol 

and Drug Abuse

Austin, TX

Flo Stein

Chief

Substance Abuse Services

Division of Mental Health, Development 

Disabilities, and Substance Abuse Services

Department of Health and Human Services

Raleigh, NC

Ronald White, M.D.

Program Director

Project New Life

Jamaica Plain, MA

Ronald Williams

President and CEO

New York Therapeutic Communities, Inc.

Stay ‘N Out

New York, NY

Robert A. Wilson, Ph.D.

Director

Health Services Policy Research Group

School of Urban Affairs and Public Policy

University of Delaware

Newark, DE

CSAT STAFF (ROCKVILLE, MD) 

Mady Chalk, Ph.D.

Director

Office of Managed Care

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community

Assistance

Herman Diesenhaus, Ph.D.

Public Health Analyst

Office of Evaluation, Scientific Analysis 

and Synthesis

Joan Dilonardo, Ph.D.

Social Science Analyst

Office of Managed Care

Thomas Edwards, Jr.

Branch Chief

Organization of Services Branch

Division of Practice and Systems

Development

THE NATIONAL TREATMENT PLAN INITIATIVE
33

STEERING GROUP

John Gregrich

Chief

Treatment Research Branch

Office of Demand Reduction

Executive Office of the President

Office of National Drug Control 

Policy 

Washington, DC

Melody Heaps

President

Treatment Alternatives for Safe

Communities 

Chicago, IL

CONSULTANTS: THE LEWIN GROUP 

(FALLS CHURCH, VA)

Dianne Faup, J.D.

Senior Manager

Errol Fields

Research Analyst

PANEL MEETING SPEAKERS 

AND CONTRIBUTORS

John Allen, Ph.D.

National Institute on Alcohol Abuse 

and Alcoholism

Bethesda, MD

Peter B. Edelman, LL.B.

Professor of Law

Georgetown University Law Center

Washington, DC

John French, M.A.

Research Consultant

Gaithersburg, MD 

Constance Weisner, Dr.P.H.

Professor

Department of Psychiatry 

University of California, San Francisco

Berkeley, CA

Terry Zobeck, Ph.D.

Chief

Programs and Research Branch

Office of Programs, Budget, Research 

and Evaluation

Office of National Drug Control Policy

Washington, DC

REPORT OF PANEL I

Changing the Conversation

Report of Panel II:

Reducing Stigma and

Changing Attitudes

35

REPORT OF PANEL II

THE NATIONAL TREATMENT PLAN INITIATIVE

THE NATIONAL TREATMENT PLAN INITIATIVE

Changing the Conversation

37

REPORT OF PANEL II

Table of Contents

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

II. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

A. Definitions of Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .42

B. Individual Experiences with Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .43

C. National Efforts to Reduce or Prevent Stigma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D. Public Opinion Research on Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .45

E. Formal Approaches to Reducing Stigma and Changing Attitudes . . . . . . . . . . . . . . . . . . . . . . . .46

F. Previous Recommendations Addressing the Reduction of Stigma and Change in Attitudes . . . .48

III. THEMES FROM THE PUBLIC HEARINGS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

IV. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

V. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

VI. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
38

Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

“We envision a society where people who are addicted to alcohol or other drugs, people in recovery

from addiction, and people at-risk for addiction are valued and treated with dignity; and where

stigma, accompanying attitudes, discrimination and other barriers to recovery are eliminated. We

envision a society where addiction is recognized as a public health issue — a treatable disease for

which individuals should seek and receive treatment; and where treatment is recognized as a specialized field of expertise.”

— The Panel’s Vision Statement 

I. Executive Summary

Dependence on alcohol or other drugs is often not understood to be a disease. Similarly, people in

recovery from addiction often suffer degradation and discrimination because many do not understand that these individuals have overcome a disease and are not “bad people” or “immoral” or

“weak-willed.” This stigma can cause ostracism, shame, and even denial of life’s necessities — such

as employment and a place to live - for which the person in recovery is fully qualified and deserving.

Changing the Conversation initiated the first intensive exploration of the stigmas and attitudes 

that affect people with alcohol and drug problems. The Panel addressed stigma as a powerful,

shame-based mark of disgrace and reproach that impedes treatment and recovery. Prejudicial attitudes and beliefs generate and perpetuate stigma; therefore, people suffering from alcohol and/or

drug problems and those in recovery are often ostracized, discriminated against, and deprived of

basic human rights. Their families, treatment providers, and even researchers may face comparable

stigmas and attitudes. Ironically, stigmatized individuals often endorse the attitudes and practices

that stigmatize them. They may internalize this thinking and behavior, which consequently

becomes part of their identity and sense of self-worth.

Stigma often causes people to lose self-esteem and confidence in their ability to seek treatment and

remain in recovery, to obtain and maintain employment, and to trust the systems intended to assist

them. The stigma, whether internal or external, ultimately hinders an individual’s ability to participate fully in society.

Public support and public policy are influenced by addiction stigma. Addiction stigma delays

acknowledging the disease and inhibits prevention, care, treatment, and research. It diminishes the

life opportunities of the stigmatized.

Society tends to group all individuals with substance abuse problems, which prevents them from

being seen as individual human beings worthy of treatment. An individual convicted of a crime

who also has an alcohol or other drug addiction must receive adequate treatment. In sum, people
39

at risk for, suffering from, or in recovery from alcohol or other drug addiction come in all “shapes

and sizes,” regardless of gender, race, ethnicity, sexual orientation, religious affiliation, socioeconomic status, and geographic locality. All people should have access to appropriate treatment.

The Panel’s recommendations are based on four themes that emerged from the Panel’s deliberations

and consideration of the eloquent testimony provided in the public hearings: (1) conduct sciencebased marketing research; (2) launch a social marketing plan; (3) build the capacity of the recovery

community; and (4) encourage the respect and rights of people at risk for, suffering from, or in

recovery from alcohol or other drug abuse. The development of a common language among criminal justice, mental health, and substance abuse communities and specifically, the replacement of

“substance abuse” with an alternate term or phrase, for example, “addiction” was suggested during

several hearings.

One complication in establishing a national strategy to reduce stigma and change attitudes is that persons who are addicted or in recovery are perceived by many people in the larger society to have caused

their illness. However, recent studies suggest that more persons believe that addiction is a medical condition and that those suffering from the illness should receive professionally indicated treatment.

The Panel proposes a four-point approach for the substance abuse field to reduce the stigmas and

change attitudes about people at risk for, in need of treatment for, or in recovery from alcoholism

and drug addiction. Family, significant others, support networks, and allies are also included in this

model, which comprises the following recommendations:

1. Conduct science-based marketing research (i.e., polling, surveys, focus groups) to provide the basis

for a social marketing plan. This effort should begin with a language audit to determine problems

or opportunities inherent in the language currently used in the field and in public discussions.

2. Based on the results of the marketing research and language audit, develop and implement a

social marketing plan designed to change the knowledge, attitudes, beliefs, and behavior of

individuals and institutions to reduce stigma and its negative consequences. One goal of the

plan should be to develop a commonly accepted, clearly worded taxonomy to describe alcoholism and drug addiction and the treatment and services available.

3. Facilitate and support grassroots efforts to build the capacity of the recovery community to

participate in the public dialogue about addiction, treatment, and recovery.

4. Promote the dignity of and reduction of stigma and discrimination against people in treatment

or in recovery from alcohol or other drugs by encouraging the respect for their rights in a manner similar to people who have suffered from and overcome other illnesses.

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Changing the Conversation

The Panel is particularly concerned about the effect of overlapping and compounding stigmas associated with alcoholism and drug addiction. The stigmas experienced by an individual may vary

based on the substance used or the treatment provider. Demographic factors may increase the likelihood and degree of stigma, such as: race, ethnicity, gender, age, religion, employment status, geography, disability, sexual orientation, education, position/profession, lineage, and criminal justice status. The Panel strongly believes that these factors influence human behavior and the extent and

degree to which people suffering from addiction will be stigmatized. The relationship among these

conditions also affects how and why a particular substance is used, the specific substance(s) used,

and which treatment interventions prove to be most effective. Additionally, these demographic factors also affect which treatment and prevention messages and which methods create responses.

II. Understanding the Problem

The National Treatment Plan Initiative (NTP) presented the first opportunity for a concerted exploration of the stigmas and attitudes that affect people with alcohol or drug problems and therefore

affect efforts to provide treatment. To provide a context for changing the conversation, the Panel

explored the types of stigmas and attitudes faced by individuals at risk for, suffering from, or in

recovery from alcohol and/or other drug addiction. A review of relevant literature provided the

basis for the Panel’s discussion of the following issues:

• Definitions of stigma;

• Individual experiences with stigma;

• National efforts to reduce or prevent stigma;

• Public opinion research on addiction;

• Formal approaches to reducing stigma and changing attitudes; and

• Previous recommendations addressing the reduction of stigma and change in attitudes.

The stigma of addiction, like that associated with severe mental illness, physical disabilities, such as

blindness or paraplegia, and physical illnesses such as HIV/AIDS, cancer, and Alzheimer’s disease,

“strikes with a two-edged sword” (Corrigan and Penn, 1999). The first blow is the disease, which is

a chronic relapsing medical condition with a complex set of symptoms. The second blow is the 

stigma associated with the disease of addiction, which is often as debilitating as the disease.

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Addiction stigmas subject individuals to various forms of discrimination in a variety of institutions,

such as:

• Criminal/juvenile justice,

• Education,

• Employment,

• Housing,

• Health,

• Insurance, and

• Human services.

The Panel agreed that there is no proven strategy for reducing stigma and affecting and changing

attitudes directed toward people at risk for, suffering from, or in recovery from alcohol or other

drug addiction. Stigma is a long-standing problem that has been addressed by persons with different perspectives using various approaches.

Efforts have been made to reduce stigmas in various arenas including civil and human rights, health

care, education, and environmental protection. Social psychologists, health professionals, counselors, law enforcement officials, policymakers, and media professionals have striven to reduce 

stigmas and change attitudes in the public interest. The roots of stigma are deep, stemming from

ancient civilization.

The Panel does not believe that the stigma reduction recommendations cited will eliminate addiction stigma or that they will reduce stigma and change attitudes overnight. Change is an evolutionary process. By using the tactics outlined, though, the general public and target audiences will begin

to learn that the disease of addiction is a relapsing medical condition for which proper treatment

and a continuum of care are required. The Panel anxiously awaits the time when the disease of

addiction is no longer treated as a criminal justice issue, but as a public health problem. Moreover,

the Panel embraces the notion of a society that enables any individual with a substance abuse problem, regardless of criminal history, to receive treatment in a safe and respectful environment. The

Panel hopes to create a climate in which people who are at risk for, suffering from, or in recovery

from alcohol or other drug addiction are valued and treated with dignity.

The Panel hopes that by beginning to change the conversation around the stigma and attitudes associated with the substance abuse field, so too, will the stereotypes about the disease of addiction 

REPORT OF PANEL II
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Changing the Conversation

change. Persons who are addicted or in recovery will play a central role in educating the public

about this disease. They will help to create “an environment of respectability and compassion

for...people who suffer...from the disease and those who care about them.” The Panel believes that

their four recommendations will build and strengthen linkages within and among stakeholder 

communities, organizations, and institutions. Last, the Panel aspires that implementation of these 

recommendations will bring the Nation closer to realizing its potential as a stronger, fairer, healthier

society, as indicated in the Panel’s vision statement:

We envision a society where people who are addicted to alcohol or other drugs, people in recovery

from addiction, and people at-risk for addiction are valued and treated with dignity; and where

stigma, accompanying attitudes, discrimination and other barriers to recovery are eliminated. We

envision a society where addiction is recognized as a public health issue, a treatable disease for

which individuals should seek and receive treatment; and where treatment is recognized as a 

specialized field of expertise.

A. DEFINITIONS OF STIGMA

The Greeks coined the term stigma to refer to “bodily signs designed to expose something unusual and

bad about the moral status of the signified.” Today, stigma generally connotes ignominy, a discrediting

effect, an “undesired differentness” (Goffman, 1963). There are three general categories of stigmas:

• Abominations of the body: various physical deformities;

• Blemishes of individual character: weak will, domineering, deviant passions, distorted beliefs,

and dishonesty, evidenced by, for example, substance abuse, alcoholism, mental disorder, prostitution, imprisonment, or suicidal tendencies; and

• Tribal stigma: race, religion, nationality and gender (Goffman, 1963).

In all three types of stigma, the same sociological features are found:

“An individual who might have been received easily in ordinary social intercourse possesses a trait

that can obtrude itself upon attention and turn those of us whom he meets away from him, breaking the claim that his other attributes have on us. He possesses a stigma, an undesired differentness

from what we had anticipated.... [W]e believe the person with a stigma is not quite human. On

this assumption we exercise varieties of discrimination, through which we effectively, if often

unthinkingly, reduce his life chances” (Goffman, 1963).

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43

Different fields have adapted working definitions of stigma based on recurring themes. For the purposes of this report, the Panel adopted a five-point definition of stigma:

• The stigma of alcohol or other drug addiction is a powerful, shame-based mark of disgrace 

and reproach.

• Prejudicial attitudes and beliefs generate and perpetuate stigma.

• The result is discrimination directed at individuals at risk for, suffering from, or in recovery from

addiction to alcohol or other drugs, and those associated with them.

• People suffering from alcohol or other drug addiction and those in recovery are ostracized,

discriminated against, and deprived of basic human rights.

• Often, individuals who are stigmatized internalize such attitudes and practices, making them 

part of their identity.

B. INDIVIDUAL EXPERIENCES WITH STIGMA

Substance abuse treatment approaches are based on underlying assumptions and viewpoints regarding the individual, the substance used, and the treatment modality. Stigma is associated with certain

treatment programs, such as methadone maintenance. Varying degrees of stigma are also related to

substance choice, for example, crack cocaine versus powder cocaine; alcohol versus prescription medication. The addict is also stigmatized and often disqualified from full social acceptance. The addict,

in many regards, is viewed as predatory and parasitic. However, the addict is not a monolith.

Society tends to group together all individuals with substance abuse problems, which prevents them

from being seen as individual human beings worthy of treatment. An individual convicted of a crime

who also has an alcohol or other drug addiction must receive adequate treatment. In sum, people at

risk for, suffering from, or in recovery from alcohol or other drug addiction come in all “shapes and

sizes,” regardless of gender, race, ethnicity, sexual orientation, religious affiliation, socioeconomic 

status, and geographic locality. All people should have access to appropriate treatment.

Research suggests that whereas all persons who are addicted or in recovery are stigmatized, some are

stigmatized more than others. More specifically, women, persons of color, youth, the elderly, the

poor and the dually diagnosed (i.e., individuals with co-occurring psychiatric and substance related

disorders) are more prone to be stigmatized than others with addictive disorders. Consequently,

these population groups represent a small percentage of those who actually seek and/or remain in

treatment. The Panel acknowledges that these persons and others who are addicted or in recovery

need and deserve customized care.

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Changing the Conversation

C. NATIONAL EFFORTS TO REDUCE OR PREVENT STIGMA

The Panel, based on the professional experience of its members and outside sources, discussed what

other tools health and human service-related fields used to combat stigma and prejudicial attitudes.

In the mental health field, government and non-governmental organizations as well as advocacy

groups have used various strategies to reduce the effect of stigma on persons with severe mental 

illnesses. These strategies include protest, education, and contact (Corrigan and Penn, 1999). In 

the field of HIV/AIDS, a variety of strategies have been used to reduce the stigma associated with

this disease, for example, public information campaigns grounded in message-based persuasion,

and legislative and regulatory advocacy (Devine, Plant, and Harrison, 1999). The Civil Rights

Movement of the 1960s used an entire armamentarium of devices to reduce stigmas and change

attitudes about racial and ethnic minorities: constituency building,1 public education, protest,

legislative and legal advocacy, and contact (Corrigan and Penn, 1999).

Upon analyzing activities within the substance abuse field, the Panel discovered that most organized

efforts undertaken to reduce stigma and change attitudes have been in the prevention arena, especially through the Center for Substance Abuse Prevention (CSAP). Primarily, these initiatives are

aimed at discouraging youth from using alcohol, other drugs, tobacco, inhalants, and preventing

driving while under the influence of alcohol. However, the Panel believes that these prevention

strategies also can sometimes actually increase the stigma experienced by people at risk for, addicted

to, or in recovery from alcohol or other drug problems.

Similarly, the Office of National Drug Control Policy (ONDCP) has instituted a specific prevention

goal to educate and enable America’s youth to reject illegal drugs as well as alcohol and tobacco

(ONDCP, 1999). This strategy recognizes that families and communities forge values, attitudes, and

behaviors of youth and that they must be positively influenced. To this end, the Strategy includes:

Objective 1: Educate parents or other caregivers, teachers, coaches, clergy, health 

professionals, and business and community leaders to help youth reject 

illegal drugs and underage alcohol and tobacco use.

Objective 10: Support and highlight research, including the development of scientific 

information, to inform drug, alcohol, and tobacco prevention programs 

targeting young Americans.

Although to date no specific recommendations have been advanced nationally for reducing stigmas

and changing attitudes associated with addiction, a new objective in development under ONDCP’s

National Drug Control Strategy 2001 focuses on reducing stigma.

THE NATIONAL TREATMENT PLAN INITIATIVE

1 The Civil Rights Movement organized The Coalition of Conscience — a broad and diverse group of individuals and associations including the faith community, organized labor, women’s organizations, community-based organizations, professional, social, fraternal and Greek Letter organizations.
45

D. PUBLIC OPINION RESEARCH ON ADDICTION

One complication in establishing a national strategy to reduce stigma and change attitudes is that

persons who are addicted or in recovery are perceived by many people in the larger society to have

caused their illness, unlike persons with other illnesses. However, recent public perception research

regarding people addicted to alcohol or other drugs and people in recovery offers reason for 

cautious optimism. Poll data suggest that today, more persons are aware that someone they know

and care about is suffering from an addiction. More persons believe that addiction is a medical

condition and that those suffering from the illness should receive professionally indicated treatment.

As part of the Panel deliberations, members reviewed the paucity of existing public opinion research

conducted to date. Such findings available on drugs, alcohol, and addiction reported:

• Sixty-nine percent knew a friend or acquaintance with an alcohol or other drug problem.

Fifty percent indicated that there is a problem in their family (Hazelden, 1999).

• Fifty-seven percent described “drug abuse” as an extremely or quite serious problem in their

community. Fifty-one percent indicated that “alcohol abuse” is extremely or quite serious 

(The Field Institute, 1998).

• Ninety-six percent strongly agreed that treatment should be available to all persons who need it,

although only twenty-four percent characterized treatment as very effective (Hazelden, 1999).

• Seventy-three percent reported believing that addiction is a disease (Hazelden, 1999).

• Fifty-three percent viewed drug abuse as a public health problem best handled by prevention and

treatment programs, rather than a crime problem best handled by the criminal justice system

(Drug Strategies, 1995).

• Fifty percent favored requiring drug users to enter court-supervised treatment rather than jail

(Drug Strategies, 1995).

Additionally, news accounts are helping to increase public awareness about the disease of addiction.

A September 9, 1999 Wall Street Journal article summarized the findings of an annual household

survey conducted by the Department of Health and Human Services (DHHS).2 The survey found,

most notably, that:

• Seven of ten people who used illegal drugs in 1997 had full-time jobs.

REPORT OF PANEL II

2 “Report Finds 70% of Illegal-Drug Users Hold Full-Time Jobs, Dispelling Stereotype.”
46

Changing the Conversation

• Young adults, men, whites, and those with less than a high school education were more likely to

use drugs than other workers.

The general lack of data suggests the need for a greater understanding about the chronic relapsing

nature of the disorder of addiction. Panel members also identified the general public’s lack of confidence in substance abuse treatment. Whereas the above data are far from definitive, they indicate

that the public has grown more empathetic to addicted persons and treatment over the years.

The empathy may be grounded in part in the realization that substance abuse crosses racial, ethnic,

gender, and socioeconomic sectors. The empathy may be rooted in the increase in public information about the disease of addiction and persons who are addicted or in recovery. The data also 

suggest the need for greater public awareness about the etiology of the disease of addiction and the

effectiveness of treatment.

The data and a review of stigma reduction efforts in other fields led the Panel to conclude that 

providing greater information to the stigmatized, those who stigmatize, the public at large, and

those who affect the perceptions of the public, such as policymakers and the media, should be a central component of any stigma reduction effort. Education must not be the sole component of the

stigma reduction strategy. Education can help change attitudes and break down some barriers to

understanding the disease of addiction. Advocacy is needed to create an environment that will 

likely change behaviors. Data indicate that new information may change attitudes, but will likely 

not change behaviors.3, 4

E. FORMAL APPROACHES TO REDUCING STIGMA AND CHANGING ATTITUDES

The Panel considered a range of models to determine the best approach to reduce stigma and

change attitudes about persons at risk for, suffering from, or in recovery from addiction to alcohol

or other drug addiction and those associated with them. The approaches considered include: public service campaigns (PSCs); comprehensive community-based health communications campaigns;

“strategic media” or “media advocacy”; and social marketing.

PSCs can be one effective component of an overall public health mass media campaign. They can

increase public recognition of a problem and establish it as a primary concern (Drug Strategies,

1995). A sponsoring organization can be positioned as an agent of change by PSCs. For example,

by adding a hotline number, callers can get additional information about a public health problem,

legislative and regulatory action relating to the problem, and ways to obtain more information

THE NATIONAL TREATMENT PLAN INITIATIVE

3 Some suggest that attitude change follows, rather than precedes, behavioral change (NIAAA, 1995). Those who subscribe to this school of thought postulate, for example,

that a change in a law, policy or practice may prod a change in attitude by inducing behavioral change. Research on the cognitive dissonance effect supports this position.

4 Other respected social psychologists share the views of Corrigan and Penn, Krauss, and Petty that attitude-behavior relationships are not bivariate but, rather, are multivariate. As such, changing attitudes/beliefs will not necessarily result in changing behaviors.
47

(Drug Strategies, 1995). An effective PSC also provides information to bolster public receptivity to

initiatives announced through press conferences and other vehicles (Drug Strategies, 1995). PSCs

can generally raise awareness about public health concerns and contribute to attitude changes. PSCs

focus on a general audience to increase awareness or motivate personal behavior. However, standing

alone, they have not been found to affect behavior.

Comprehensive community-based health communications campaigns that include the mass media

are proven to be effective in changing attitudes in several public health areas, including alcohol and

tobacco (National Institute on Alcohol Abuse and Alcoholism [NIAAA], 1995). They have been

used successfully to disseminate knowledge. However, these campaigns have been less effective in

changing health-related behavior. When behaviors are ingrained, more intensive instruction is

needed to foster a change in the behavior. A strategy “that encourages the learner’s active participation and provides corrective feedback” will likely be most effective (NIAAA, 1995).

Media advocacy is “the strategic use of mass media to advance a social or public policy initiative”

(Advocacy Institute, 1992). It seeks to promote a paradigm shift from the traditional public service

announcements relied on by many organizations to a more proactive approach. Media advocacy

focuses on the social, political, and economic environment of a causative factor in health problems.

It advances policy solutions to the problems. Media advocacy gives communities a voice with which

to define problems and promote policy solutions. Media advocacy seeks to shift the focus of the

media from unhealthy behavior of particular individuals to policy approaches and changing the

environment. It integrates a variety of methods to reduce stigmas and change attitudes, taking

advantage of “multiple entry points” to “raise the salience of issues on the Nation’s legislative and

public policy agenda” (Advocacy Institute, 1992). Media advocacy tactics include: conducting 

scientific research (focus groups, polling); identifying messages, themes, and symbols; building

coalitions; coordinating media activities; and taking advantage of economies of scale by sharing

technology and research (Advocacy Institute, 1992).

Social marketing is the application of commercial marketing technologies to the analysis, planning,

execution, and evaluation of programs designed to influence the voluntary behavior of target audiences in order to improve their personal welfare and that of their society” (Enoch, Rohrbaugh, Davis,

Harris, Ellingson, Andreason, Moore, Varner, Brown and Eckardt, 1995). It is also designed to promote “involuntary change” for example, by law, regulation, or administrative fiat in the public interest

or among target audiences. Social marketing has grown out of an understanding that people will not

necessarily change or adopt behaviors simply because they are provided information. People need to

be persuaded to act, often by reducing barriers that prevent the desired behavior or offering incentives to change their attitudes and behaviors (Academy for Educational Development, 2000). Social

marketing also recognizes that the environment (i.e., government regulation, social norms, processes

and procedures) in which individuals make behavioral decisions often needs to change as well.

To ensure change and measurable success, social marketing has become a multifaceted process that

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Changing the Conversation

includes research, program planning, design, execution, and evaluation. Research drives the planning

process, allowing program designers to create programs that focus on target audiences with carefully

developed messages. Social marketing campaigns use multiple tactics for change including coalition

building and network development techniques, mass media vehicles, interpersonal delivery systems,

and other commercial marketing technologies and advocacy strategies.

F. PREVIOUS RECOMMENDATIONS ADDRESSING THE REDUCTION OF STIGMA

AND CHANGE IN ATTITUDES

The Panel resolves that the stigma reduction tactics ultimately used should be grounded in established principles and models based on findings from previous efforts to promote voluntary behavior

change to improve personal or public welfare. Some of these ideas are briefly noted here.

• Stigma reduction requires a long-term commitment to creating change. Changing norms,

values, and policies is a complex undertaking that may require years to accomplish, as evidenced

by the evolution of changes in tobacco use (Hahn, Charlin, Sussman, Dent, Manzi, Stacy, Flay,

Hansen and Burton, 1990).

• The behavior change theories should be applied directly to the problem. Social learning and

communication theories can provide the necessary structure for developing interventions that

move people from awareness to skill development to behavior change to behavior maintenance

(Mok, Laing, and, Farquhar, 1984; Flora, Maiback, and Maccoby, 1989).

• Apply the consumer orientation of social marketing, which uses a consumer perspective,

to develop, package, and implement interventions, with an emphasis on consumer benefits

(Lefebvre and Flora, 1988). Audience segmentation, channel analysis, presenting, and 

other types of formative research are necessary to develop an effective campaign 

(Atkin and Freimuth, 1989).

• Using multiple channels of mass communication is the best strategy for reaching the intended

audience. Television tends to be considered the final product of media campaigns, but depending on the audience, it may be the least effective and least economic approach. Reinforcing the

message through various communication channels can enhance the message and better ensure

that the target population is reached (Atkin and Arkin, 1990).

• Strategically using entertainment and news programming will provide more exposure for the

topic. Several advocacy groups have been effective in inserting their message into prime-time

entertainment programming. Sometimes groups can use “social problem” or “disease of the

week” television movies to increase audience exposure to their particular topic. Other groups

have been able to promote news stories that give their topics added exposure (NIAAA, 1995).

THE NATIONAL TREATMENT PLAN INITIATIVE
49

Taken together, previous experience and studies suggest the following approaches may be effective.

• Stimulating interpersonal communication will increase the likelihood of behavior change by

reinforcing the message and supporting the expected change. Taking steps such as purchasing

media time and space will ensure that the intended audience is exposed to the campaign. Other

strategies include working with local media outlets to encourage them to sponsor the campaign,

thus giving it higher visibility. For some issues, corporate sponsorship might be appropriate.

• Media strategies should be linked with community-based programs. Virtually every mass media

campaign that has shown any evidence of success has been supplemented with community-based

programs. The most effective and sustained campaigns include coalition- and capacity-building

programs. Using media alone, except in rare situations, is unlikely to produce a positive effect.

• The mass media can focus attention on social, economic, and cultural factors that affect health

behavior. Changing individual behavior may be necessary, but insufficient, to stimulate improvements in health status. Alcohol, tobacco, and nutrition groups are increasingly shifting attention

to broader social factors as part of the prevention and social change process.

• Public affairs strategies need to be integrated with public policy strategies because changing

behavior sometimes requires changing laws and policies. In these instances, media and advocacy

activities should be designed to change the laws and policies necessary to prod behavioral change.

• Finally, process evaluation should be used by program managers to judge how well their intervention is being delivered to the intended audience. Outcome evaluation will let managers know

if planned key goals and objectives are being met.

Building on these ideas and the models used for stigma reduction and attitude change in other

fields, the Panel developed a four-point model for reducing the stigmas and changing the attitudes

associated with addiction and recovery. This model is described in more detail in the

Recommendations (see Section IV of this Panel report).

III. Themes from the Public Hearings

As part of the National Treatment Plan Initiative, The Center for Substance Abuse Treatment convened six public hearings to gather input from a broad and diverse group of stakeholders about

ways in which to improve the availability, accessibility, and quality of substance abuse treatment

services and outcomes. More than 400 people participated in the public hearings.

At the NTP public hearings, witnesses from across the country testified about the effect of compound stigmas on specific groups. A diverse group testified about their experience with stigma, and

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Changing the Conversation

its effect on them or their family member, significant other, or friends seeking and/or remaining in

treatment. The following examples provide a sense of the range of experiences:

• Older adults: Masks signs of addiction as part of the aging process.

• Women: Prevents them from having their gender-specific treatment needs met.

• Gays, lesbians, bisexuals, and transsexuals: Prevents them from having their unique treatment needs met.

• Youth, especially African American and Latino youth: Results in numbers of these young persons

receiving “time” rather than treatment for non-violent, drug-related crimes; prevents them from

being placed in post-incarceration programs to reintegrate them into schools, vocational/technical

training programs, families, and/or a job.

• Dually diagnosed individuals with mental illness and substance abuse problems: Leads to improper

medical treatment, inadequate human services, homelessness, and incarceration.

• Children of persons in recovery or suffering from addiction: Hinders their ability to make friends,

excel in school, obtain and retain employment.

• Persons in drug sub-cultures and second and third generation addicts: Creates multiple barriers to

these persons receiving adequate and appropriate treatment.

• Persons living in rural areas or on reservations: Face unique geographic and cultural 

barriers to treatment.

Multiple and overlapping stigmas need to be addressed by considering the effect of race, ethnicity,

gender, socioeconomic status/class, and compounding medical conditions (HIV/AIDS, cancer, mental health conditions). Consensus emerged that the public should be educated about the disease of

addiction. To put a human face on the disease of addiction, the recovery community must play a

key role in changing attitudes toward people in recovery, addiction, and substance abuse treatment.

People in recovery should serve as role models/examples of the success of treatment. The unique

treatment needs of specific populations (e.g., Native Americans, older adults, women, children and

adolescents, drug subcultures, second- and third-generation addicts and children of parents in

recovery) also should be recognized. Last, the classification of addiction as a disease should be

reflected in legislation, regulatory, and administrative changes.

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51

IV. Recommendations

The impetus behind these recommendations lies at the crux of the language that is used in everyday

vernacular. The Panel laments that the words society uses are stigmatizing, from which prejudicial

knowledge, attitudes, and beliefs stem. Therefore, the Panel incorporates a language audit and taxonomy development for the substance abuse field in its first two recommendations, respectively.

1. Conduct science-based marketing research (i.e., polling, surveys, focus groups) to provide the

foundation for a social marketing plan.

The Panel recommends that the initial step in the process of reducing the stigmas and changing the

attitudes about people with alcohol or other drug addiction, people in or seeking recovery and their

families, significant others, support networks, and allies, must be to conduct science-based marketing research, which should begin with a “language audit” to identify terms that contribute to stigma

and negative attitudes. This research is needed to provide baseline data and benchmarks for the

development and implementation of a social marketing plan that includes a language audit.

Discussion

The Panel proposes that this recommendation be implemented through a public/private partnership

catalyzed by CSAT with other Federal and nongovernmental organization participants and stakeholders. More specifically, the Panel recommends that the research should be: (1) conducted by 

relevant independent, external experts; (2) recognize relevant representational and diversity issues

including race, ethnicity, gender, age, culture, sexual orientation, disability, socioeconomics, and

geography; and, (3) acknowledge individual experiences with and the effect of addiction on the 

people with alcohol or other drug addiction and people in or seeking recovery and their families,

significant others, and allies, as well as treatment providers and researchers.

Implementation of this recommendation should begin immediately in order to gather baseline data

upon which to design, pre-test, execute, and evaluate a social marketing plan. Ongoing tracking of

the implementation of this Panel’s recommendations should be an integral component of implementation plan in order to evaluate the outcomes of the interventions. Monitoring should continue

for at least one full year after the implementation plan is completed to obtain the best evaluative

data on the effect of the interventions.

The impetus for this recommendation is the paucity of science-based market research about the

current knowledge, attitudes/beliefs, and attitude-driven behaviors about and toward people in or

seeking recovery and their families, significant others, support networks, and allies. Only piecemeal

research about the size of the market and the demographic details exists. No current baseline upon

which to measure a reduction in stigma and/or changes in attitudes is available. The proposed 

REPORT OF PANEL II
52

Changing the Conversation

science-based marketing research would provide the basis upon which to design, conduct, and 

evaluate the social marketing plan proposed in Recommendation Two.

2. Based on the results of the marketing research, develop and implement a social marketing plan

designed to change the knowledge, attitudes, and beliefs of individuals and institutions to

reduce stigma and its negative consequences.

The Panel recommends that a social marketing plan should be developed and implemented using

the science-based marketing research obtained in the implementation of Recommendation One,

above. Additionally, the language audit conducted as part of Recommendation One will be used to

develop a taxonomy, or clear categorization for substance abuse and addiction. Social marketing is a

program planning process designed to promote voluntary behavior changes in target audiences by

reducing barriers people face, using persuasion, and creating a demand for the desired outcome.

The proposed social marketing plan would use coalition-building and network development techniques, mass media vehicles, interpersonal delivery systems, other commercial marketing technologies and advocacy strategies to create a climate that supports increased treatment funding and

acceptance of people in or seeking recovery and their families, significant others, support networks,

and allies.

Discussion

CSAT and a range of stakeholders and associations should be involved in the planning, funding,

implementation, and analysis phases of this recommendation. Many groups will play a role in the

implementation: the recovery and treatment communities, faith communities, policymakers, educators, criminal and juvenile justice officials, community-based associations, labor unions, human services organizations, health professionals, mental health professionals, and civil rights organizations.

Communications experts, social psychologists and the Panel embrace three prevailing schools of

thought on reducing stigmas and changing attitudes:

• Stereotypes, prejudice, and discrimination are beliefs, attitudes, and attitude-driven behaviors

that will change when people’s attitudes change.

• Attitude-behavior relationships are not bivariate, but multivariate and therefore, changing 

attitudes/beliefs will not necessarily result in changing behaviors.

• Attitude change follows rather than precedes behavior change.

The social marketing plan recommended by the Panel should include features that incorporate all

three schools of thought.

THE NATIONAL TREATMENT PLAN INITIATIVE
53

The Panel recognizes social marketing as an effective way to “influence the voluntary behavior 

of target audiences in order to improve their personal welfare and that of their society” (Enoch, et.

al., 1995). The social marketing plan should be designed to combine mass media, interpersonal,

and community organization approaches to change behaviors. The plan should involve a broad

consortium of grassroots organizations in a bottom-up effort to reduce stigma and change attitudes.

An attendant result will likely be the strengthening of the addiction constituency and communitybased leadership.

The science-based research obtained in Recommendation One will dictate the design and approach

of the social marketing plan. However, the Panel recommends consideration of at least the following tactics:

• Identify and acquire necessary resources to implement the plan.

• Design and execute a public education campaign.

• Develop a more active and public recovery community. Highlight success stories of recovering

people and their families in an effort to put a human face on addiction and recovery.

• Use biological and scientific data that demonstrate that addiction is a disease — a relapsing 

medical condition for which proper treatment and a continuum of care are required.

• Develop and use an identifiable campaign theme.

• Build third party coalitions.

The social marketing plan should include public education and advocacy campaigns. The public

education campaign should promote voluntary behavior change based on the delivery of targeted,

accurate messages about alcohol or other drug addiction; people in or seeking recovery and their

families, significant others, support networks, allies and/or treatment providers; and other addiction

health care and human services workers. The advocacy campaign should build a grassroots network

to change the attitudes of key decisionmakers and elected officials.

3. Facilitate and support grassroots efforts to build the capacity of the recovery community to

participate in the public dialogue about addiction, treatment, and recovery.

The Panel recommends that the coalition building of the recovery community will occur simultaneously with the implementation of Recommendations One and Two. The tools (i.e., surveys, focus

groups, and network development) developed and used for each of these recommendations serve 

as a basis for capacity-building of the recovery community at the local and grassroots levels.

REPORT OF PANEL II
54

Changing the Conversation

Discussion

The Panel suggests that this recommendation be implemented by a coalition that may include the

private sector, foundations, faith organizations, corporate funders, purchasers of health care,

education institutions, people in recovery, family members affected by addiction, communitybased organizations, and professionals in the field. Government agency involvement in the implementation of this recommendation will be limited to enable this effort to devolve fully and flourish

at the local level.

The coalition created for the implementation of this recommendation should conduct activities

such as the following:

• Create tools, toolboxes, message and educational materials, and guidelines to establishment

grassroots organizations and conduct stigma reduction education campaigns.

• Partner with community-based, non-profit organizations and professional associations to 

co-sponsor a national planning conference.

• Convene three consecutive national annual forums to create opportunities for people who are

at-risk for, suffering from, or in recovery from alcohol or other drug addiction, and those associated with them to network and organize. These forums should mirror in microcosm what the

Panel did in macrocosm.

• Encourage and support community-based non-profits to conduct regional public education 

conferences to enhance existing groups and encourage the establishment of new groups.

• Continue to provide economic and technical support to local recovery groups.

• Provide funding and technical support to grassroots organizations comprised of people in 

recovery and their family members. This would include providing materials, peer mentoring,

training, networking opportunities, and communications assistance; and convening conferences.

The Panel believes that implementation of this recommendation would: increase stakeholder

involvement; broaden the base of involvement in the support network; increase the credibility of the

movement; strengthen the bonds among the stigmatized population; and build a collaborative

structure for the recovery community to network and organize.

Implementation of this recommendation should begin immediately and continue until an apparent

need for a public dialogue on addiction, treatment, and recovery no longer exists. The Panel proposes this recommendation in the hope of establishing an organized, visible, and vocal constituency

that carries the message of addiction recovery to targeted audiences and the general public.

THE NATIONAL TREATMENT PLAN INITIATIVE
55

4. Promote the dignity and reduction of stigma and discrimination against people in treatment

for or in recovery from alcohol or other drug addiction by encouraging the respect for their

rights in a manner similar to people who have suffered from and overcome other illnesses.

The Panel strongly believes that the rights defined for people in recovery in two Federal Acts, the

Americans with Disabilities Act (ADA) and Rehabilitation Act represent the model for all laws, policies, and practices. In other words, individuals with a history of addiction should be treated the

same as other persons, including others with a history of a disability. This model successfully 

balances public and private rights by simultaneously prohibiting discrimination against those persons with a history of disability who are qualified, and providing no protection to individuals whose

history of disability renders them unqualified.

Discussion 

The ADA and Rehabilitation Act, and the State and local laws based on these Acts, have been very

effective in protecting many people in recovery from discrimination without compromising other

social interests. The two acts have either directly or indirectly enabled thousands of people 

in recovery, including those in treatment, to obtain jobs, housing, human services, health care,

and other necessities.

Despite the great progress achieved by these laws, and by similar policies enacted in much of the

private sector, stigma and discrimination against people in recovery, including those in treatment,

remain all too prevalent. The Panel recommends that CSAT convene a broad and diverse coalition

to implement this recommendation. This coalition should include persons in the recovery community, public officials and policymakers, health opinion leaders, mental health opinion leaders, treatment providers, health and human services officials, journalists/media, research scientists, educators

and training professionals, clergy and faith organizations, organized labor, business leaders, civil

rights attorneys and organizations, foundations, and other advocates in related areas.

The Panel believes that implementing this recommendation will:

• Reduce labeling/stereotyping.

• Recognize that individuals with addictive disorders have the same rights as others with a history

of disability.

• Acknowledge the disease of addiction as a public health issue.

• Empower people in recovery who are still stigmatized to maintain recovery and enjoy the full

benefits of society.

REPORT OF PANEL II
56

Changing the Conversation

• Encourage people with addictive disorders to seek treatment by reducing the fear of discrimination.

• Expand substance abuse treatment options.

• Make laws, policies, and practices more consistent with the Federal Americans with Disabilities

Act and Rehabilitation Act; and consequently, promote more effective and cost-efficient 

national policies.

This recommendation should be implemented immediately and continuously until a reduction in

the disparate treatment of people with addictive disorders is achieved.

Dependence on alcohol or other drugs is often not understood to be a disease. Similarly, people 

in recovery from addiction often suffer degradation and discrimination because many do not understand that these individuals have overcome a disease and are not “bad people” or “immoral” or “weakwilled.” This stigma can cause ostracism, shame, and even denial of life’s necessities — such as

employment and a place to live — for which the person in recovery is fully qualified and deserving.

The Panel believes that laws, policies, and practices inconsistent with the requirements of the Federal

Americans with Disabilities Act and Rehabilitation Act: (1) encourage, promote, and foster prejudicial attitudes and beliefs as well as discriminate against individuals in recovery from alcohol or other

drug addiction; (2) deter diagnosis and entry into treatment; and (3) deprive persons in recovery of

basic human rights. The focus of this recommendation is to combat discrimination and stigma

against people in treatment or in recovery from alcohol or other drugs. This recommendation does

not address laws, policies, and practices related to current addiction to alcohol or other drugs.

The proposed recommendation is designed to induce change in behaviors and, in turn, lead to a

positive shift in public attitudes and beliefs about persons in the recovery community. The recommendation is targeted to policymakers, regulators, judges and other law enforcement officials, corporations, medical education officials, continuing medical education (CME) certification officials,

and medical licensing authorities.

THE NATIONAL TREATMENT PLAN INITIATIVE
57

V. Selected Bibliography

The sources listed reflect those used by the panel members based on the data current at that time.

Subsequent sources were not incorporated into the individual reports, but may be in the companion

report, Changing the Conversation, Improving Substance Abuse Treatment: The National Treatment

Plan Initiative.

Advocacy Institute, Media Strategies for Smoking Control Guidelines (Washington, D.C.: NIH, 1992)

p. 262.

Atkin, C. and E. Arkin, “Issues and Initiatives in Communicating Health Information,” in Mass

Communication and Public Health: Complexities and Conflicts, C. Atkin and L. Wallack, eds.

(Newbury Park, CA: Sage, 1990) pp. 13–40.

Atkin, C. and V. Freimuth, “Formative Evaluation Research in Campaign Design,” in Public

Communication Campaigns, 2nd ed., R. Rice, and C. Atkin, eds. (Newbury Park, CA: Sage, 1989).

Corrigan, P. W. and D. L. Penn, “Lessons from Social Psychology on Discrediting Psychiatric

Stigma,” American Psychologist. 54(9), 1999. pp. 765–76.

Devine, P.G., Plant, E.A., and Harrison, K. “The problem of ‘us’ versus ‘them’ and AIDS stigma,”

American Behavioral Scientist. 42(7), 1999. pp. 1212–28.

Drug Strategies, “Americans Look at the Drug Problem”, Peter D. Hart Public Opinion Surveys.

Washington, D.C.: Drug Strategies. 1995.

Enoch, M. A., J.W. Rohrbaugh, E.Z. Davis, C.R. Harris, R.J. Ellingson, P. Andreason, V. Moore, J.L.

Varner, G.L. Brown, and M.J. Eckardt. “Relationship of Genetically Transmitted Alpha EEG

Traits to Anxiety Disorders and Alcoholism,” American Journal of Medical Genetics. 60(5),

1995. pp. 400–8.

Field Institute, The, California Wellness Foundation’s Health Improvement Initiative. 1998.

Sacramento, CA: The California Wellness Foundation.

Flora J. A, E.W. Maibach, and N. Maccoby, “The Role of Media across Four Levels of Health

Promotion Intervention,” Annual Review of Public Health. 10, 1989. pp. 81–201.

Goffman, E., Stigma: Notes on the Management of Spoiled Identity. Englewood Cliffs, NJ: Prentice

Hall. 1963.

REPORT OF PANEL II
58

Changing the Conversation

Hahn, G., V.L. Charlin, S. Sussman, C.W. Dent, J. Manzi, A.W. Stacy, B. Flay, W.B. Hansen, and W.

Burton. “Adolescents’ First and Most Recent Use Situations of Smokeless Tobacco and

Cigarettes: Similarities and Differences,” Addictive Behaviors. 15(5), 1990. pp. 439–48.

Hazelden National Overnight Poll. Center City, MN: The Hazelden Foundation. February 1999.

Lefebvre, R.C. and J.A. Flora, “Social Marketing and Public Health Intervention,” Health

Education Quarterly. 15(3), 1988 Fall. pp. 299–315.

Mok J.Y., I.A. Laing, and J.W. Farquhar, “Young Diabetics: Memories, Current Lifestyles and

Attitudes,” Diabetes Medicine. 1(3), Sept. 1984. pp. 227–30.

National Institute on Alcohol Abuse and Alcoholism, Monograph-28 The Effects of the Mass Media on

the Use and Abuse of Alcohol. Rockville, Maryland: DHHS. 1995.

Office of National Drug Control Policy, The National Drug Control Strategy, 1999. (Washington,

D.C.: ONDCP, 1999).

Personal communication, Gregory Niblett, Senior Vice President, Academy for Educational

Development, March 13, 2000.

THE NATIONAL TREATMENT PLAN INITIATIVE
59

VI. Participants PANEL MEMBERS

Sue Thau (Co-Chair)

Public Policy Consultant 

Community Anti-Drug Coalitions 

of America 

Washington, DC

Andrea G. Barthwell, M.D. (Co-Chair)

President 

Encounter Medical Group, P.C.

Oakland Park, IL

Johnny W. Allem

Director of Operations

Commission on Mental Health Services

Washington, DC

John L. Avery, LCSW, M.P.A.

Cambridge and Somerville Program

for Alcohol Rehabilitation

Boston, MA

Jeffrey Blodgett, M.P.A.

Coordinator

The Alliance Project

St. Paul, MN

George R. Bloom, M.A.

Past President

Johnson Institute Foundation

Minneapolis, MN

Alpha Estes Brown, Ph.D., J.D., D.Min.

Chair

‘Cause Children Count Coalition

Washington, DC

June Gertig, J.D.

Project Director

Recovery Community Support Program

Technical Assistance Project

Health Systems Research

Washington, DC

Amalia Gonzalez del Valle, M.S.W., M.P.H.,

LCSW

Program Manager

Contra Costa Community Substance 

Abuse Service

Martinez, CA

Patricia D. Hawkins, Ph.D.

Associate Executive Director

Whitman Walker Clinic

Washington, DC

Benjamin A. Jones, M.S.W., C.S.W.

President and CEO

National Council on Alcoholism and

Drug Dependence, Inc.

Greater Detroit Area

Detroit, MI

Judi Kosterman, Ed.D.

Director

National Center for the Advancement 

of Prevention

Washington, DC

Chris Koyanagi 

Policy Director

Bazelon Center for Mental Health Law

Washington, DC

Henry C. Lozano

President and CEO

Californians for A Drug Free Youth, Inc.

Big Bear City, CA

Donald Masters, J.D.

Chairman

National Partnership for Recovery 

and Prevention

Denver, CO

Carol McDaid

Senior Vice President

R. Duffy Wall and Associates, Inc.

Washington, DC

REPORT OF PANEL II
60

Changing the Conversation

Kevin E. McEneaney

Executive Vice President

Phoenix House Foundation

New York, NY

Lisa Nan Mojer-Torres, Esq.

Civil Rights Attorney

Lawrenceville, NJ

Dennis Moore, Ed.D.

Associate Professor 

Department of Community Health

Director, Substance Abuse Resources 

and Disability Issues

Rehabilitation, Research, and Training 

Center on Drugs and Disability

Wayne State University

Kettering, OH

William Cope Moyers

President

Johnson Institute Foundation

Minneapolis, MN

Stacia Murphy

President

National Council on Alcoholism and Drug 

Dependence, Inc.

New York, NY

Gregory R. Niblett

Senior Vice President

Social Development Programs

Academy for Educational 

Development

Washington, DC

Lynn M. Paltrow, J.D.

Director

National Advocates for Pregnant Women

New York, NY

Kim Peck

Interim Director

Illinois Alcoholism & Drug 

Dependence Association

Springfield, IL

Lynn D. Powers, M.S.M.

Vice President 

Dreamcatchers, L.L.C.

West Mystic, CT

José A. Rivera, J.D.

President and CEO

Rivera, Sierra & Company, Inc.

Brooklyn, NY

Charles R. Schuster, Ph.D.

Director

Substance Abuse Research Division

Department of Psychiatry and 

Behavioral Neuroscience

Wayne State University School of Medicine

Detroit, MI

Harold Tarbell

President

National Association for Native American 

Children of Alcoholics

Ontario, Canada

Carol Tracy

Executive Director

The Women’s Law Project

Philadelphia, PA

THE NATIONAL TREATMENT PLAN INITIATIVE
61

CSAT STAFF (ROCKVILLE, MD)

Jutta Butler

Public Health Advisor

Division of Practice and Systems 

Development

Marjorie M. Cashion, M.S.W.

Executive Secretary

CSAT National Advisory Council

George Gilbert

Director

Office of Policy Coordination and Planning

Catherine D. Nugent, M.S.

Public Health Advisor

Division of State and Community 

Assistance

Ivette A. Torres, M.Ed., M.S.

Director

Office of Communications and 

External Liaison

STEERING GROUP

Paul N. Samuels, Esq.

Director and President

Legal Action Center

New York, NY

CONSULTANTS: THE LEWIN GROUP

(FALLS CHURCH, VA)

Lezli Baskerville, J.D.

Senior Manager

Christina Hughes

Associate

PANEL MEETING SPEAKERS AND

CONTRIBUTORS

A number of outside experts provided wise

counsel and technical assistance at various

stages of the panel process. We deeply appreciate the support and assistance of the following persons:

Matthew Johnson, Ph.D.

Professor

John Jay College

Benny Primm, Ph.D.

Addiction Research and Treatment Corp.

Brooklyn, NY

Wade D. Nobles, Ph.D.

Executive Director

Institute for the Advanced Study of

Black Family Life & Culture

San Francisco State University

San Francisco, CA

REPORT OF PANEL II

Changing the Conversation

63

REPORT OF PANEL III

THE NATIONAL TREATMENT PLAN INITIATIVE

Report of Panel III:

Improving and Strengthening

Treatment Systems

Changing the Conversation

65

Table of Contents

I. EXECUTIVE SUMMARY. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

II. PROFILE OF THE CURRENT TREATMENT SYSTEM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67

A. Facilities and Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67

B. The Client Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68

C. Quality of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69

D. Effectiveness of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .70

E. Role of Government . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71

III. UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

A. Treatment Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73

B. Financing and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74

C. Management and Business Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76

IV. THEMES FROM THE PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

V. RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

VIII. APPENDIX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

THE NATIONAL TREATMENT PLAN INITIATIVE

REPORT OF PANEL III
66

Changing the Conversation

I. Executive Summary

Substance abuse disorders affect a wide range of individuals from all walks of life, and involve the

use of various substances ranging from alcohol to illicit drugs. Substance abuse is a recurring 

disorder that affects the individual’s medical/physical, psychological, and social functions. Because

the disorder itself is highly complex, the system that has evolved to treat it is equally complex. The

philosophy guiding the Panel’s deliberations was that the core of successful treatment must be the

client and the client’s needs.

The specialty substance abuse sector is a comparatively new and diverse system that has developed

in relative isolation from other health and human services systems over the past 30 years. The proliferation of diverse community-based organizations (CBOs) around the country, most of which are

mission driven and focused on a single basic program of care, is a result of the evolution of the system. Today’s diverse treatment system can be characterized as a group of organizations providing

culturally sensitive care in program or service-based settings with limited financial resources. This

report highlights some of the system’s strengths while also identifying some problems, including:

• Treatment planning that is program based rather than client centered;

• Inconsistent use and application of available tools to match client need to treatment;

• Insufficient financial resources;

• Changing payor relationships and insufficient reimbursement; and

• Inadequate management skills and inconsistent business practices.

Panel members believe that to effect change, the following recommendations should 

be implemented:

1. Treatment plans should be based on an individual’s needs and should respond to changes in

need as he or she progresses through stages of treatment. Evidence-based practices should

guide screening, intervention, assessment, engagement, individual and group therapies, aftercare, and relapse prevention so that the individual enters at an appropriate level of care,

becomes engaged in services, and progresses through a continuum of care.

2. Reimbursement mechanisms should be aligned with treatment goals and should incorporate

performance measures and outcome standards to guide resource allocation as well as rates sufficient to cover both reasonable costs and a surplus to support reinvestment.

THE NATIONAL TREATMENT PLAN INITIATIVE
67

3. Treatment programs, payors, and regulators should promote organizational cultures that

improve the quality, effectiveness, and efficiency of services through the adoption of best business practices for program management and operations. These should include effective governance and leadership for the board of directors and senior management; management and

operation of human resources, marketing, and finance; information and data management

operating systems; and capital and facilities.

These three recommendations comprise the framework that the Panel believes is essential to

improve and strengthen substance abuse treatment systems.

II. Profile of the Current Treatment System

Many diverse organizations throughout the country provide substance abuse treatment, using 

various approaches in outpatient, inpatient, and residential settings. Both providers and government agencies generally focus on either alcohol or drug problems. Frequently treatment programs

have been established to provide a specific program or service to a designated population. The end

result is a system in which no two organizations are alike and the approaches to treatment are as

diverse as are the providers.

A. FACILITIES AND SERVICE

According to the Substance Abuse and Mental Health Services Administration (SAMHSA) Uniform

Facility Data Set (UFDS), there were approximately 10,800 treatment facilities in the United States

in 1997. More than 80 percent of those treatment facilities were private organizations (not-forand for-profit). The remainder comprised government-owned Federal, State, and local entities.

However, public funds pay for nearly two-thirds of all treatment. Due to organizations’ limited

capacity and access to resources, more than 75 percent of facilities serve fewer than 100 clients.

Based on their available resources, most organizations are able to provide only a limited array of

services. Nearly two-thirds of all facilities provide outpatient, non-methadone services, making this

the most common form of care (Horgan and Levine, 1998) (see Figure III.1). About 17 percent of

the facilities are residential, while only three percent of all facilities have inpatient units. Most of

these facilities, although collectively covering a wide range of services, do not provide a full continuum of care. Individual therapy, comprehensive assessment, and group therapy are the most common

services offered. Maintenance services such as family counseling, aftercare, and relapse prevention

are offered in almost all facilities, but outcome follow-up is offered in only 66 percent of the facilities.

Fewer than 25 percent of facilities offer academic classes, smoking cessation programs, prenatal 

care, or childcare.

REPORT OF PANEL III
Figure III.1. Type of Care

B. THE CLIENT POPULATION

October 1997 estimates showed 929,086 clients in treatment, with approximately 55 percent of those

in private not-for-profit facilities (SAMHSA’s UFDS data, 1997). The most common reasons for

entry into treatment are alcoholism and heroin or cocaine abuse (Horgan and Levine, 1998) (see

Figure III.2). Nearly 69 percent of all patients treated are men. Although studies indicate that ethnic populations are at high risk for substance abuse disorders, the majority of patients in treatment

are white men, highlighting the concern that the current system is not effectively reaching certain

populations (e.g., women, juveniles, the physically challenged, and many ethnic or culturally diverse

groups) (SAMHSA’s UFDS data, 1997). The treatment programs targeting these populations are

limited in number and often difficult to access.

The criminal justice system is the largest referral source of clients, accounting for approximately 34

percent of those in treatment. Voluntary or self-referrals are the next largest source of treatment

referrals, comprising 21 percent of the total. Various inter-system linkages, including other healthcare providers and human services agencies, accounted for 16.6 percent of clients.

68

Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

Inpatient

Residential

Outpatient Methadone

Outpatient Non-Methadone

Inpatient and/or Residential

with Outpatient NonMethadone

3.0

17.4

5.0

61.1

13.6

Source: Horgan and Levine (1998)

Facility Percent of Providing Care
Figure III.2. Patient Characteristics

C. QUALITY OF CARE

The quality of treatment varies across the treatment system. There is no system-wide, agreed-upon

quality measurement protocol. However, various generally accepted indicators are used, particularly

length of stay and retention rates. Currently, the field relies on an array of approaches to assess

quality of care, including the use of performance measures, practice guidelines, accreditation, licensing and certification, credentialing and privileging, and report cards (Institute of Medicine [IOM]

Managing Managed Care Report, 1997).

In response to the need for quality improvement initiatives, CSAT’s Office of Managed Care convened the Washington Circle Group (WCG) in March 1998 to improve the quality and effectiveness

of substance abuse services through the use of performance measurement systems. The March 2000

WCG report emphasized that core measures should consider external accountability, the extent to

which a healthcare system meets a pre-existing agreed-upon standard; and accountability for the

entire process of care, such that the service delivery level should be equal to the level of responsibility for overall performance measurement.

69

White

REPORT OF PANEL III

Black

Hispanic

Asian

Native American

57

24

12

1

3

8

13

31

28

14

<18

18-24

25-34

35-44

45+

Source: Horgan and Levine (1998)

Alcohol

Heroin

Cocaine

Marijuana

Amphetamines

43

18

15

10

3

Race/Ethnicity Percent of

Patients

Percent of

Patients Age Primary Drug

Being Treated

Percent of

Patients
70

Changing the Conversation

Another mechanism designed to promote quality care is the American Society of Addiction

Medicine’s (ASAM) Patient Placement Criteria. Through the Patient Placement Criteria, ASAM

established a set of diagnostic criteria to create standards for decision-making for placement, continued stay, and discharge of patients with alcohol and other drug problems. Accrediting organizations such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) and the

Commission on Accreditation of Rehabilitation Facilities (CARF) have incorporated measures that

involve substance abuse treatment in their evaluation of programs.

D. EFFECTIVENESS OF CARE

Changes in purchase of service contracts are accelerating the evolution of performance and outcome

monitoring. Increasingly, State and Federal governments are implementing contracts that require

demonstrations of specified levels of outcomes rather than just purchasing the delivery of services.

Many studies show that treatment is an effective strategy that enables individuals with substance

abuse disorders to lead productive lives. Effectiveness of substance abuse disorder treatments can be

measured through an array of indicators that capture the breadth of the treatment process itself.

Treatment outcomes can include direct reduction in drug use, improved functioning at work,

improved general and mental health status, reduced crime, reduced domestic violence, and reduced

engagement in at-risk behavior for HIV infection.

Two national studies funded by SAMHSA support the effectiveness of substance abuse treatment

programs, the National Treatment Improvement Evaluation Study (NTIES, 1997) and the Services

Research Outcomes Study (SROS). NTIES showed that with treatment:

• Primary drug use was decreased by 48 percent;

• Reported alcohol/drug-related medical visits declined by 53 percent;

• Criminal activity decreased by as much as 80 percent;

• Illicit drug use for young adults (ages 18–20) declined by 47 percent; and

• Client financial self-sufficiency improved (i.e., employment increased by 19 percent, welfare

recipients declined by 11 percent, and the proportion of clients who reported being homeless at

some point during the previous year dropped by 43 percent).

SROS also showed the substantial benefit individuals receive from treatment. Specifically, SROS

showed that: there was a 21 percent decrease in the use of any illicit drug following treatment; those

remaining in treatment for longer periods were more likely to reduce or eliminate the abuse of substances following treatment; there was a substantial decrease in crime; and more reliable housing

was secured after treatment.

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The National Institute on Drug Abuse (NIDA) initiated The Drug Abuse Treatment Outcome

Studies (DATOS) in 1990 to evaluate drug abuse treatment outcomes and emerging treatment issues

in the United States. DATOS results were similar to those seen in NTIES. For example, criminal

activity and unemployment were decreased when an individual entered treatment, regardless of the

treatment setting. Furthermore, the DATOS study revealed that clients who remained in treatment

for three months or longer consistently showed significantly more favorable follow-up outcome

measures than those who left before they reached the three-month mark.

E. ROLE OF GOVERNMENT

Much of the nation’s substance abuse resources are directed at curbing the supply of drugs and at law

enforcement programs, rather than at reducing demand for drugs through treatment and prevention

initiatives. According to The White House Office of National Drug Control Policy’s (ONDCP) 1999

National Drug Control Strategy, the Federal government spends about $6 billion on demand reduction activities for illicit drugs, less than half the amount it spends on supply reduction.

Treatment programs, together with research, constitute a major demand reduction strategy. Federal

dollars allocated for treatment and research in fiscal year 2000 are $3.6 billion, slightly more than

one-third the amount allocated for domestic law enforcement ($9.2 billion). According to the best

current estimate, in 1996 $12.6 billion was spent on alcohol and substance abuse treatment, with

public funds (Federal and State) accounting for 63 percent, or nearly $8 billion (McKusick, Mark,

King, Harwood, Buck, Dilonardo, and Genuardi, 1998). This was an increase from 1986, when public funding accounted for 53 percent of total substance abuse expenditures. Federal dollars, including the Federal government’s share of Medicaid, Medicare, Department of Defense (DoD), and the

Veteran’s Administration (VA), paid for nearly one-third of national expenditures on substance

abuse treatment funding. The State/local share was approximately equivalent at 31 percent 

of national expenditures.

As the country’s drug crisis has grown over the past 30 years, Federal and State governments 

have responded by passing legislation that addresses pertinent issues. To understand how the 

treatment system has evolved, it is important to understand the organizations that regulate, oversee

and/or promote treatment.

The ONDCP is charged with producing a National Strategy, which directs the nation’s anti-drug

efforts and establishes a program, budget, and guidelines for Federal, State, and local cooperation.

The ONDCP also evaluates, coordinates, and oversees both the international and domestic antidrug efforts of executive branch agencies, and ensures that such efforts sustain and complement

State and local anti-drug activities.

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Changing the Conversation

SAMHSA provides national leadership to ensure that science-based knowledge and state-of-the-art

practices are effectively used for prevention and treatment of addictive and mental disorders.

SAMHSA was established in 1992 by P.L. 102-321, which divided substance abuse and mental health

programs into a research focus at the National Institutes of Health (NIH) and a services focus at

SAMHSA. SAMHSA was charged with improving the quality and availability of prevention, treatment, and rehabilitation services in the United States in order to reduce illness, death, disability, and

cost to society from substance abuse and mental illnesses. Further, a SAMHSA goal was to improve

access and reduce barriers to high quality, effective programs and services for individuals who suffer

from or are at risk for these disorders, as well as for their families and communities.

Within SAMHSA, the Center for Substance Abuse Treatment (CSAT) retains the primary responsibility for treatment programs, while the Center for Substance Abuse Prevention (CSAP) focuses on

prevention activities. Among CSAT responsibilities are administering the Substance Abuse

Prevention and Treatment (SAPT) Block Grant, supporting knowledge development and application

projects, conducting evaluations, and providing technical assistance to states and Block Grant subrecipients. The Federal SAPT Block Grant is the cornerstone of funding for State substance abuse

programs, accounting for about 47 percent of all public funds expended for treatment and prevention. Formula-driven, the Block Grant includes several mandatory distributions and set-asides that

States must follow to receive the funds. The Block Grant provided $1.59 billion in alcohol and substance abuse treatment spending in fiscal year 1999. The following statistics highlight the importance of the Block Grant:

• In 1997, 19 states reported that the Block Grant provided the majority of their funding for 

substance abuse treatment services.

• More than 7,000 community-based organizations receive Block Grant funding.

• In fiscal year 1998, SAPT Block Grants supported treatment for an estimated 300,000 individuals.

Within the NIH, the National Institute on Drug Abuse (NIDA) supports more than 85 percent of

the world’s research on the health aspects of drug abuse and addiction. NIDA is not only seizing

unprecedented opportunities and technologies to further the understanding of drug abuse effects on

the brain and behavior, but also is working to ensure rapid and effective transfer of scientific data to

policymakers, drug abuse practitioners, other healthcare practitioners, and the general public.

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) supports and conducts biomedical and behavioral research on the causes, consequences, treatment, and prevention of alcoholism

and alcohol-related problems. NIAAA also provides leadership in the national effort to reduce the

severe and often fatal consequences of these problems through a wealth of research and information

dissemination that includes the science and treatment fields and covers numerous stakeholders.

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The organizational placement of substance abuse administrations within States varies. The Hughes

Act (PL 91-616) required states to create a single State authority (SSA) to receive Federal funds.

Currently, 30 States have an independent substance abuse authority separate from mental health.

The remaining 20 States have combined substance abuse and mental health authorities into 

one umbrella agency.

SSA powers and duties recently have lessened in some States due to reorganization in State government, downsizing, and implementation of reform initiatives. In point of fact, the SSA is vital to the

substance abuse policy framework because it is the lead State agency for developing and coordinating an integrated substance abuse prevention and treatment strategy. It is often the focal point from

which Federal, State, and private funds are obtained and disbursed and, thus, assumes commensurate responsibility, accountability, and authority. Other SSA duties and roles include serving as purchaser of quality prevention and treatment services; overseeing planning and implementation of

services at the local level, including technical assistance, training, and accountability; taking leadership in the development and dissemination of prevention and treatment best practices; and formulating a workforce development plan for prevention and treatment.

III. Understanding the Problem

A. TREATMENT PLANNING

CLIENT-FOCUSED TREATMENT. The base of knowledge about substance abuse has advanced significantly in the past two decades. Increasingly, substance abuse is viewed as a recurring, relapsing 

disease based on biological, psychological, and social factors. Providing treatment for such a 

complex disorder is difficult. To receive effective treatment, patients require access to a full 

continuum of client-focused services.

Due to the diversity among providers within the treatment system, it has been difficult to develop

consistent approaches to treatment planning. Additionally, the roles, priorities, and views about

substance abuse and treatment vary across systems and providers, leading to inconsistent approaches and standards for treatment regardless of setting. Many organizations in various systems (e.g.,

healthcare, mental health, social services) deal with individuals with substance abuse disorders on a

daily basis and do so with different approaches; yet, all the care provided is considered treatment.

The result of the diversity of providers and patient populations (often coming from various referral

sources) is inconsistent treatment approaches across the system. Just as the treatment approaches

vary, so does the application of the existing treatment planning tools. This inconsistent application

has had a negative impact on patient assessment procedures and, ultimately, on the ability of an 

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organization to match a patient to appropriate care. When combined, these flaws in the treatment

planning process result in poor retention and outcomes.

MATCHING THE CLIENT WITH THE APPROPRIATE TREATMENT. No single treatment approach or

setting will be effective for all individuals in need of care. Treatment results often are linked to the

ability of the program to address patient-specific treatment needs. The diverse and culturally segmented provider mix enhances the system’s ability to provide gender and culturally sensitive care.

Further, the emphasis on program-based care has made it easier to target specific communities or

problems. However, this specialization also inhibits the ability of any single program to address all

types of substance abuse, various stages of treatment, or specific client demographic and clinical

characteristics. A significant number of clients are channeled into the programs that are available,

rather than being directed to programs that would meet their individual needs.

To achieve optimal outcomes, providers should aggressively promote the concept of a continuum of

care and provide access to alternative treatment approaches, settings, or services through interprogram or inter-system alliances and case management efforts. A positive correlation exists

between effectively matching patients to treatment and treatment outcomes, emphasizing the

importance of effective application of screening and assessment tools and outcome measures. A

variety of tools have been developed over the years, but treatment providers often lack the resources

or training to use available tools effectively. Further, the diversity of providers (with varying treatment approaches) has led to inconsistent application of the tools.

B. FINANCING AND REIMBURSEMENT

FINANCING. The most conservative estimates count at least 10 million to 13 million individuals in

the United States in need of substance abuse treatment (see Panel I Report). This level of demand

requires significant resources, both financial and non-financial. The adequate supply and effective

use of resources are key elements to improving and strengthening the treatment system.

Only a small portion of services currently provided in the treatment system are covered by commercial insurance, whose set rates often are lower than rates for similar services (e.g., counseling) 

provided in other settings such as mental health or primary care. Thus, many programs that rely 

on Federal and State funding and charitable donations are inadequately funded.

According to a recent review of the field (IOM, 1997), the diverse financial structure of the substance abuse delivery system “involves a complex combination of public and private financing” that

exacerbates the problems of fragmentation and inconsistency. “Public sector services are financed

either with State and Federal appropriations or through Medicaid and Medicare coverage. Private

systems of care have different structures but coexist and often overlap with public sector coverage.”

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Due to the lack of parity for substance abuse treatment in private as well as public insurance 

programs (i.e., Medicare/Medicaid), the public treatment system assumes major responsibility for

funding care. Individuals are covered by specific public or private payors, and their ability to enter a

specific program depends on that program’s acceptance of the specific payor type. Individuals in

need of treatment frequently cannot find programs of care that meet both need and payor criteria

(the Panel I Report describes these problems in more detail).

REIMBURSEMENT. Providers have developed creative ways to use multiple funding sources to overcome the inadequacy of funding from any single source. However, the sheer complexity of reimbursement mechanisms (e.g., multiple funding sources, various rate-setting methodologies), hinders

providers and States in maximizing available resources. For example, some States still do not

include a general substance abuse treatment benefit in their Medicaid program.

Rates established by many payors fail to reflect the true cost of care or the margins that providers

need to invest in resources and infrastructure. Providers often lack the resources to improve the

infrastructure (e.g., management information systems to track client outcomes, staff training, billing

systems) needed for better, more efficient care and to respond to increased demands for accountability. Furthermore, current reimbursement rates do not include the modest margins that providers

need to access capital, retain staff, invest in new programs, and remain a financially viable organization. When combined, these problems create an under-funded system in which resources do not

cover the cost of providing treatment.

MARKET FORCES AND THE IMPACT OF MANAGED CARE. The substance abuse treatment system

is rapidly evolving in the same direction as the healthcare system, with reimbursement mechanisms

and market forces driving changes in how services are financed and delivered. The emergence of

managed care has affected programs organizationally, financially, and with regard to delivery of

services. Currently, there are approximately 161 million individuals in managed care plans,

accounting for 60 percent of the United States population (IOM, 1997). Like general healthcare

services, managed care has had a strong and pervasive impact on the organization and delivery of

substance abuse services, including restricting access through controlled use of services and predefined benefit packages, limiting panels of providers, and capitating reimbursement mechanisms.

Managed care has begun to focus attention on the measurement of outcomes, but also has placed

emphasis on cost instead of patient needs. Public interest in quality of care in managed environments is high, and many purchasers desire research and data to help them make decisions on the

value and effectiveness of different managed care options. Federal, State, and local governments,

accreditation organizations, purchaser coalitions, consumer groups, professional organizations, the

media, and managed care organizations (MCOs) themselves all are involved in defining, measuring

and monitoring quality (IOM, 1997).

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C. MANAGEMENT AND BUSINESS PRACTICES

Among the diverse providers in the treatment system, organizational leaders (both management and

boards) possess varying skill sets. In some cases, this leads to organizations that do not operate on

sound business practices or with strong leadership. To effectively operate in the changing environment,

organizations will need to improve business practices and provide culturally sensitive services while

meeting client needs. This will be a difficult task requiring a large investment by management teams.

As previously discussed, many treatment organizations have limited resources that hamper their

ability to develop business strategies and infrastructures. Management teams frequently consist of

individuals who have “grown up” in the system, who might or might not be those having the

strongest business or management skills. Organizations often operate with insufficient staff and

outdated management information systems. As the market shifts and reimbursement requirements

change, they must now function in a more competitive environment than ever before. Many organizations will be unable to sustain existing operations without significant changes and improvements.

IV. Themes from the Public Hearings

To gain insight into community perspectives, CSAT held six public hearings around the country,

hearing more than 400 testimonies from individuals from 31 states. They represented, among 

others, the recovery community, State and local agencies, treatment providers, educators,

and researchers.

The issues that emerged at the public hearings supplemented and often echoed Panel member opinions. There were numerous testimonies on the need for a continuum of care that will allow better

access to treatment, effective integration of overlapping systems throughout treatment, and

increased availability of continuing and aftercare programs. Additionally, testimony was presented

requesting that substance abuse expenses be reimbursed in the same manner as those for other

medical conditions. Another major theme from the public hearings was that treatment programs

should be better able to address the needs of special populations such as women, youth, seniors, and

various ethnic groups.

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Further issues that were raised included the need to:

• Address treatment within the managed care environment;

• Ensure high quality standards in the administration of treatment;

• Fund treatment programs based on client needs rather than program needs;

• Improve access to and availability of treatment services; and 

• Increase communication between service delivery and research communities to ensure dissemination of best treatment practices.

The issues raised reflect community opinions and were considered as Panel members developed the

recommendations.

V. Recommendations

The Panel identified three areas vital to improving and strengthening the treatment system: treatment planning; financing and reimbursement; and management systems. Treatment planning

addresses the prevalence of program-based care rather than individual-focused treatment, and the

importance of standards to monitor and improve quality and outcomes. The finance recommendation addresses insufficient reimbursement rates and the allocation of resources. Finally, the management recommendation addresses ways to improve the management and operations of organizations that function within or interact with the treatment system. Each set of recommendations

builds on the work and recommendations of other authoritative groups that have conducted 

relevant examinations of these problems.

TREATMENT PLANNING

To address the issues that have resulted from the diversity of providers, inconsistent treatment

approaches, and the difficulty in matching client to appropriate treatment, the Panel developed the

following recommendation.

1. Treatment plans should be based on an individual’s needs and should respond to changes in

need as he or she progresses through stages of treatment. Evidence-based practices should

guide screening, intervention, assessment, engagement, individual and group therapies, aftercare, and relapse prevention so that the individual enters at an appropriate level of care,

becomes engaged in services, and progresses through a continuum of care.

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Discussion

Panel members recognize the valuable contributions of the body of research on the organization

and classification of treatment services. Moreover, they believe that implementation of a clientfocused treatment model will promote needed changes in the substance abuse treatment 

system, including:

• A shift from program-based treatment approaches to client-based approaches that reflect 

individual needs and diagnoses;

• Standard indicators/protocols for client assessment and monitoring care; and

• Use of baselines/benchmarks to measure quality and outcomes.

The Panel believes that the development of a client-focused treatment model will improve and

strengthen the treatment system. Specifically, the suggested model organizes and guides assessment

of client needs, treatment interventions, and monitoring of performance. The model should incorporate treatment techniques that reflect cultural and other differences represented by clients.

It comprises four components:

• Screening to identify major treatment needs;

• Intake/clinical evaluation and placement at the appropriate level of care;

• Treatment planning, engagement, and retention; and

• Continuing care.

The proposed model should reflect effective inter-system linkages, culturally competent services,

and a broad range of care and services required. The model incorporates linkages with collateral

systems of primary care, mental health, and social services. The anticipated result is improved intersystem communication and coordinated care. Ideally, a user-friendly and integrated management

information system supports the model by monitoring biopsychosocial progress and providing

feedback to clients, providers, managers, and purchasers.

The Panel feels that an important aspect of patient care is that substance abuse treatment include

culturally competent services that consider communication and other specific needs of diverse populations requiring treatment. Treatment services should be provided in an environment responsive

to the unique needs of the groups being served.

The model’s purpose is to ensure that patients receive a full continuum of care appropriate to meet

their needs. This recommendation includes identification and validation of the tools necessary to

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REPORT OF PANEL III

conduct assessment, planning, treatment, and monitoring processes. These tools (e.g., consistent

screening, assessment, and placement indicators) have been proven effective, resulting in treatment

services that are relevant for the population at hand and that match patients to the appropriate program and level of care. These tools also provide appropriate “interim criteria” for evaluating effectiveness and guiding application of specialized cognitive and behavioral interventions shown to

improve treatment management, retention, and outcomes.

The Panel believes that although the modalities and settings for substance abuse treatment are commonly understood in general terms, there is a lack of understanding of the treatment process, that

is, what occurs after someone enters treatment. Lack of a common understanding of the treatment

process hinders development and use of appropriate client assessment and placement tools, treatment methods, quality improvement measures and processes, and client outcome and program 

performance measures and methods. It also contributes to the lack of understanding by the general

public and some policy makers and payors concerning the effectiveness of treatment. Therefore, the

Panel believes that a model treatment process should be defined that encompasses at least the elements illustrated in Figure III.3.

Development of a treatment model should be accompanied by and, in fact, might depend on,

development of a taxonomy of treatment services.

To support this recommendation, the Panel feels that a taxonomy of treatment should be developed

to provide a consistent description of substance abuse services. The taxonomy should serve as a

framework for reimbursement and billing arrangements between purchasers and providers, in both

the public and private sectors. It would also be beneficial in four areas:

• Communication with the public — consumers, media, public policy officials, and purchasers of

services — about types of substance abuse services available and how these services form a continuum of services.

• Treatment Planning to facilitate matching of patients with services appropriate to their needs and

the evaluation of treatment outcomes.

• Treatment Evaluation by fostering precision in characterizing interventions and facilitating the

synthesis of information from evaluations of treatment.

• Reimbursement by serving as framework for reimbursement and billing agreements between 

purchasers and providers, in both the public and private sectors.
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Changing the Conversation

Figure III.3. Treatment Process

The Panel recommends that groups such as the American Society of Addiction Medicine (ASAM), the

National Association of State Alcohol and Drug Abuse Directors (NASADAD), CSAT, the Office of

Applied Studies (OAS), NIDA, NIAAA, and others should be involved in developing the taxonomy.

The Panel examined numerous reports and studies that have addressed the need for improving

treatment systems (see Selected Bibliography). The Panel’s recommendation on treatment planning

and, more specifically, on the development of a client-focused model in many ways encapsulates

that body of previous work and sets a specific, practical agenda for producing the proposed changes.

Recommended Action Steps 

The Panel suggests that after the release of the National Treatment Plan Iniative (NTP), CSAT

should convene a group of national stakeholders to identify the tools, protocols, and practices

required to facilitate and evaluate implementation of individualized programs of care. To support

this and to promote the individualization of treatment, CSAT should analyze and compare current

technologies for assessment, placement, treatment planning, and treatment implementation.

THE NATIONAL TREATMENT PLAN INITIATIVE

Patient Referral

Treatment

Intervention

Engagement/

Retention in

Treatment

Treatment

Completion

Continuing

Care/After

Care

Follow-up

Monitoring

Individual

Treatment

Plan

Screening/Brief

Intervention (if

indicated)*

Assessment

Treatment

Matching

Placement in

Treatment

*Screening, brief intervention, and referral might occur in a number of sectors outside the substance abuse treatment system such 

as the justice system, the school systems, the public health systems, the welfare system, and the workplace.
81

Panel members discussed and developed a series of activities that, if completed, will assist in the

implementation of the recommendation. These activities include the following:

• State substance abuse authorities and other payors should phase in requirements for individualized treatment planning, recognizing that public and private systems of care must develop the

capacity and infrastructure to support the adoption of these tools and practices.

• State accrediting and licensing authorities should incorporate requirements for individualized

treatment planning into operational policies and accrediting standards.

• Treatment practitioners should be trained to implement individualized treatment planning and

should use the tools and practices required to support the individualization of treatment.

FINANCING AND REIMBURSEMENT

Many community treatment programs struggle to survive because funding and resources are limited. Without adjustments in the level of reimbursement to support a full continuum of care, many

providers may be unable to continue or simply will fall short of serving the community’s needs 

(see Panel I Report). To address this problem the Panel recommends the following:

2. Reimbursement mechanisms should be aligned with treatment goals and should incorporate

performance measures and outcome standards to guide resource allocation, as well as rates 

sufficient to cover both reasonable costs and a surplus to support reinvestment.

Discussion

This recommendation encourages a flexible approach to reimbursing treatment to address the

undercapitalization of the treatment system. The current negative attitude toward profit within the

treatment system makes it difficult for many organizations to compete in the market and effectively

reinvest in their organizations. Combined with insufficient reimbursement rates, this attitude

makes it nearly impossible for organizations to operate effectively or efficiently.

This recommendation takes a three-point approach aimed at addressing some of the problems of

the current reimbursement system. First, it calls for the creation of a reimbursement system that

aligns financing with desired clinical processes and outcomes. The revised system should account

for variations in patient severity.

The second component of the recommendation is the establishment of rate-setting methodologies

that account for total cost of treatment and infrastructure. A fair and equitable payment system

might involve the sharing of risk so that reimbursement adequately covers costs.

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The final component of the recommendation is to ensure that the reimbursement rate allows for

margins after the base cost of services is covered. The Panel believes that this will have a positive

impact on the quality of treatment, as providers are able to reinvest resources in programs, staff, and

facilities. The strengthening of information systems and the infrastructure to support programs will

enable organizations to compete in a managed care environment.

The substance abuse field has devoted much attention to the problems associated with financing

substance abuse treatment. Although most previous recommendations were aimed at increasing or

reallocating the amount of resources directed at the treatment system, this recommendation calls for

adjustment of reimbursement rates (ASAM, 1995; IOM, 1998). The Panel’s recommendation to

realign reimbursement mechanisms with the goals of treatment clearly takes a new approach to

revamping the structure of the finance system.

Recommended Action Steps

As the first step, the Panel believes that all payors should review and (where demonstrably 

justified) adjust their rate structure on an ongoing and regular basis, which should be no less than

every two years. Further, CSAT should publish guidelines for establishing the true and reasonable

costs of services.

MANAGEMENT SYSTEMS

The Panel acknowledges that treatment providers must operate in a cost effective and efficient 

manner. The Panel stressed that improving overall operational and financial performance of an

entity will enhance its ability to serve a greater number of clients. Therefore, the Panel 

recommends the following:

3. Treatment programs, payors, and regulators should promote organizational cultures that

improve the quality, effectiveness, and efficiency of services through the adoption of best business practices for program management and operations. These should include effective governance and leadership for the board of directors and senior management; management and

operation of human resources, marketing, and finance; information and data management

operating systems; and capital and facilities.

Discussion

As delivery of care becomes increasingly more business oriented, providers need to strengthen 

their management skills, resources, and operating infrastructure to compete effectively in the marketplace. This recommendation seeks to match the business skills needed for viability with the 

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mission-driven values and the not-for-profit culture of treatment providers. The organizational

culture should include improvements in the following areas:

GOVERNANCE AND LEADERSHIP. An organization’s direction and ability to respond to market

pressures on a timely basis are shaped by its governing body. In many instances, governing boards

have evolved based on financial contributions or charitable interests of their members rather 

than on members’ knowledge of the substance abuse treatment field or strong leadership skills.

Successful provider boards should comprise members who possess strong management skills and

industry knowledge. The organization’s governance structure should reflect the community it serves.

Included in this recommendation is the development of guidelines for establishing governing bodies,

decision-making processes, and the training of boards that might be experiencing problems.

BUSINESS SKILLS DEVELOPMENT. Because of the changing times, many organizational leaders are not 

fully equipped to deal with managed care and other pressures. Often, individuals who serve as leaders

of treatment organizations need to strengthen business management skills. It is essential in the increasingly competitive healthcare industry that management and boards of directors obtain necessary training for organizational management skills, financial planning, and effective allocation of resources.

This recommendation calls for the development of training programs and courses for organizational leaders. The courses should focus on developing management skills and changing the thinking regarding:

• Financial skills such as budgeting, reimbursement management and planning, capital requirements, and investment strategies; and

• Hiring and retention plans, allocation of resources throughout the organization, infrastructure

development, facilities improvements, and general management.

The proposed training should be centralized and conducted nationally so that business practices

and skill sets become more consistent across providers. The Panel recommends that CSAT leverage

its existing initiatives, such as the National Leadership Institute (NLI), for this purpose. The NLI

was established by CSAT to provide a learning environment in which community-based substance

abuse treatment providers can share their expertise in management and business practices, while

also building a new body of knowledge for the public treatment field. The NLI’s mission is to help

community-based treatment providers obtain business and management knowledge and technologies needed to successfully meet the challenges posed by the rapidly changing healthcare services

delivery and payment environment. The NLI provides support to treatment providers primarily

through technical assistance and training.

INFORMATION SYSTEMS. This recommendation also calls for the improvement of management

information systems (MIS) to support clinical functions (e.g., treatment planning, client monitoring, and assessment of program outcomes) and management functions (e.g., budgeting, accounting,

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human resources) in addition to Federal and State reporting requirements. The systems should provide feedback to clients, providers, program managers, and purchasers, and where feasible, through

automated means. Management systems must be accessible and user friendly and present data that

are appropriate to the audience. The MIS also should be integrated to the greatest extent possible

across the client encounter in support of the treatment model.

CAPITAL AND FACILITIES. Many facilities do not meet the standards mandated by the Americans

with Disabilities Act (ADA) or accrediting bodies such as the JCAHO. Often the condition of facilities hinders the ability of providers to deliver treatment and reinforces the negative stigma of addiction, recovering individuals, and treatment itself. A clear problem is the inability of providers to

access low interest loans or capital grants to fund new construction or renovation. This is due, in

part, to providers’ need for better knowledge of potential sources of capital as well as the precarious

financial situation of treatment organizations that may preclude their obtaining loans.

The issue of capital includes facilities, but extends beyond to include other operational aspects of

treatment providers such as MIS, which entail large capital expenditures. Other costs include providing transitional housing and transportation for clients, including the expense of vehicles and

drivers. Providers need increased knowledge of financial resources, a greater understanding of how

to tap sources of capital, and honed financial skills to facilitate their ability to obtain loans.

Few previous recommendations or reports have focused on management issues. One exception,

however, is the longstanding focus on the importance of client-oriented data systems capable of

both tracking clients through the continuum of care and analyzing data on costs (DHHS, 1998; Join

Together, 1998). These recommendations, however, did not address the implementation process or

the core elements needed to make the MIS functional. Consequently, the Panel recommends steps

necessary to develop and implement a user-friendly, integrated information system.

Recommended Action Steps

The Panel believes that after the release of the NTP, CSAT should convene a representative group of

various types of payors and stakeholders. This group should be tasked with defining goals of treatment and establishing performance standards and outcome measures. When completed, CSAT

should make available to providers necessary training and support to implement these guidelines.

Panel members felt that to successfully implement the recommendation, CSAT and providers 

must emphasize improvement of business practices. Specifically, some recommended steps include

the following:

• CSAT should develop a knowledge base and training for those provider organizations that need

assistance in accessing capital to enable the critical access to capital and a stable and financially

healthy provider community.

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• CSAT, in collaboration with State substance abuse authorities and trade associations, should prepare and disseminate case studies illustrating the application of exemplary business practices for

governance, leadership, human resources, marketing, finance, information management, and capital and facilities, inclusive of the potential impact that implementation will have on providers.

• CSAT should earmark a portion of its technical assistance resources, including the Addiction

Technology Transfer Centers (ATTCs) and the NLI, for implementation and adoption of exemplary business practices in substance abuse treatment programs.

• CSAT, State substance abuse authorities, and trade groups should support the development and

dissemination of training and educational materials to foster skill development for board governance, human resources, information management, and capital and finance.

• Substance abuse treatment organizations should examine their business infrastructure and

upgrade systems and operations as necessary to conform with exemplary business practices.

Because larger scale and more efficient operations often are required to support the necessary

infrastructure for information and human resource management systems, it might be desirable

to form cooperatives and networks or to merge to create larger organizations.

• Substance abuse treatment programs should monitor program outcomes, performance, and 

satisfaction and use that information to guide and improve program operations and service.

• Based on the efforts outlined in the prior action steps, providers should prepare and disseminate

reports on program performance, productivity, and efficiency to payors, community, consumers,

and staff.

• Substance abuse treatment programs should invest in staff development and training to ensure a

culturally sensitive organization that values professional and business skills.

REPORT OF PANEL III
86

Changing the Conversation

VI. Selected Bibliography

The sources listed reflect those used by the panel members based on the data current at that time.

Subsequent sources were not incorporated into the individual reports, but may be in the companion

report, Changing the Conversation, Improving Substance Abuse Treatment, The National Treatment

Plan Initiative.

American Society of Addiction Medicine, Patient Placement Criteria for the Treatment of SubstanceRelated Disorders (ASAM PPC-2), 2nd ed. (Chevy Chase, MD: The Society, 1996).

American Society of Addiction Medicine, Public Policy Statement, Federal Funding for Addiction

Prevention, Treatment, and Rehabilitation. (Chevy Chase, MD, ASAM, 1995) Online,

<http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

———, Public Policy Statement, National Drug Policy. (Chevy Chase, MD, ASAM, 1994) Online,

<http://www.asam.org/ppol/pubpol3.htm>, Aug. 1999.

Department of Health and Human Services, Appendices A and C, Medicaid Services for Substance

Abuse Treatment, in Blending Perspectives and Building Common Ground: A Report to

Congress on Substance Abuse and Child Protection (Washington, DC: DHHS, 1999).

———, Comprehensive Case Management for Substance Abuse Treatment, TIP No. 27 (Rockville,

MD: DHHS, 1998).

———, Treatment Drug Courts: Integrating Substance Abuse with Legal Case Processing, TIP No. 23

(Rockville, MD: DHHS, 1996).

———, Combining Alcohol and Other Drug Abuse Treatment with Diversion for Juveniles in the

Justice System, TIP No. 21 (Rockville, MD: DHHS, 1995).

———, Approval and Monitoring of Narcotic Treatment Programs: Guide on Roles of Federal and

State Agencies, TAPS No. 12 (Rockville, MD: DHHS, 1994).

———, Coordination of Alcohol, Drug Abuse and Mental Health Services, TAPS No. 4 (Rockville,

MD: DHHS, 1991).

Institute of Medicine, Bridging the Gap between Practice and Research: Forging Partnerships with

Community-Based Drug and Alcohol Treatment (Washington, D.C.: National Academy Press,

1998).

———, Managing Managed Care: Quality Improvement in Behavioral Health (Washington, D.C.:

National Academy Press, 1997).

———, Broadening the Base of Treatment for Alcohol Problems (Washington, D.C.: National

Academy Press, 1990).

THE NATIONAL TREATMENT PLAN INITIATIVE
87

———, Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and

Private Drug Treatment Systems, Volume 1 (Washington, D.C.: National Academy Press,

1990).

Join Together, Treatment for Addiction: Advancing the Common Good (Boston: Join Together,

1998). Online, <http://www.jointogether.org/sa/files/pdf/ jtadvanc.pdf>, Aug. 1999.

———, Health Reform for Communities (Boston: Join Together, 1993).

Kunnes, R., R. Niven, T. Gustafson, N. Brooks, S.M. Levin, M. Edmunds, J. Trumble, and M.J. Coye,

“Financing and Payment Reform for Primary Health Care and Substance Abuse Treatment,”

Journal of Addictive Diseases 12(2), pp. 23–42.

Legal Action Center, Blueprint for a New and Effective National Drug and Alcohol Strategy, Rev. ed.

(New York: LAC, 1993).

McKusick, D., T.L. Mark, E. King, R. Harwood, J.A. Buck, J. Dilonardo, and J.S. Genuardi, “Spending

for Mental Health and Substance Abuse Treatment, 1996,” Health Affairs 17(5), Sept./Oct.

1998. pp. 147-157.

National Association of Alcohol and Drug Abuse Counselors, Position Paper, Managed Care and

Public Sector Agencies (Arlington, VA: NAADAC, 1996) Online,

<http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Women’s Issues in Chemical Dependency (Arlington, VA: NAADAC, 1992)

Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Treatment on Demand (Arlington, VA: NAADAC, 1990) Online,

<http://www.naadac.org/pstnst.htm>, Aug. 1999.

———, Position Paper, Equalizing of Excise Tax on Beer, Wine, and Distilled Spirits (Arlington, VA:

NAADAC, 1986) Online, <http://www.naadac.org/pstnst.htm>, Aug. 1999.

National Institute on Alcohol Abuse and Alcoholism, Subcommittee on Health Services Research,

National Advisory Council on Alcohol Abuse and Alcoholism, Executive Summary,

Improving the Delivery of Alcohol Treatment and Prevention Services: Executive Summary,

NIH Publication No. 97-4224 (Bethesda, MD: NIAAA/NIH/DHHS, 1997).

National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide

(October 1999).

______, Diagnostic Source Book on Drug Abuse Research and Treatment, Rounsaville, B.J., F.M. Tims,

A.M. Horton, Jr., and B.J. Sowder (Eds.). (Rockville, MD: DHHS, 1993).

REPORT OF PANEL III
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Changing the Conversation

Office of National Drug Control Policy, The National Drug Control Strategy, 1999 (Washington,

D.C.: ONDCP, 1999a).

______, Treatment Protocol Effectiveness Study (Washington, D.C.: ONDCP, 1996).

Substance Abuse and Mental Health Services Administration, “Cultural Issues are Key in Substance

Abuse Treatment,” press release, July 9, 1999.

———, Office of Applied Studies, Summary of findings from 1998 National Household Survey on

Drug Abuse (Rockville, MD: DHHS/SAMHSA, 1999).

———, Uniform Facility Data Set Survey, 1995–1997 (Rockville, MD: DHHS/SAMHSA/OAS, 1999).

THE NATIONAL TREATMENT PLAN INITIATIVE
89

VII. Participants PANEL MEMBERS

Victor Capoccia, Ph.D. (Chair) 

Principal 

Dougherty Management Associates, Inc.

Lexington, MA

Douglas Anglin, Ph.D.

Co-Director

UCLA Drug Abuse Research Center

Los Angeles, CA

Gaurdia E. Banister, Ph.D.

Director of Nursing

Behavioral Health Services

Providence Hospital

Washington, DC

Karst J. Besteman, M.S.W.

Chief Executive Officer

CMAC, Inc.

Washington, DC

Thomas H. Bornemann, Ed.D.

Deputy Director

Center for Mental Health Services

Rockville, MD

Benjamin P. Bowser, Ph.D.

Professor

Department of Sociology and 

Social Services

California State University at Hayward

Hayward, CA

Angela G. Burgess, M.B.A.

Manager 

Washington Business Group on Health

Washington, DC

Neal Cash, M.S.

CEO Community Partnership of

Southern Arizona 

Tucson, AZ

Stephenie Colston, M.A.

Vice President

Johnson, Bassin & Shaw, Inc.

Silver Spring, MD

L. Foster Cook 

Director

Substance Abuse Programs

University of Alabama at Birmingham

Birmingham, AL

Michael Couty, M.S.C.J.

Director

Division of Alcohol and Drug Abuse

Missouri Department Of Mental Health

Jefferson City, MO

Diana Yazzie Devine, M.B.A.

Executive Director

Native American Connections, Inc.

Phoenix, AZ

Nancy Ferreyra

Executive Director

Progressive Research and Training 

for Action

Oakland, CA

Geoffrey Laredo, M.P.A.

Acting Director

Office of Policy, Legislation and 

Public Liaison

National Institute on Alcohol Abuse 

and Alcoholism (NIAAA)

Bethesda, MD

Dennis McCarty, Ph.D.

Research Professor

Brandeis University

Waltham, MA

Carole J. Otero

Director

Albuquerque Metropolitan Central Intake

Albuquerque, NM

REPORT OF PANEL III
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Changing the Conversation

Anthony B. Radcliffe, M.D.

Chief of Service

Department of Addiction Medicine

Kaiser Permanente

Fontana, CA

Roy I. Ross, M.A.

Chairman and CEO

CiviGenics, Inc.

Marlborough, MA

D. Dwayne Simpson, Ph.D.

Director

Institute of Behavioral Research

Texas Christian University

Ft. Worth, TX

Zili Sloboda, Sc.D.

Senior Research Associate

Center for Health and Social Policy

Professor

Department of Sociology

University of Akron

Akron, OH

Frank Sullivan, Ph.D.

Senior Advisor for Mental Health 

and Substance Abuse

Health Care Financing Administration 

Baltimore, MD

Beth Weinman

National Drug Abuse Program Coordinator

Federal Bureau of Prisons

Washington, DC

Joan Zweben, Ph.D.

Executive Director

14th Street Clinic

East Bay Community Recovery Project

Clinical Professor of Psychiatry

University of California, San Francisco

Berkeley, CA

Janet Zwick

Director

Division of Substance Abuse and 

Health Promotion

Iowa Department of Public Health

Des Moines, IA

CSAT STAFF (ROCKVILLE, MD)

Sharon Amatetti

Public Health Analyst

Office of Policy Coordination and Planning

Rockville, MD

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community 

Assistance

Rockville, MD

Jon Gold

Branch Chief

Synthesis Branch

Office of Evaluation, Scientific Analysis 

and Synthesis

Rockville, MD

Ray Hylton, Jr.

Public Health Advisor

Office of Pharmacologic and Alternative 

Therapies

Rockville, MD

Rick Sampson

Director

Division of State and Community 

Assistance

Rockville, MD

Jane Taylor, Ph.D.

Director

Division of Practice and 

Systems Development

Rockville, MD

THE NATIONAL TREATMENT PLAN INITIATIVE
91

Karl D. White, Ed.D.

Public Health Analyst

Office of Evaluation, Scientific Analysis 

and Synthesis

Rockville, MD

CONSULTANTS: 

THE LEWIN GROUP 

(FALLS CHURCH, VA)

Dianne Faup, J.D.

Senior Manager

Jonathan Lo

Research Analyst

Andrew Tucker

Research Analyst

PANEL MEETING SPEAKERS 

AND CONTRIBUTORS

Meeting I: Connecting

Research to Treatment

Systems

Constance Horgan, Sc.D.

Professor and Director, Health 

Services Research

Schneider Institute for Health Policy

The Heller School

Brandeis University

Waltham, MA

Aaron Johnson

Project Coordinator

Center for Research on Behavioral

Health and Human Services Delivery

Institute for Behavioral Research

University of Georgia

Athens, GA

Meeting II: Substance Abuse

Reimbursement

Ron Dreskin, M.B.A.

President

Integrated Healthcare, LLC

Greenwich, CT

Drug Treatment Outcomes

Dwayne Simpson, Ph.D.

Director

Institute for Behavioral Research

Texas Christian University

Ft. Worth, TX

REPORT OF PANEL III

THE NATIONAL TREATMENT PLAN INITIATIVE

Changing the Conversation

REPORT OF PANEL III

Appendix

Profile of the Current System:

Relevant Tables
94

Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

Table III.1. Profile of Substance Abuse Treatment Facilities in the United States

Individual Therapy 96.6

Comprehensive Assessment/Diagnosis 93.7

Group Therapy 91.7

Family Counseling 85.6

Aftercare 82.3

Relapse Prevention Groups 78.4

HIV/AIDS Counseling 75.5

Self-Help or Mutual Help Groups 71.3

Outcome follow-up 66.8

Combined Substance Abuse and Mental Health 66.5

Transportation 48.6

TB Screening 42.1

Employment Counseling/Training 40.7

Detoxification 25.6

Smoking Cessation 24.4

Academic/GED Classes 17.2

Childcare 12.9

Prenatal Care 11.7

Acupuncture 4.7

Source: Horgan and Levine (1998)

Private Nonprofit

Private For-Profit

State/Local Gov’t

Tribal Gov’t 

Federal Gov’t

59.8

23.5

12.6

1.4

2.7

23.9

19.9

32.6

18.1

5.6

<15

15-29

30-99

100-299

300+

Source: SAMHSA, Uniform Facility Data Set

Specialty SAT

Mental Health

Physical Health

Community

Criminal Justice

54.4

21.1

13.5

5.8

5.1

Table III.2.

Services Offered Primary Drug Being Treated Percent of Patients

Ownership Percent of

Facilities

Percent of

Facilities

No. of

Clients

Organizational

Setting

Percent of

Facilities
REPORT OF PANEL III

95

Criminal Justice System 34.0

Self-Referred/Voluntary 21.3

Other Treatment Facility 11.6

Health/Mental Health Provider 9.4

Welfare/Social Service Agency 7.2

Family/Friend 7.4

Employer 4.5

Other 4.8

Client 9

Private 29

Medicare 8

Medicaid 15

Other Federal 13

Other State 26

Total 100

1.1

3.6

1.0

1.9

1.7

3.3

12.6

Source: Horgan and Levine (1998)

Source: McKusick, et al. (1998)

Referral Source Percent of Patients

Payor Type $ Billions Percent of Exp.

Table III.3. Referral Source

Table III.4. National Expenditures by Payor Type, 

Alcohol and Substance Abuse Treatment

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Changing the Conversation

REPORT OF PANEL IV

Report of Panel IV:

Connecting Services 

and Research

Changing the Conversation

99

Table of Contents

I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100

II. BACKGROUND AND UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . 103

A. Current Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .104

B. Why We Need A System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106

III. THEMES FROM THE PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

IV. RECOMMENDATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107

V. DISCUSSION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111

A. The CSR System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111

B. Proposed Vision of Implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115

C. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121

VI. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

VII. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124

REPORT OF PANEL IV

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Changing the Conversation

I. Executive Summary 

Substance abuse research has contributed to the field’s understanding of pharmacological, behavioral, psychological, and environmental factors in treating clients. As stated in the Office of National

Drug Control Policy’s (ONDCP) 1999 National Drug Control Strategy, “recent research in the area of

pharmacotherapies and behavioral therapies for abuse of cocaine/crack, marijuana, opiates and stimulants . . . will improve the likelihood of successfully treating substance abuse.” Equally important is

alcohol addiction and the research efforts aimed at the treatment and prevention of alcoholism.

Clearly, it is important that the field use research findings to develop effective, evidence-based practices

and to set standards for the purpose of improving services and better serving clients.

Despite many advances in research, however, study findings are not making the intended impact on

the service delivery community. As emphasized in the 1998 Institute of Medicine (IOM) Report,

Bridging the Gap Between Practice and Research, there is great need for, and value in, “enhancing 

collaborative relationships between the drug abuse research community and the community-based

treatment programs.” In response to this gap, The National Treatment Plan Initiative Panel IV has

made specific recommendations to successfully connect services and research.

For research findings to be used by service providers and for research to meet the needs of those

providers, a true collaborative relationship between the service delivery and research communities

must be established. Service providers (as well as other stakeholders, including the recovery community, payors, educators, and policymakers) must have ample opportunity to contribute to

research through participation, and also through the generation of treatment and services research

questions to be addressed by the national research agenda. Furthermore, researchers must have the

opportunity to contribute to service provision, not only through publication in the professional literature, but by sharing findings in a structure and format that facilitates practical application.

Current efforts to bridge research and practice, although moving in the right direction, remain 

disjointed. Without a systems change, such fragmentation is likely to continue. A new structure

should be developed that coordinates research and practice initiatives. The proposed new coordinating structure should enable and encourage efforts among the various players to increase the 

likelihood that research reflects providers’ needs and that research findings have practical applications in service delivery. The system should support the essential participation from all relevant

stakeholders in contributing to the treatment services research agenda while fostering an environment in which researchers and practitioners work together to achieve successful knowledge 

transfer and application.

THE NATIONAL TREATMENT PLAN INITIATIVE
101

Panel IV has developed a plan to create such an interactive system. The Panel recommends the

establishment of a system designed to connect services and research (CSR system), which 

would be supported and maintained through the Substance Abuse and Mental Health Services

Administration’s (SAMHSA) Center for Substance Abuse Treatment (CSAT). The system should

provide an ongoing structure to enable and encourage consistent communication and collaboration

among service providers, researchers, and other relevant stakeholders. The system should focus on

the interdependent functions of knowledge development, transfer, and application, and should have

the responsibility for advising, overseeing, and reporting on the progress and efforts of its mission.

To ensure the success of the CSR system:

• Efforts should occur on the national, regional, and State/local levels.

• A national level panel should work to facilitate communication among the regional, State and

local levels as well as among CSAT, the National Institute on Drug Abuse (NIDA), the National

Institute on Alcohol Abuse and Alcoholism (NIAAA), and other Federal agencies.

• CSAT should enter into formal memoranda of agreement with NIDA and NIAAA to establish a

clear understanding of roles and expectations in the development and operation of the system.

• The CSR system should be incorporated into the ONDCP National Drug Control Strategy as the

focal point of the CSAT/SAMHSA response to Goal 3, Objectives 5 and 6.1

The knowledge development component of the CSR system should facilitate new research based on

the concerns reported by providers and other stakeholders who will be active participants in this

process. An objective is to ensure that much of the new treatment and services research undertaken

will be responsive to the needs expressed by providers and other stakeholders for information

regarding both effective and efficient service delivery strategies (e.g., clinical management,

organization, and financing).

The knowledge transfer component of the CSR system should synthesize research results and 

disseminate information on evidence-based treatment practices, policies, and strategies likely to

improve the effectiveness and efficiency of treatment for substance abuse. The system should also

ensure that a broad range of resource materials are produced for a diverse set of providers and other

stakeholders who affect the substance abuse treatment system, such as regulators, policymakers,

insurers, purchasers, and academic institutions that can incorporate new services knowledge in 

curricula designed to train clinicians entering the field.

REPORT OF PANEL IV

1 Goal 3: Reduce Health and social costs to the public of illegal drug use. Objective 5: Support research into the development of medications and related protocols to prevent or reduce drug dependence and abuse. Objective 6: Support and highlight research and technology, including the acquisition and analysis of scientific data, to reduce

the health and social costs of illegal drug use.
102

Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

The knowledge application component of the CSR system should make use of established interpersonal strategies (e.g., training, consultation, technical assistance, and innovative techniques to

achieve implementation and infusion of recommended evidence-based practices). Those strategies

and techniques should be used to enhance provider practices, may be seen as impacting policy and

regulatory activity, and should themselves be the subject of study to advance our understanding of

how best to facilitate knowledge application.

The ultimate goal of the CSR system would be to ensure that research findings in substance abuse

treatment and services are both useful to the field and effectively infused into practice. It should be

noted that there is currently much more emphasis placed on knowledge development and knowledge transfer efforts, and much less effort devoted to ensuring that service providers are able to

obtain the technical and problem-solving assistance necessary to implement innovations. Therefore,

the Panel believes that there is a particular need to focus on knowledge application strategies,

beyond knowledge transfer and dissemination, to ensure that new practices are adopted effectively.

To achieve these objectives, CSR efforts need to be made at the national, regional, and State/local

levels to facilitate widespread involvement of researchers, providers, State and local government,

payors, and consumers in CSR activities, and to encourage the likelihood that those activities will

enjoy the broadest possible support. The success of the CSR system will rely on coordinated leadership among CSAT, NIDA, and NIAAA.

The national CSR panel should have representatives from the service provider and research communities, State substance abuse authorities, CSAT, NIDA, and NIAAA. Participation from other relevant Federal agencies (e.g., Agency for Healthcare Research and Quality (AHRQ) [previously, the

Agency for Health Care Policy and Research (AHCPR)], which has an important role in connecting

services and research in the healthcare field) should be encouraged. However, because Panel IV’s

charge is focused on the issue of substance abuse, the responsibility for this effort should primarily

fall with CSAT, NIDA, and NIAAA.

The Panel recommends that CSAT enter into formal memoranda of agreement with NIDA, NIAAA,

and other appropriate Federal agencies regarding CSR efforts to ensure systematic, ongoing collaboration for the development and operation of the CSR system, and to clarify roles and expectations.

The CSR system would be responsible for advising, overseeing, and reporting on progress and

efforts toward the mission of connecting services and research, and appropriately involving

researchers, service providers, and all other relevant stakeholders in knowledge development, transfer, and application efforts. The national panel would be expected to issue an annual status report

describing the effect, successes, and barriers of the activities of the CSR system (and the various

stakeholders). The report should be addressed to the relevant Federal authorities, and should be 
103

made available as a resource to all relevant Federal, State, and local agencies; legislative bodies; the

service provider community; and concerned organizations.

To ensure accountability, the CSR system should be incorporated into the ONDCP National Drug

Control Strategy as the focal point of the CSAT/SAMHSA response to objectives to support the

development and application of research around preventing or reducing drug abuse and dependence (Goal 3, Objectives 5 and 6). The CSR national panel will facilitate communication among the

national, regional, and State levels and will promote coordination among CSAT, NIDA, NIAAA, and

other Federal agencies. The CSR national panel should act under the general authority of the

Department of Health and Human Services, with support and direction provided by the Director of

CSAT. CSAT should have the primary responsibility for establishing and maintaining the CSR system.

II. Background and Understanding the Problem

Government funding for research on substance abuse and treatment has increased for more than 

25 years. Many rigorous studies of carefully crafted substance abuse treatment components found

to be effective have great potential for helping service providers serve their clients better. Yet, for a

variety of reasons, these treatment practices are often not implemented in community treatment

settings. Also, there are additional areas of study that need to be researched that could have a significant, positive effect on treatment outcomes.

The communication problem between the research and service provider communities is neither new

nor unique to substance abuse. Although the field has made “great strides in research on the etiology, course, mechanisms, and treatment of addiction,” there remain “serious gaps of communication.

. . between the research community and community-based drug treatment programs” (IOM, 1998).

For treatment to continue to improve and to take full advantage of the investment in research, a

true collaborative relationship must be established between the service delivery and research communities. Providers and other stakeholders must have the opportunity to contribute to treatment

and services research, not only through participation in studies, but also in generating treatment

and services topics to be addressed by the national research agenda. Service providers, policy makers, and State regulators need to receive the products of research in a form that facilitates their

implementation, application, and adoption. Technical assistance and other hands-on training techniques are necessary to successfully infuse research. Furthermore, it should be recognized that there

are inevitable costs associated with changing administrative policies and treatment practices. State

authorities and local providers will need financial assistance in adopting new practices on a broad

scale (see Panel III Report).

Collaboration among the responsible Federal agencies will enable research and services to learn

from and respond to each other. As recommended in the 1998 IOM report, “CSAT, NIDA, NIAAA,

REPORT OF PANEL IV
104

Changing the Conversation

and AHCPR are the Federal agencies that should develop formal collaborations, where appropriate,

to synthesize research, reduce the barriers to knowledge transfer, and provide updated information

about drug and alcohol treatment strategies to purchasers of health care.”

NIDA and NIAAA concentrate more on research and knowledge development, while CSAT focuses

more on services and knowledge transfer and application efforts. To enable research and services to

learn from and respond to each other, collaboration among the leading federal agencies is essential.

A system that will facilitate this collaboration and ensure this kind of interaction needs to be established and is the major concern of this Panel report.

A. CURRENT INITIATIVES 

In response to the 1998 IOM report, Bridging the Gap Between Practice and Research, CSAT, NIDA,

NIAAA, and others have developed important programs and initiatives designed to increase communication between substance abuse treatment providers and the research community, including

the following:

CSAT — CSAT initiated the Practice/Research Collaboratives (PRCs) program to organize networks

of community-based substance abuse treatment providers, researchers, and policymakers. The

intention of the PRCs is to develop the necessary infrastructure to increase interaction and knowledge in funded communities. As stated in the Guidelines for Application (GFA), providers and

researchers involved in the PRCs are expected to be “full collaborators in the development of the

research proposals, implementation of protocols, interpretation of data, and publication of results.”

NIDA — The NIDA Clinical Trials Network program was developed to establish a research infrastructure to conduct multisite clinical trials of interventions such as testing the integration of new

medications and behavioral interventions in clinical practice. Additionally, under its Research to

Practice program, NIDA will support research to improve knowledge of how to move research-based

drug abuse treatment interventions into clinical practice. Despite research on a variety of psychosocial, behavioral, and pharmacological treatments, many of these interventions are still not in widespread clinical use.

NIAAA — Knowledge development activities at NIAAA include the publication of Improving the

Delivery of Alcohol Treatment and Prevention Services, a national plan for identifying the research

needs in the field and focusing future research efforts in those areas. This report set forth a broad

agenda for research in such areas as managed care, treatment access, treatment outcomes, treatment

costs, prevention services, and the research infrastructure. On the knowledge transfer side, NIAAA,

in collaboration with CSAT, has held a series of Research to Practice Forums, which bring together

leading researchers with directors of public and private treatment centers and others in the field to

discuss the latest research advances that should be incorporated into clinical practice. Interest

THE NATIONAL TREATMENT PLAN INITIATIVE
105

expressed at the Research to Practice Forums has led to an additional development, a Researcher in

Residence Program. Also, a joint NIAAA/CSAT effort, this program places research experts for brief

periods of residence at participating treatment centers for the express purpose of facilitating the

adoption of specific changes in clinical practice.

AHRQ — In 1997, AHRQ (formally AHCPR), launched its initiative to promote evidence-based

practice in everyday care through establishment of 12 Evidence-based Practice Centers (EPCs).

The EPCs develop evidence reports and technology assessments on clinical topics that are common,

expensive, and/or are significant for the Medicare and Medicaid populations. With this program,

AHRQ became a “science partner” with private and public organizations in their efforts to improve

the quality, effectiveness, and appropriateness of clinical care by facilitating the translation of evidence-based research findings into clinical practice.

State Efforts — A number of States have demonstrated initiative and leadership in efforts toward

provider-researcher collaborations. For example, in Iowa, four academic institutions are connected

with State policymakers. In this model, three advisory panels act on internal, external, and executive

levels to increase communication between research and practice. Another example is Connecticut’s

Academic Partnerships, which have been designed to develop and implement research and service

planning initiatives relevant to substance abuse State policy and service topics. The principles

behind this alliance are to collaboratively identify research projects, jointly develop and implement

research proposals, disseminate results to partners and stakeholders, and promote ongoing dialogue

between researchers and providers.

It should be noted that CSAT has several programs that provide knowledge about substance abuse

treatment and related topics to treatment providers:

The Addiction Technology Transfer Centers (ATTCs) were established in 1993. By 1998 CSAT funded

a network of 13 geographically dispersed ATTCs covering 39 States, the District of Columbia,

Puerto Rico, and the Virgin Islands, along with a National Office to coordinate cross-site activities.

Drawing from current health services research from NIDA and NIAAA and applied research from

SAMHSA, the ATTCs develop and disseminate curricula and state-of-the-art addictions information

through comprehensive education and training programs, work toward the upgrading of standards

of professional practice for addictions workers in multiple settings, prepare practitioners to function

in managed care settings, and stimulate educational providers to address addiction in academic programs for relevant disciplines. The ATTC programs address all elements of addiction treatment and

recovery for addictions treatment and public health/mental health personnel, institutional and community corrections professionals, and other related disciplines. These programs are presented in

traditional format as well as through a variety of innovative distance technologies and other models

of dissemination such as the presentation of symposia/workshops/papers at national, regional, and

State professional meetings, exhibit booths, newsletters, and Web sites.

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The National Leadership Institute (NLI) was established to provide a learning environment in which

community-based substance abuse treatment providers can share their expertise in management

and business practices, while also building a new body of knowledge for the public treatment field.

The mission of the NLI is to help community-based treatment providers obtain the business and

management knowledge and technologies needed to successfully meet the challenges posed by the

rapidly changing health care services delivery and payment environment. The NLI provides support

to treatment providers primarily through technical assistance and training.

The Knowledge Application Program (KAP) was initiated in 1999 and provides for a comprehensive

array of knowledge application activities designed to ensure that knowledge developed by CSAT

grants, cooperative agreements and contracts is appropriately “packaged” and disseminated to 

targeted audiences in the substance abuse treatment field and related fields (e.g., criminal justice,

and welfare). The program also provides for activities to encourage and support the adoption by

the substance abuse treatment and related fields of best treatment practices.

B. WHY WE NEED A SYSTEM

The programs described in the “Current Initiatives” section, although clearly laudable, are nonetheless limited in scope and fragmented, and there are few existing efforts to establish linkages among

relevant Federal organizations. The various Federal agencies have generally focused attention on

their particular constituencies. Thus, NIH programs typically concentrate on the concerns of

researchers, whereas CSAT programs focus on the concerns of service providers.

The Panel strongly endorses a systemic approach that would build on and support the independent

efforts of all stakeholders, help to coordinate their efforts, and fill existing gaps that currently prevent necessary connections. The system should address the entire research process, including the

development, transfer, and application of new knowledge, with a particular emphasis on the knowledge application component. Federal efforts have historically focused on research efforts and 

dissemination of research findings, but have had only limited involvement in knowledge application

(i.e., the implementation and adoption of treatment components found to be effective).

A system that can address the entire spectrum of knowledge development, transfer, and application

would create opportunities to multiply the effect of various efforts by individual agencies or groups.

It would support and enhance the efforts of researchers and service providers alike to ensure that

new research is focused on appropriate subjects and that evidence-based practices are developed and

effectively adopted by the field — a crucial element in improving substance abuse treatment. The

Panel has proposed a framework for such a system, which is detailed in the “Recommendations”

section of this Panel report.

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III. Themes from the Public Hearings

Because a community perspective is vital to this effort’s success, CSAT held six public hearings

across the Nation to gather their input. More than 400 testimonies were heard from individuals

from 31 states and included representatives from the recovery community, State, and local agencies,

treatment providers, educators, and researchers.

Two main concerns emerged from these testimonies. First, many individuals expressed the need 

for a more effective and efficient method of disseminating research findings and outcomes data 

and, more specifically, to use those findings to identify the best treatment practices. Second, much

testimony also focused on encouraging collaborations between community-based organizations 

and researchers that would result in funding and performing research that is relevant to the

provider community.

Other needs expressed during testimony called for:

• Critical research area identification;

• Continuum of care; and

• Culturally sensitive treatment research.

The concerns raised during the public hearings reflect community opinions and were considered by

the Panel members as they developed their overall recommendations.

IV. Recommendation

The Panel recommends the establishment of a system designed to connect services and research

(CSR system), which would be supported and maintained through CSAT. The system should provide an ongoing structure to enable and encourage consistent communication and collaboration

among service providers, researchers, and other relevant stakeholders. The system should focus on

the interdependent functions of knowledge development, transfer, and application, and should have

the responsibility for advising, overseeing, and reporting on the progress and efforts of its mission.

To ensure the success of the CSR system:

• Efforts should occur on the national, regional, and State/local levels.

• A national level panel should work to facilitate communication among the regional, State and

local levels as well as among CSAT, NIDA, NIAAA, and other Federal agencies.

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• CSAT should enter into formal memoranda of agreement with NIDA and NIAAA to establish a

clear understanding of roles and expectations in the development and operation of the system.

• The CSR system should be incorporated into the ONDCP National Drug Control Strategy as the

focal point of the CSAT/SAMHSA response to Goal 3, Objectives 5 and 6.

Guiding Principle of the CSR System

The guiding principle of this CSR system should be to involve service providers and researchers appropriately in mutually supportive ways throughout the development of the national research agenda, the

conduct of research, and the application of evidence-based practices to improve service delivery. The

CSR system should provide the structure and mechanisms necessary to connect the researcher and

provider communities, working in conjunction with CSAT and the relevant research agencies.

Functions of the CSR System

A successful CSR system should allow treatment services research issues to emanate from the field

and should also ensure that evidence-based practices are appropriately infused at the community

level. It should promote the identification of treatment questions that need to be answered, the

development of answers, the communication of findings to service providers, the application of

findings, and the receipt of input from the field for revised and/or new research questions. The following diagram (Exhibit IV.1) illustrates the relationships among the knowledge development,

transfer, and application parts of the CSR system.

Exhibit IV.1 Knowledge, Development, Transfer, & Application Cycle

Design Knowledge

Transfer & Application

Strategies

Examine Successes

& Barriers in 

Knowledge 

Application Implement Knowledge

Transfer & Application

Strategies

NATIONAL

CSR 

PANEL

Service Providers • Federal/StateAgenc ei s O• S reht at ek ho dl ers • Researchers •

Assess Findings & 

Recommend

Service 

Applications

Assess 

Knowledge

Needs & 

Research

Questions

Examine Results

of Review & Funding 

Processes

Develop

Research

Agenda

Recommend Research

Initiatives

Knowledge Development

Knowledge Transfer

Knowledge Application
109

As illustrated by the diagram, the three knowledge areas should not be seen as separate processes,

but rather as continuous and related throughout the cycle. The CSR system should ensure that the

knowledge development process contains within it a consideration of how the research should ultimately be transferred and applied. Similarly, the knowledge application process should always include

within it an evaluation component. That is, what is the outcome of the efforts to implement evidencebased practices at the local level? What do we learn about barriers as well as successful outcomes?

How is this information incorporated into developing the continuing research agenda? 

The nucleus of the cycle is the national CSR panel, which should include representation from service providers, researchers, Federal and State agencies, and other relevant stakeholders. This national

panel would be responsible for guiding and overseeing the operation of the system throughout the

knowledge development, transfer, and application cycle.

KNOWLEDGE DEVELOPMENT. It is crucial for providers to have the opportunity to have an active

role in establishing the national treatment/services research agenda, so that the provider perspective

can be adequately addressed in research studies. Innovative and promising strategies can then

emanate from the treatment community and be subjected to appropriate study.

Furthermore, with appropriate attention given to the needs expressed by providers in the development of research agendas and the conduct of research, researchers will be better equipped to participate in the process of synthesizing and disseminating findings of maximum clinical importance.

The CSR system should be responsible for soliciting treatment issues and research questions from

service providers and other stakeholders in the substance abuse treatment field, and for making recommendations to relevant funding agencies. The goal should be that service provider contributions

acquired through the CSR system would be appropriately reflected in the research agendas of funding agencies through the program announcements (PAs) and requests for applications (RFAs) issued

by these agencies. Specific knowledge development activities include:

• Assessing knowledge needs and research questions;

• Contributing to the development of the national treatment/services research agenda;

• Providing input to the development of research grant announcements; and 

• Examining results of the grant review and funding processes to understand the extent to which

provider/stakeholder priorities and concerns are reflected in pending research.

KNOWLEDGE TRANSFER. This process ensures that research findings are communicated to service

regulators, policy makers, and treatment providers in a structure and format that encourages understanding and use. Knowledge transfer and dissemination efforts to date include, for example,

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CSAT’s Treatment Improvement Protocol series (TIPS) and the Technical Assistance Publications series

(TAPS), NIDA Notes and NIDA Therapy Manual series, and NIAAA’s Alcohol Research and Health,

Alcohol Alert, and Frontlines series.

Building on such products, the CSR system should focus on designing and producing products to

meet additional user needs, in particular, information products that are user-friendly and tailormade to a wide range of audiences (including various types of clinicians, agency directors, policymakers, regulators, purchasers, and academic institutions). It is also essential that the knowledge

transfer products developed are relevant to specific underserved populations and that questions of

diversity are addressed.

The knowledge transfer component of the system should synthesize new knowledge, formulate policy and strategy recommendations relevant to improving the effectiveness of service delivery, and

disseminate research findings and recommended practices to the treatment field. The system would

be responsible for an annual review of findings from studies funded by CSAT, NIDA, and NIAAA

performed in conjunction with these agencies. Based on that analysis, and working in conjunction

with CSAT and the Institutes, appropriate findings should be transmitted to the field (including

findings with regard to clinical practices, as well as management, organizational, and financial practices). Specific knowledge transfer activities should include:

• Assessing research to identify findings that could and should affect practices/policies;

• Synthesizing these findings and translating them into knowledge transfer products useful to all

relevant audiences; and

• Assessing implementation of national and regional knowledge transfer strategies.

KNOWLEDGE APPLICATION. Historically, knowledge application has received significantly less

attention than knowledge development and transfer. This complex function of knowledge application needs to be emphasized and understood to ensure the infusion of proven treatment interventions and approaches into general practice. Studies of knowledge transfer and application have

demonstrated that circulating written materials alone achieves little in terms of adopting new technologies. For treatment clients to derive maximum benefit, evidence-based practices need to be

absorbed into the broad range of community settings involved in substance abuse treatment. It

should also be acknowledged that many community-based programs do not have the infrastructure

or resources to take advantage of state-of-the-art dissemination approaches; innovative approaches

need to be developed to address this problem.

Accordingly, the CSR system should have a strong focus on knowledge application efforts.

Knowledge application should include a careful examination of the adoption process, what strategies facilitate application, and what barriers limit application of a recommended practice. Although

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much can be accomplished with existing knowledge application strategies, the capacity of more

innovative techniques to encourage the use of evidence-based treatment practices needs to be fully

realized. Different strategies should be studied to understand outcomes and to clarify the process of

adopting new treatment practices with different groups and organizational structures.

To appropriately support the implementation of evidence-based practices at the State/local level,

treatment interventions and approaches would first be identified as effective and appropriate for

application through the annual review of study findings (described in the “Knowledge Transfer”

section) to design effective strategies. The national CSR panel, in continuing partnership with the

Federal agencies, would take responsibility for identifying barriers to adopting the evidence-based

treatment components and for describing successful approaches to achieve implementation.

Specific knowledge application activities include:

• Designing and implementing knowledge application strategies for evidence-based treatment

interventions and approaches that are appropriate for adoption;

• Examining successes and barriers in knowledge application;

• Providing needed training and technical assistance; and

• Feeding lessons learned back into new research questions and new knowledge transfer and 

application strategies.

V. Discussion

A. THE CSR SYSTEM

To achieve its objectives, CSR efforts should be made at the national, regional, and State/local levels,

with a structure facilitating communication among them. This will help to link all levels and ensure

that decisions are not made only from the top-down. Also, this multilevel system will help to ensure

that involvement in the CSR activities is widespread, encouraging the likelihood that those activities

will enjoy the greatest possible support.

NATIONAL ROLE. Currently, CSAT, NIDA, and NIAAA each make important and distinct contributions to knowledge development, transfer, and application efforts. The goal of the CSR system is to

better connect, support, and extend these efforts. Crucial to the establishment of an effective system

is the coordination of activities among the CSR panel and these Federal agencies, as well as the system’s capacity to receive and share information with all relevant stakeholders.

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A national CSR panel would facilitate coordination among CSAT, NIDA, NIAAA, and other relevant

stakeholders. The specific responsibilities of this panel should include developing research issues

based on input from providers and other stakeholders to inform the national treatment research

agenda; sharing treatment research findings with the service provider community to improve and

increase client services; and periodically reporting on the progress of collaborative knowledge development, transfer, and application efforts to the Directors of CSAT, NIDA, and NIAAA, as well as

other relevant agencies.

To achieve the needed cooperation, Panel IV recommends that the Director of CSAT, in collaboration with the Directors of NIDA and NIAAA, appoint the Chair (who would not be a Federal

Official) and the members of the national CSR panel. Membership should be based, in part, on an

equal number of nominations from CSAT, NIDA, and NIAAA of their grantees as well as representatives from the service delivery and treatment research fields and from the Single State Agencies, up

to a maximum number of 15 panel members. Representatives from the service delivery field would

constitute a minimum of 50 percent of panel members. The Directors of CSAT, NIDA, and NIAAA,

or their designates, would serve as ex officio panel members. A representative from the DHHS

Office of the Secretary, from ONDCP, and from AHRQ should also be included as ex officio members. Other stakeholders (e.g., NASADAD, State substance abuse authorities, substance abuse treatment professional organizations, other DHHS agencies and other Federal agencies) should be called

on to participate in the panel deliberations as needed, for example, through subcommittees established by the national CSR panel.

Additionally, the Panel recommends that CSAT enter into formal memoranda of agreement 

with NIDA and NIAAA regarding CSR activities to ensure systematic, ongoing collaboration 

for the development and operation of the CSR system, and to establish a clear understanding of

roles and expectations.

To ensure its accountability, the CSR system should be incorporated into the ONDCP National

Drug Control Strategy as the focal point of the CSAT/SAMHSA response to Goal 3, Objectives 5

and 6, which address the need to base effective treatment on research findings. Goal 3, Objective 5

is to “support research into the development of medications and related protocols to prevent or

reduce drug dependence and abuse.” Objective 6 is to “support and highlight research and technology, including the acquisition and analysis of scientific data, to reduce the health and social costs of

illegal drug use” to ensure that “federal, state, and local leaders [are] given accurate, objective information about treatment modalities” (ONDCP 1999 National Drug Control Strategy). The CSR system should be built into the Performance Measures of Effectiveness system (PME) currently being

developed and implemented by ONDCP to assess the performance of the National Drug Control

Strategy. In this way, the CSR system will be held publicly accountable through the ONDCP

National Drug Control Strategy reporting process.

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REGIONAL ROLE. Whereas the national panel should work at a macro-level, most of the needs

assessment and knowledge application work should be conducted at the regional and State/local levels.

Regional-level efforts should facilitate the flow of information about new strategies from the national

level to the field and should also help to communicate the needs of the field to the national level.

The ATTCs and other existing programs should play a significant role in the CSR system at a

regional level. Consideration should be given to modifying the responsibilities of the ATTCs to

allow them to play a substantial facilitative role to identify topics for research and to develop and

conduct knowledge transfer and application.

Specifically, regional efforts should:

• Create a mechanism to ensure participation from providers, researchers, State agency officials,

representatives from the CSR State level, and other relevant stakeholders;

• Classify the data collected from the States with regard to research identified as significant in 

the region;

• Provide support to the States in the development of State panels or other such mechanisms;

• Develop knowledge transfer products and application strategies for implementation at the

regional, state, and local level to improve outcomes. These products should be “hands-on” and

usable by the entire range of community-based providers;

• Coordinate knowledge transfer and application activities; and

• Help determine the success of application efforts and problems in implementation.

In addition to providers, it is essential to include State agency officials, researchers, and other 

appropriate stakeholders drawn from their respective regions.

STATE ROLE. States play a critical role in the financing and management of substance abuse service

systems, as well as in the promotion of quality care. Part of the State’s role in establishing a successful CSR system should be to ensure that local providers are involved in the work of the system and

have the opportunity to contribute to the treatment/services research agenda and participate in the

conduct of the research. Local providers and relevant stakeholders should be contacted to develop

possible research topics.

States should also be responsible for providing leadership to implement knowledge transfer and

application strategies. State agency officials should provide financial incentives and assistance 

to the effort to implement treatment research findings and strategies, and should involve providers,

researchers, and other stakeholders in the particular State, under the leadership of the State 

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substance abuse authority. These efforts should be geared toward the full range of expertise among

community-based providers.

A number of states currently support research and data collection efforts and/or have training 

programs in place for the substance abuse service providers in their State. By building on these

already existing activities and the ongoing relationships they have with their provider systems (contractual, regulatory and otherwise) States are in a position to contribute significantly to the success

of the CSR system.

State service provider associations also exist in many States that are in a unique position to contribute to the success of the CSR system, both to identify research questions and as a mechanism for

knowledge transfer and application.

CSR REPORTING RESPONSIBILITY. The CSR national panel will issue an annual status report

describing the effect, successes, and barriers of the activities of the CSR system. The report should

address the effectiveness of the knowledge transfer and application process with particular emphasis

on the degree to which specific innovations were actually adopted into clinical practice. The purpose of this report is to hold the CSR system accountable for making a difference in successfully

connecting services and research and to encourage modifications or improvements to the system

where warranted. The chair of the CSR national panel would be responsible for the issuance of that

report. The report should specifically address:

• Efforts by the CSR system to obtain research topics and promising treatment interventions

appropriate for research from service providers and other stakeholders;

• The extent to which the topics and interventions identified are actually expressed by the research

initiatives (e.g., PAs and requests for proposals (RFPs) undertaken by CSAT and the Institutes;

• CSR efforts, in conjunction with CSAT and the Institutes, to identify and select research-based

treatment interventions appropriate for application;

• Efforts to develop knowledge transfer strategies that make findings readily available and accessible to service providers and other relevant stakeholders;

• Efforts to develop knowledge application strategies to achieve the adoption of those treatment

interventions and address and overcome barriers to adoption; and

• The extent to which research-based treatment interventions are adopted by service providers.

The report will provide information to CSAT for its reporting to ONDCP on progress toward meeting the relevant research and knowledge transfer goals and objectives of the National Drug Control

Strategy (i.e., Goal 3, Objectives 5 and 6). Additionally, the report should be addressed to the other

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relevant Federal authorities, and should be made available as a resource to Federal, State and local

agencies, legislative bodies, the service provider community, and concerned organizations.

Clarification and elaboration of report findings should be provided to recipients of the report as

necessary and appropriate. In this way, the CSR system should be able to act as a resource for credible information from the field regarding the capacity for the treatment community to benefit from

research conducted, and to contribute to the course of future research.

B. PROPOSED VISION OF IMPLEMENTATION

The CSR system should be responsible for performing specific activities to accomplish its mission

and proposed implementation plan, which are detailed in this section and are illustrated by the

knowledge development, transfer, and application cycle diagram shown previously. Panel IV proposes the following plan as a guide for implementing the CSR system. The Panel recognizes the

need for flexibility in building the system.

1. KNOWLEDGE DEVELOPMENT

Assess Knowledge Needs and Research Questions

The CSR system should encourage the development of research studies that focus on the treatment

questions that are posed by service providers and other stakeholders in the course of contemporary

service delivery. This goal will be accomplished by creating a mechanism that invites opinions from

service providers to the national treatment/services research agenda.

Service providers will be solicited for their concerns regarding service delivery. In addition, there

can be important and innovative strategies practiced by treatment providers (e.g., successful 

partnerships between substance abuse treatment providers and housing unit programs) that are 

currently not being communicated to the research community. It will be the responsibility of the

CSR system to provide essential linkages between members of the research and service delivery

communities to permit significant issues and promising approaches to be incorporated into the

eventual research agenda.

The CSR system should also encourage studies conducted within typical treatment settings to

increase the practicality and generalizability of the findings from research. CSAT, related Federal,

State, and local agencies, and private agencies should support both treatment development (focused

on developing new therapies, treatment practices, and medications) and health services research

(focused on access, effectiveness, outcomes, financing, and organization, and their relationship to

public policy) within “real world” treatment organizations. This “real world” context should include

both urban and rural treatment programs, as well as diversity-related topics (e.g., gender-specific 

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and cultural competency concerns). Every effort will be made to achieve research goals without 

creating major disruptions in the existing treatment process of these programs.

Develop Research Agenda

The CSR system should ensure that a broad representation of providers and other stakeholders and

disciplines is included in the development of the national treatment/services research agenda.

The CSR system should conduct a formal needs assessment that identifies the questions of greatest

relevance and importance to the substance abuse treatment field. These questions will be recommended as subjects to be addressed by the research initiatives of funding agencies (e.g., NIDA,

NIAAA, and other Federal agencies that might conduct relevant research). The system will also

inform itself regarding programs funded by those agencies and of research programs planned in

order to make certain its recommendations do not duplicate ongoing or planned activity. The CSR

national panel should convene at least one meeting each year to seek out knowledge needs expressed

at the State and regional levels and to review agency activities. This information will be used to

develop the research agenda, and in this way, the CSR system will ensure that service providers and

other stakeholders will have the capacity to identify areas of importance not being studied or

planned for study in the research agenda.

As described previously, treatment providers can affect research by identifying important treatment

issues and promising treatment approaches from the field. Provider, State agency, and other stakeholder input can also include systematic feedback on the effectiveness of knowledge transfer and

application strategies, as well as identify barriers to the application and use of evidence-based 

treatment approaches.

Recommend Research Initiatives

The CSR system will encourage research funding agencies to emphasize the importance of

researcher-provider collaborations in research initiatives issued. Specifically, the CSR system should

work to ensure that Federal, State, and local funding agencies (public and private) provide the

financial resources and manpower required by treatment programs to support the collaborative

research efforts. The CSR system should also develop recommendations for Federal funding agencies on how to incorporate information from service providers and other stakeholders into their

research agendas as reflected by the PAs, RFAs, and RFPs issued by these agencies.

There should be a continuing investment in demonstration research programs, which would permit

a mix of funding for research and for service delivery in support of that research. These demonstration research programs would permit the development of treatment models for testing in community settings, and permit greater collaborative efforts between researchers and service providers.

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An example of a potentially useful demonstration research area might involve the subject of group

counseling. Although we have information indicating that group counseling is the predominant

treatment component, we do not have a delineation of the group strategies used and possess virtually no information on the effectiveness of different strategies or of their effectiveness compared 

with individual counseling.

Examine Results of the Review and Funding Processes

The CSR system will regularly examine the results of research grant/contract awards to assess

progress in meeting the goals of linking the research and provider communities and incorporating

provider concerns in approved and funded study. To that end, the system will work with CSAT,

NIDA, and NIAAA to ensure their respective capacities to hear and incorporate the needs and concerns of the treatment community into their research agendas. This will be done by: (1) assessing

and reporting treatment research obtained from the provider community; and (2) encouraging that

PAs, RFPs, and GFAs reflect, to the extent possible, that provider input. Finally, there should be a

periodic assessment of the extent to which provider concerns are actually reflected in approved and

funded programs (i.e., the effectiveness of the CSR process).

2. KNOWLEDGE TRANSFER AND APPLICATION

Assess Research Findings and Recommend Service Applications

The CSR system will work with CSAT, NIDA, and NIAAA to assess the findings developed from

those organizations’ research and knowledge development efforts, and to recommend evidencebased practices for field application. Annually, CSAT, NIDA, and NIAAA will be asked to review

their research findings on evidence-based practices and nominate candidate treatment protocols to

use in the field. The CSR national panel will then work in conjunction with CSAT and the Institutes

to determine which evidence-based practices should be implemented in treatment settings.

The following steps are examples of what might be undertaken:

• The national CSR panel works with CSAT, NIDA, and NIAAA to establish essential criteria to

select evidence-based practices (e.g., robust research findings and feasibility regarding cost and

personnel required).

• The national expert panel solicits nominations from the Federal agencies for evidence-based

practices appropriate for dissemination and implementation.

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• The national CSR panel reviews practices nominated for generalizability regarding both the

affected populations and the issues addressed, practicality, judgment as to cost effectiveness, and

cultural relevance.

• The national expert panel receives information from the regional and State/local levels regarding

priorities and potential barriers (i.e., the list goes to the localities for review, and comes back

both prioritized and with an indication of what barriers might be experienced).

• Based on this information and a careful analysis of potential barriers to implementation, selections for evidence-based practices to be disseminated and used are finalized and a strategy for

application is developed.

Design and Disseminate Knowledge Transfer Products

With specific regard to knowledge transfer (i.e., information sharing), the CSR system will help to

ensure dissemination of research findings, working with and through CSAT. This involves the translation of research findings into useful products that are relevant to State and local providers and the

transfer of this information through, for example, manuals or other written materials, the use of

electronic techniques including websites, and knowledge sharing conferences. A product that provides a taxonomy of evidence-based practice models that can be disseminated to the field biannually

should be considered.

It should be acknowledged again that CSAT, NIDA, and NIAAA all currently produce these information products. However, a major obstacle to overcome in adopting new knowledge is that

research results are often communicated in language appropriate for academic discourse, but not in

a style useful to treatment staff. Therefore, the CSR system will work to ensure that (a) knowledge

transfer products are tailored to suit an entire range of treatment providers with varying levels of

research knowledge, and (b) appropriate training and technical assistance are available.

A broad range of materials should be produced for other stakeholders that impact the substance

abuse treatment system, such as regulators, policymakers, insurers, purchasers, and educators who

can incorporate new services knowledge into curricula designed to train existing personnel and students preparing to enter the field.

Design Knowledge Application Strategies

Many knowledge transfer products and services currently exist, but their counterparts in knowledge

application (to ensure implementation and adoption of innovations) are far less in evidence. Less

effort has traditionally been devoted to ensuring that service providers are able to obtain the technical and problem-solving assistance necessary to implement innovations.
119

Therefore, knowledge application strategies must go beyond knowledge transfer to ensure that new

practices are effectively adopted in the field. Here, the additional use of workshops, consultation,

training, and other strategies is needed. Again, it is critical to be aware of the needs and the nature

of the target group in order to ensure that the knowledge is deemed useful and appropriate. In

addition, it will be critical to receive feedback regarding how that knowledge is used and to learn the

nature and degree of organizational change achieved.

Through the CSR system, assessments will be made of the effectiveness of different application

strategies and of different reward systems (e.g., use of formal recognition, continuing course credits,

financial incentives for program achievement). Additionally, the regions and States will be asked to

conduct a careful analysis of any barriers to implementation and to make suggestions for promoting

the practical application of the selected new evidence-based practices. The field review will also

help ensure that the needs for cultural, geographic, and other adaptations on the local level are

addressed.

It should be emphasized that the CSR system will have effective strategies to achieve knowledge

application available to it immediately. Specifically, research conducted with typical substance abuse

treatment programs has demonstrated the capacity of interpersonal knowledge application strategies (i.e., workshop and consultation models) to achieve the adoption of novel treatment components (Hall, Sorensen, and Loeb, 1988; Sorensen, Hall, Loeb, Allen, Glaser, and Greenbey, 1988).

Thus, knowledge application strategies are now available to further increase the capacity of treatment programs to respond effectively to client populations. The CSR system described provides an

opportunity to use those existing strategies and to understand the effectiveness of additional strategies of knowledge application. The CSR system will identify successful knowledge application and

adoption strategies that address regulatory, financing, administrative, and supervisory matters,

as well as practitioner skill.

Implement Knowledge Transfer and Application Strategies

After the national CSR panel determines the products and strategies appropriate for successful dissemination and application of the selected evidence-based practice, the proposed action plan (tools

and methods) might be submitted for a time-limited field review at the regional and State/local levels. This would ensure that all stakeholders have the opportunity to contribute to the action plan.

The structure of the CSR system can be particularly useful to the process of achieving knowledge

transfer and application. As described previously, having participation from the regional and

State/local levels in the process of selecting treatment components for transfer based on their 

needs and interests, more likely assures the receptivity of local providers to new knowledge 

and treatment techniques.

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By having the regional level association of the ATTCs as part of the overall system, there is the

potential to develop and/or refine knowledge transfer and application strategies that are particularly

well-suited and appropriate to the needs of that region and its States.

With involvement from the State in the overall system, there is the potential for having the local

structure and resources needed to facilitate the process of knowledge transfer and application in

those areas the local providers have defined as significant to their functioning. Thus, just as the CSR

system is structured to permit comments from service providers and other stakeholders regarding

their needs and concerns to the development of the national research agenda, the CSR system is also

structured to ensure the transfer to service providers of that knowledge and those newly available

techniques that are most appropriate to their needs and concerns.

Examine Successes and Barriers in Adoption

The CSR system will also include an evaluation of the efforts made to achieve knowledge transfer

and application. The system will evaluate the adoption of research-based innovations and dissemination strategies, including feedback from practitioners to learn how easily and effectively the innovations were adopted into treatment practices. The CSR system will be responsible for seeking

information from the field regarding the enhancement of client treatment with the adoption of

new practices, and regarding the barriers, if any, that made the adoption difficult or impractical.

By studying the successes and barriers to adopting innovations into treatment settings, new and/or

revised topics may also be fed back into the research agenda.

Additionally, the CSR system could contain a recognition program. The purpose of this program

would be to acknowledge and reward researchers, policymakers, and providers for their contributions to the improvement of treatment services. Recognition of contributions to the improvement

of treatment services is both warranted and can act as an incentive to recipients and to others in the

substance abuse treatment field. For example:

• Researchers should be acknowledged for developing and helping to implement significant 

evidence-based practice initiatives.

• Policymaking groups should be recognized for their roles in facilitating and helping to institutionalize evidence-based practices.

• Providers and other entities such as managed care organizations should be rewarded for special

achievements in the implementation of evidence-based practices.
121

C. CONCLUSION

The CSR system is designed to be comprehensive and to provide the needed linkage between the

service provider and the researcher, such that the researcher receives the benefit of input from the

service provider regarding the provider’s needs and concerns, and the service provider receives

information from the researcher in a format and structure that facilitates practical application of

findings on behalf of the client population to be served. The CSR system, organized and maintained in conjunction with CSAT, would: (a) facilitate input from State and local providers to the 

creation of the national services research agenda, and (b) support the development of knowledge

transfer and application strategies to ensure that the accomplishments of research have the widest

possible application.

Most importantly, by developing a system to enable the service delivery and research communities

to work together more productively, the needs of the client community can be best addressed, and

substance abuse treatment can be made still more effective.

REPORT OF PANEL IV
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Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

VI. Selected Bibliography

The sources listed reflect those used by the panel members based on the data current at that time.

Subsequent sources were not incorporated into the individual reports, but may be in the companion

report, Changing the Conversation, Improving Substance Abuse Treatment: The National Treatment

Plan Initiative.

Brown, B.S., “From Research to Practice: The Bridge Is Out and the Water’s Rising,” Advances in

Medical Sociology 7, Apr. 2000. pp. 345–365.

Hall, S.M., J.L. Sorensen, and P.C. Loeb, “Development and Diffusion of a Skills-Training

Intervention,” (as cited in Assessment and Treatment of Addictive Disorders, Eds.

T.B. Baker and D.S. Cannon [New York: Praeger, 1988]), 1988. pp. 180–204.

Institute of Medicine, Bridging the Gap between Practice and Research: Forging Partnerships with

Community-Based Drug and Alcohol Treatment (Washington, D.C.: National Academy 

Press, 1998).

———, Dispelling the Myths about Addiction: Strategies to Increase Understanding and Strengthen

Research (Washington, D.C.: National Academy Press, 1997).

———, Managing Managed Care: Quality Improvement in Behavioral Health (Washington, D.C.:

National Academy Press, 1997).

———, Pathways of Addiction: Opportunities in Drug Abuse Research (Washington, D.C.: National

Academy Press, 1996).

———, The Development of Medications for the Treatment of Opiate and Cocaine Addictions: Issues

for the Government and Private Sector (Washington, D.C.: National Academy Press, 1995).

———, Broadening the Base of Treatment for Alcohol Problems (Washington, D.C.: National

Academy Press, 1990).

———, Treating Drug Problems: A Study of the Evolution, Effectiveness, and Financing of Public and

Private Drug Treatment Systems Volume 1 (Washington, D.C.: National Academy Press,

1990).

———, Prevention and Treatment of Alcohol Problems: Research Opportunities (Washington, D.C.:

National Academy Press, 1989).
123

Levy, J.A., R.C. Stephens, and D.C. McBride, Eds., Emergent Issues in the Field of Drug Abuse

(Stamford, CT: JAI Press, 2000).

National Institute on Alcohol Abuse and Alcoholism, Subcommittee on Health Services Research,

National Advisory Council on Alcohol Abuse and Alcoholism, Executive Summary,

Improving the Delivery of Alcohol Treatment and Prevention Services, NIH Publication No.

97-4224 (Bethesda, MD: NIAAA/NIH/DHHS, 1997).

Office of National Drug Control Policy, The National Drug Control Strategy, 1999 (Washington,

D.C.: ONDCP, 1999).

Sorensen, J.L., S.M. Hall, P. Loeb, T. Allen, E.M. Glaser, and P.D. Greenberg, “Dissemination of a Job

Seeker’s Workshop to Drug Treatment Programs,” Behavior 19, 1988, pp. 143–55.

REPORT OF PANEL IV
124

Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

VII. Participants

PANEL MEMBERS

Constance Horgan, Sc.D. (Chair)

Professor and Director

Health Services Research

Schneider Institute for Health Policy

The Heller School

Brandeis University

Waltham, MA

Barry Brown, Ph.D.

Adjunct Professor

Department of Psychology

University of North Carolina 

at Wilmington

Carolina Beach, NC

Daniel Conti, Ph.D.

Employee Assistance Program Director

Bank One

Chicago, IL

Brian Cuffel, Ph.D.

Vice President of Research and Evaluation

United Behavioral Health

San Francisco, CA

John Daigle

Executive Director

Florida Alcohol and Drug 

Abuse Association

Tallahassee, FL

Thomas D’Aunno, Ph.D.

Associate Professor

School of Social Service Administration

University of Chicago

Chicago, IL

Bennett Fletcher, Ph.D.

Branch Chief

Services Research Branch

Division of Clinical and Services Research

National Institute on Drug Abuse

Bethesda, MD

Steven L. Gallon, Ph.D.

Project Director

Northwest Frontier

Addiction Technology Transfer Center

Salem, OR

David Gastfriend, M.D.

Massachusetts General Hospital

Associate Professor of Psychiatry

Harvard Medical School

Boston, MA

Merwyn Greenlick, Ph.D.

Professor and Chair

Public Health and Preventive Medicine

Oregon Health Sciences University

Portland, OR

Michael Hilton, Ph.D.

Health Scientist Administrator

Division of Clinical and 

Prevention Research

National Institute on Alcohol Abuse 

and Alcoholism 

Bethesda, MD

Michael W. Kirby, Jr., Ph.D.

Chief Executive Officer

Arapahoe House, Inc.

Thornton, CO

Jeffrey Kushner

Drug Court Administrator

Missouri Municipal Courts

St. Louis, MO

Therissa A. Libby

Chair

NAADAC Research Committee

Graduate Program in Neuroscience

University of Minnesota

Minneapolis, MN
125

Howard A. Liddle, Ed.D.

Professor and Director

Center for Treatment Research 

on Adolescent Drug Abuse

Center for Family Studies

Miami, FL

Cirilo Madrid

Executive Director

Aliviane No-Ad, Inc.

El Paso, TX

Jean-Marie Mayas, Ph.D.

President

The MayaTech Corporation

Silver Spring, MD

Thomas McLellan, Ph.D.

Scientific Director

The Treatment Research Institute

Philadelphia, PA

Robert Rosenheck, M.D.

Director

Northeast Program Evaluation Center 

VA Connecticut Health Care System

West Haven, CT

Arthur J. Schut

Executive Director

Mid-Eastern Council on Chemical Abuse

Iowa City, IA

Kenneth D. Stark

Director

Division of Alcohol and Substance Abuse

Washington Department of Social 

and Health Services

Olympia, WA

James Swartz, Ph.D.

Director

Research and Information Services

Treatment Alternatives for

Safe Communities, Inc.

Chicago, IL

Constance Weisner, Dr.P.H.

Professor, Department of Psychiatry 

University of California, San Francisco

Berkeley, CA

CSAT STAFF (ROCKVILLE, MD)

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community 

Assistance

Frances Cotter

Social Science Analyst

Office of Managed Care

Edwin M. Craft, Dr.P.H., M.Ed., LCPC

Program Analyst

Office of Evaluation, Scientific Analysis 

and Synthesis

Jon Gold

Branch Chief

Synthesis Branch

Office of Evaluation, Scientific Analysis 

and Synthesis

Sheila Harmison, D.S.W.

Public Health Analyst

Division of State and Community 

Assistance

James M. Herrell, Ph.D., M.P.H.

Public Health Analyst

Division of Practice and Systems 

Development 

Roger Straw, Ph.D.

Deputy Director

Office of Evaluation, Scientific Analysis 

and Synthesis

REPORT OF PANEL IV
126

CONSULTANTS: THE LEWIN GROUP

(FALLS CHURCH, VA)

May Chao, M.S.W.

Senior Associate

Andrew Tucker

Research Analyst

PANEL MEETING SPEAKERS AND

CONTRIBUTORS

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

Deputy Commissioner

State of Connecticut 

Department of Mental Health 

and Addiction Services

Hartford, CT

Gene M. Lutz, Ph.D.

Director

Center for Social and Behavioral Research

University of Northern Iowa 

Cedar Falls, IA

Flo Stein

Chief

Substance Abuse Services

Division of Mental Health, Development 

Disabilities and Substance Abuse Services

Department of Health & Human Services

Raleigh, NC

Roger Straw, Ph.D.

Deputy Director

Office of Evaluation, Scientific Analysis 

and Synthesis

Center for Substance Abuse Treatment

Rockville, MD

Jane Ungemack, Dr.P.H

Assistant Professor

Health Services Research Division

Department of Community Medicine 

and Health Care

University of Connecticut Health Center

Farmington, CT

Janet Zwick

Director

Division of Substance Abuse and 

Mental Promotion

Iowa Department of Public Health

Des Moines, IA
THE NATIONAL TREATMENT PLAN INITIATIVE

Changing the Conversation

REPORT OF PANEL V

Report of Panel V:

Addressing Workforce Issues

Changing the Conversation

129

Table of Contents

I. EXECUTIVE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130

II. BACKGROUND AND UNDERSTANDING THE PROBLEM . . . . . . . . . . . . . . . . . . . . . . . . . . . 133

A. Prevalent Problems for the Substance Abuse Treatment Workforce . . . . . . . . . . . . . . . . . . . . . .134

B. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .137

III. RECOMMENDATIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

IV. DISCUSSIONS: OPPORTUNITIES FOR THE FUTURE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156

A. Education and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

B. Credentialing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .156

C. Supply, Demand, and Distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157

D. Factors to Consider in Moving Forward . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .158

V. SELECTED BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

VI. PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

VII. GLOSSARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170

REPORT OF PANEL V

THE NATIONAL TREATMENT PLAN INITIATIVE
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Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

Substance abuse treatment providers are “responsible for adapting to changing realities that affect

where they work, what skills they will need on the job, how they can best provide the services, who

they work with, and even the philosophical underpinnings that guide their efforts. It is the workforce that must be recruited to provide needed services. It is the workforce that must be trained to

provide the types of services that are being put into place. It is the workforce that must often meet

special certification and accreditation requirements. And it is the workforce that is ultimately

responsible for supporting the individual growth and development of the people who are receiving

. . . . health services” (Fazzi, 1990).

I. Executive Summary

Fazzi (1990) identified recruitment, training, certification, and accreditation requirements as key

issues related to workforce. In line with this approach, the Workforce Issues Panel (the Panel) members identified current workforce topics causing concern, and organized these within three issue

groups: (1) Education and Training; (2) Credentialing; and (3) Supply, Demand, and Distribution.

The objective of professionals to guarantee universal delivery of optimum standards of care, together with the recent connection between provider reimbursement and education levels, call for a 

formal strategy and defined standards for educating and training substance abuse treatment staff.

However, currently there is no consensus on the best approach to educating and training the substance

abuse treatment workforce. Moreover, the lack of categorical funding for education and training

impedes the work that can be done to address this at a system level and at a program level. The variety

of educational backgrounds that staff bring to the field dictates an approach to basic and continuing

education that is widely applicable. The changing patient population, the introduction of managed

care, as well as other environmental and policy changes introduce substantial complexity.

The Panel recognizes the compelling need to integrate the variety of approaches to substance abuse

counselor credentialing that currently exist. Credentialing processes employed in other professions

whose members practice in healthcare (e.g., nurses, physicians, social workers) exacerbate this diversity of approaches, as do those employed in professions whose members are credentialed for practice by their own profession but might also have a specialty credential in addiction. Clearly, the field

needs a more cohesive and unified approach to credentialing.
REPORT OF PANEL V

131

Inadequacy of quantitative workforce data to inform discussion severely hampers analysis of supply

and demand. In addition to a lack of general and specialist skills, there is anecdotal evidence of a

shortage of staff with administrative skills, staff with an understanding of the substance abuse system, and staff who work in research and/or academic settings. Furthermore, the increasing ethnocultural diversity in the treatment population calls for a workforce that is ethnically and culturally

diverse and sensitive to the cultural concerns of different client groups.

The recommendations of the Center for Substance Abuse Treatment (CSAT) National Treatment

Plan Initiative (NTP) Workforce Issues Panel address all three core issue groups, with the intent of

bringing the substance abuse treatment field closer to the Panel’s vision of the future, as delineated

in the Analysis section. Presented in Figure 1, the recommendations fall into three types: (1) those

that address the need for a Federal agency, with responsibility for workforce-related issues such as

education and development; (2) those that seek to strengthen the workforce infrastructure in the

substance abuse treatment system, (e.g., workforce strategies, policies, and procedures); and 

(3) those that require implementation at a field and/or program level.
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Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE Recommendations Goals Establish funding mechanisms to support workforce recruitment, retention, and development 

initiatives.

Advocate for 

competency-based

career ladder

opportunities in

addiction treatment

settings.

Advocate for all health

and human servicerelated accrediting and

certifying/re-certifying

agencies to require 

education and competence in addiction and

inclusion of addiction

questions on all 

credentialing exams.

Establish standards 

for didactic, clinical,

and experiential 

education and 

training of addiction

professionals and 

other health and

human 

services providers.

Advocate for and

encourage academic

institutions to develop

and offer degree 

programs for 

addiction 

professionals at the

undergraduate and

graduate levels.

Develop and

strengthen

a comprehensive

infrastructure that

attracts, supports,

and maintains a 

competent, diverse

workforce,

reflective of its

Provide a national

client population.

platform to address

workforce issues.

Establish a National

Workforce

Development

Office at CSAT.

Ensure the development 

of core curricula based on 

CSAT’s Technical Assistance 

Publication 21, Addiction Counseling

Competencies: The Knowledge, 

Skills, and Attitudes of Professional

Practice for the education 

of addiction counselors.

Ensure inclusion of basic 

addition-related curricula 

in all levels of education and 

training programs for health 

and human services providers, 

that is appropriate for their 

scope of practice.

Improve the competency of a diverse

addiction workforce

by providing didactic,

clinical, and experiential education and

training based on a

core body of the latest

evidence-based

knowledge

Figure 1. Goals and Recommendations of the Workforce Issues Panel
REPORT OF PANEL V

133

II. Background and Understanding the Problem 

The introductory quote by Fazzi powerfully conveys the crucial role of the substance abuse treatment workforce as well as the importance of workforce policies in the delivery of quality treatment

services. The substance abuse treatment workforce presents multiple issues and challenges, which

have rarely, if ever, been addressed as a whole. Many groups and individuals have undertaken excellent work on individual aspects of the substance abuse treatment workforce; however, the complexity of issues and the number of agencies in contact with individuals with substance-related disorders

require a more holistic approach. Establishment of a Panel to address workforce issues provides the

substance abuse treatment field with an opportunity to undertake the first comprehensive, qualitative analysis of substance abuse treatment workforce issues and to present recommendations that

can serve as an agenda for improving the workforce in the twenty-first century.

The substance abuse treatment workforce includes a wide array of practitioners and lay persons 

who care for clients with a range of substance abuse problems, in a variety of settings. Psychiatrists

and other physicians, psychologists, nurses, social workers, counselors, marriage and family therapists, individuals recovering from a substance related-disorder, clergy, and many others are involved

in client interventions.

The degree to which professional staff are educated in substance abuse treatment differs from one

discipline to another. Requirements for substance abuse treatment credentialing also vary from one

discipline to another. The diversity of educational backgrounds within this workforce, as well as the

diversity of client needs, creates a unique challenge to the substance abuse treatment field in its

efforts to develop workforce policies and procedures consistent with established healthcare professions. Furthermore, policy decisions on credentialing requirements, opportunities for further education, professional development, and the existence of a professional career ladder affect the number

and quality of staff in a given healthcare field. Therefore, the specifics of workforce policies and

procedures will have a far-reaching impact on the supply of (and, therefore, demand for) workforce

in the substance abuse treatment field.

For the purposes of this report, the substance abuse treatment workforce is defined as practitioners

in a variety of related disciplines (e.g., counselors, physicians, nurses, psychologists, social workers

with varying levels of education, training, experience and credentialing) who intervene in the lives

of people with substance use disorders.

The Panel considers good substance abuse treatment to be a function of the following workforce

characteristics:

• Quality — education, training, credentialing, experience (type and length);

• Quantity — supply and demand, staff distribution, client-staff ratio;
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THE NATIONAL TREATMENT PLAN INITIATIVE

• Social characteristics — cultural congruence, cultural competency;

• Practice — competence consistent with continuum of care, client experience, client needs, and

environmental context.

The challenge for the Panel was to develop recommendations that: (1) protect and enhance the

supply of staff; (2) establish and apply cross-disciplinary practice standards for competency development, continuing education, training, and credentialing that protect client interests, satisfy the

demands of payors, and address the interests of staff; and (3) recognize and preserve the diversity of

staff background.

The Panel structured its work on workforce issues within the core issue topics of Education and

Training; Credentialing (including licensing and certification); and Supply, Demand, and

Distribution. Although this framework proved useful in the beginning to address workforce concerns in a structured way, the Panel realizes that, in reality, extensive overlap exists. Despite this

overlap, challenges facing the substance abuse treatment workforce of the future can be well articulated under these core groups.

A. PREVALANT PROBLEMS FOR THE SUBSTANCE ABUSE TREATMENT WORKFORCE

Education and Training

SUBSTANCE ABUSE TREATMENT STAFF. Increased provision of basic education and training standards is widely supported for new substance abuse treatment professionals entering the field. With

regard to existing personnel, the field has begun to address the need for standards for basic and continuing education through initiatives such as CSAT’s Technical Assistance Publication 21 (TAP 21),

Addiction Counseling Competencies: The Knowledge, Skills, and Attitudes of Professional Practice.

1

Nevertheless, a number of factors have complicated efforts to develop a standardized approach for

staff (i.e., counselors, social workers, and physicians) who require continuing education.

Several issues have constrained the field’s ability to formulate and implement a consistent approach

to education and training. First, there is no consensus about the best approach to educate and train

current substance abuse treatment staff. Second, the political and social environment, particularly

dynamic in recent years, continues to transform the context within which this education and training takes place and to modify the nature of the solution. For example, ongoing changes in the substance abuse treatment delivery system have brought about changes in staff competency require1 Intended to provide guidance for the professional treatment of substance use disorders, Technical Assistance Publication (TAP) Series 21, Addiction Counseling

Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, presents the knowledge, skills, and attitudes required for achieving and practicing the 

competencies defined in the 1995 publication Addiction Counseling Competencies.
REPORT OF PANEL V

135

ments, largely due to the shift from inpatient to outpatient services under managed care. Third, the

lack of specific funding sources designated for education and training activities for new and existing

staff further impedes efforts to achieve general agreement.

Consolidated education and training strategies must be widely applicable to substance abuse treatment personnel from all backgrounds, some of whom may lack formal education and training in

addiction. Expansion of the substance abuse treatment system has occurred, in part, because many

individuals with personal experience of addiction and recovery have entered the field. This personal

experience is often the foundation of their knowledge, work, and commitment.

Some stakeholders are concerned that, unless the substance abuse treatment profession retools its

workforce (both staff with and without formal education in addiction), high levels of care and treatment might not be provided universally. In addition, provider reimbursement (from managed care

organizations) for substance abuse treatment services may depend on compliance with a prescribed

level of education and credentials. Conversely, others feel that if mandatory education and training

requirements are imposed, some staff might leave the field because of costs and other barriers associated with gaining the required education. The challenge is to develop an education and training

approach for the entire workforce that (a) guarantees that all staff can deliver high levels of care and

treatment, and (b) meets the needs of a changing client population.

OTHER PROFESSIONALS. All health and human services staff — as well as staff of other agencies

— who might be in a position to recognize indicators of substance abuse should receive, at a minimum, training in screening and referral. Although credentialed in their own field, primary care and

other professionals might have received little or no education about substance-related disorders.

Therefore, professionals in other disciplines who interact with clients with substance-related disorders (e.g., primary care physicians, nurses, psychologists, social workers, psychiatrists, and emergency department staff) also have education and training needs.

Credentialing

Credentialing of addiction treatment staff remains one of the most challenging matters to characterize

clearly. Mactas, Trout and Jackson (1996) present three distinct forces that impact the current debate:

• The tradition of practitioners of any art to establish boundaries that communicate who is 

qualified to practice.

• Pressure exerted by changes in the organization and delivery of healthcare, particularly the move

to managed care in the public sector. (Although the field itself struggles with how it will address

credentialing internally, the managed care industry dictates from the outside the credentials 

necessary to receive reimbursement for treating addiction.) 
136

Changing the Conversation

• Recognition that therapists make a difference in treatment outcomes and that those therapists

vary in success rate.

Much of the discussion in the Education and Training section also relates to credentialing. The

issue is further complicated by the multiple credentialing systems that exist nationally, and the wide

variation in credentialing requirements among the States. The Panel advocates for a credentialing

process that preserves the value obtained from the diversity of the substance abuse treatment workforce; responds to and supports the objectives and activities of the substance abuse treatment system;

and reflects the most current research on effective treatment approaches. The Panel also noted that,

in order to be recognized as a profession, a discipline must have a credentialing process that includes

nationally recognized educational standards and a national, competency-based examination.

The variety of approaches to individual substance abuse treatment credentialing, both within the

counseling profession and in other professions, can be confusing. Most States require that substance

abuse treatment professionals be credentialed; it is thought that around two-thirds of the total

addiction counselors in the United States are credentialed. The remainder (primarily in the public

sector) work under supervision in accredited or approved drug and alcohol treatment programs.

However, the prerequisites for credentialing and re-credentialing of substance abuse treatment professionals vary from State to State. Furthermore, other staff in the field, such as registered nurses,

social workers, and physicians, are credentialed by their own discipline/professional body and/or by

the State. These individuals might also apply for a specialty credential in substance abuse treatment.

Supply, Demand, and Distribution

Maintaining an adequate supply of competent substance abuse treatment staff who are trained to

practice at specified levels, from basic entry-level to advanced, and who can address the complex

needs of diverse client groups is critical. Yet, the field has not addressed in depth the question of

how to ensure the supply and distribution of qualified staff, perhaps because there exist no comprehensive, comparative workforce data for analysis. The possibility of conducting gap analyses is limited because there is no means of reliably identifying numbers and types of staff in the workforce,

and which staff are needed where and with what competencies.

In addition to ensuring an adequate supply of credentialed substance abuse treatment counselors

with general training, the substance abuse treatment field needs staff to be competent in specific

areas. These include co-occurring disorders (such as HIV/AIDS, mental health and disabilities),

welfare reform, criminal justice, domestic violence, child protective services, cultural competence,

and responsiveness to the diversity of clients with substance use disorders. There is also a demand

for all staff to possess an understanding of the function of the substance abuse treatment system,

including its inter-relationships with other systems and/or fields, since staff who have program

management and administrative skills are also needed. Staff effectiveness partially depends on the

THE NATIONAL TREATMENT PLAN INITIATIVE
REPORT OF PANEL V

137

structure and management of the program in which they work. Furthermore, staff who work in

research or other academic settings and those who can translate research into practice are needed.

Although university-based substance abuse treatment education programs offer a variety of education and training curricula, there is a widely held view that economic, social, cultural, and geographic isolation might prevent or deter interested individuals from entering these programs.

These and other barriers profoundly affect the supply of competent staff.

B. ANALYSIS

Environmental Context 

The Panel notes that the context within which the substance abuse treatment field operates is complex and highly politicized. Particularly in the last fifteen years, the client population and other

environmental factors have been notably dynamic and challenging. Recommendations for the

workforce developed without an understanding of the field’s history, current challenges, and

increasing complexity likely will result in a lack of problem resolution, and might even hinder the

progress of the substance abuse treatment field. Thus, analysis of this environmental complexity

and the major implications for the treatment workforce is critical to developing informed and 

effective recommendations for the future.

Section IV D, Factors to Consider in Moving Forward, presents an analysis of key environmental

developments that have affected the substance abuse treatment field in recent years. An issue that

impacts the workforce most directly is the ethno-cultural diversity of the treatment population,

which is rapidly increasing. This client diversity requires staff to possess and utilize strong, flexible

cultural competency skills and sensitivity to the varied needs of these numerous and changing client

groups. Furthermore, to ensure that clients receive the best possible care, the workforce must keep

current in changes in practice. However, research results are often not readily available or disseminated in accessible forms, which impedes their application in the field.

The Panel believes that developments in health industry structure recently have raised the profile of

staff credentialing, education and training, as managed care organizations (MCOs) have linked service reimbursement to workforce requirements in these areas. The gatekeeping strategies of these

organizations have reduced dramatically the use of treatment programs, particularly residential

treatment, which has led to program cutbacks, closings and, ultimately, job losses in the substance

abuse treatment workforce. Social policy legislation, such as Welfare Reform and Drug Free

Workplace legislation, has also impacted substance abuse treatment staff. Federal legislation that is

not substance abuse-specific also might be important to understand when considering workforce

issues. However, inadequate quantitative workforce data hamper policy debates focused specifically

on workforce issues. Lack of adequate data also hinders Panel attempts to analyze workforce supply

and demand in any meaningful way.
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THE NATIONAL TREATMENT PLAN INITIATIVE

There are no individual funding streams intended specifically for development of the workforce; as

a result, funding for workforce initiatives must come from treatment funds. The lack of a specific

budget item for the workforce ultimately results in the personal development needs of staff competing with treatment and other patient needs.

Quantitative Analysis of the Substance Abuse Treatment Workforce

Independent substance abuse agencies and/or stakeholder groups have collected data on the 

workforce. Examples include the Substance Abuse and Mental Health Services Administration’s

(SAMHSA) ongoing Office of Applied Studies Alcohol and Drug Service System Study, the National

Association of Alcohol and Drug Abuse Counselors’ (NAADAC) 1993 Salary and Compensation

Study of Alcohol and Drug Abuse Professionals, the 1996 selected Addiction Technology Transfer

Center (ATTC) survey of the education level of counselors (Adams and Gallon, 1997), and the ATTC

of New England/Harvard Medical School’s identification of training needs among New England substance abuse treatment providers (Shaffer, Hall and Vander Bilt, 1995). As a result, there are substantial areas in which the field has gained information on staff groups and specific 

workforce issues or trends. However, available research data are not linked. Typically, organizations

carry out their research studies independently. Consequently, the results do not lend themselves to

comparison, and cannot be consolidated to obtain a national picture.

Although before 1994, the National Drug and Alcohol Treatment Unit Survey (NDATUS) collected

selected data fields about the staff that make up the national substance abuse treatment workforce,

these fields were eventually dropped from the data set (SAMHSA, 1999). The new Uniform Facility

Data Set (UFDS), which integrates with the Drug and Alcohol Services Information System

(DASIS), contains no information on the substance abuse treatment workforce.

Despite the data collection and research efforts of some agencies, the Panel notes that there is still

no current national, common workforce data set or repository of substance abuse treatment staff

data. This fact emphasizes the need for new precursory data collection on the workforce, as well as

for effective secondary research. Lack of data constrains efforts to analyze and address identified

problems in the workforce.

Qualitative Analysis of the Substance Abuse Treatment Workforce

In the absence of adequate quantitative data, Panel analysis has relied on a descriptive, qualitative

review of selected current issues that concern substance abuse treatment personnel. This analysis

has been distilled primarily from transcripts of Panel speakers and discussions among Panel 

members during meetings.
REPORT OF PANEL V

139

The analysis recognizes inherent overlap among the Panel’s core issues, Education and Training;

Credentialing; and Supply, Demand, and Distribution, and illustrates the depth, breadth, and complexity of the challenges foremost in the minds of Panel members. During the process, Panel members generated many potential solutions and recommendations, suggesting numerous ideas for

developing and preparing the workforce for the future. Their discussion is summarized below.

Education and Training 

INTERNAL ISSUES. The particular skill set that each member of the workforce requires to work

competently and effectively depends on his or her discipline or employing agency, treatment modalities within which the individual works, staff practice level, and the client population served. Staff

working with different client groups, in different specialty areas, or in various allied fields have

diverse needs for substance abuse treatment education and training. For example, staff working in

residential settings encounter different education, training, knowledge, and skill requirements than

those working in private practice or in community mental health clinics. Further, the substance

abuse treatment knowledge and skills of primary care practitioners are critical because the primary

care system is a principle vehicle for accessing the substance abuse treatment system. However, the

competency of these practitioners in addressing addiction is inconsistent. Primary care staff might not

understand addictive disease, often lack the ability to screen a client, and might not be prepared to

intervene or to refer. This training gap also occurs among other health and human services and criminal justice staff.

CSAT’s TAP 21, Addiction Counseling Competencies: The Knowledge, Skills and Attitudes of

Professional Practice, identifies the competencies the Panel considers important to the substance

abuse treatment system; these competencies should be incorporated into the core curriculum of

addiction education and training programs. TAP 21 is divided into two sections. The first identifies

the knowledge and attitudes that underlie competent practice for counselors and addiction specialists in other disciplines. Functional skills might vary across disciplines, but the knowledge and attitudes highlighted here provide a basis of understanding that should be common to all addiction

professionals and that serve as a prerequisite to development of competency in each discipline.

These foundations are Understanding Addiction; Treatment Knowledge; Application to Practice;

and Professional Readiness. The second section addresses the professional practice of addiction

counseling. Eight practice dimensions are identified, with counselor effectiveness depending on the

individual’s ability to develop expertise in each. These dimensions include Clinical Evaluation;

Treatment Planning; Referral; Service Coordination; Counseling; Client, Family, and Community

Education, Documentation; and Professional and Ethical Responsibilities.

In addition to standards for basic education and training, national standards for continuing education are needed. Such standards will sustain the ongoing delivery of appropriate and effective 
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services by qualified individuals possessing knowledge of recent developments in practice.

Continuing education standards might also guard against the use of less expensive practitioners

whose knowledge is not up to date. One positive development requires that continuing education

for all substance abuse and mental health treatment staff be written into substance abuse treatment

contracts between providers and government agencies or other payors. Moreover, several states have

enacted legislation that requires continuing education for re-credentialing addiction counselors. Despite

these examples of good practice in continuing education, such approaches are far from universal.

Based on the hypothesis that all practitioners do not require the same level of skills and expertise

and that the field should develop differentiated scopes of practice, a model of clinical hierarchy is

needed. In such a hierarchy, substance abuse treatment personnel can progressively move along 

a continuum of increasing levels of knowledge, competency, and application during their career.

Different continuing education requirements, clinical and technical competency, and supervision skills

are associated with each level. Such a career ladder provides a protocol for basic and continuing education and training, encourages development of supervisory and program management skills, and,

potentially, would improve staff retention by providing a clear career path for the workforce.

Notwithstanding the tremendous variation among State credentialing and re-credentialing requirements, which has been a barrier to the development of national education and training standards,

it is imperative to avoid a “one size fits all” approach to consolidating the existing fragmented education and training system. Any single solution is unlikely to address the complexity of client needs.

Although many academic programs focus exclusively on didactic education, effective education and

training programs require a combination of didactic training and supervised clinical experience.

Finally, many health and human services professionals frequently are unaware of the need to learn

about addictive disorders.

Current resources for education and training programs are not uniformly accessible or available.

In rural or otherwise isolated communities, there is a particular shortage of education and training

opportunities. This problem is particularly prevalent among Native American and other remote

populations. Few local colleges in under-resourced ethnic communities offer education programs 

in substance abuse treatment. Distance from academic institutions that offer specialized addiction

education is often a deterrent. Further, too few fellowships, stipends, and loan-forgiveness programs

are offered to assist under-resourced individuals.
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The Panel notes that lack of access and availability is exacerbated by the context of the financial constraints characteristic of this field. Because salaries and wages, particularly for addiction counselors,

are not competitive with those of other professions, staff often cannot afford to repay college loans

when they enter the workforce. Nor can they afford to invest in continuing education, such as graduate programs. Furthermore, the reimbursement system third-party payors use does not reimburse

providers for staff education and training activities, and there has been a decrease in education and

training funds available through Federal grants. As a result, funding is needed to support the availability and accessibility of pre-service and continuing education. Still, the Panel recognizes the

importance of the personal responsibility incumbent on each individual in the substance abuse

workforce to keep current with changing technologies and treatment approaches.

Such limited access to and availability of education and training results in an inadequate supply 

of appropriately trained, qualified, and/or credentialed substance abuse treatment staff reflective 

of the client population. There is also an indirect impact on program revenue, such that treatment 

programs lacking staff with grant writing, evaluation, and other research skills might prove unable

to access funds. Although this occurs throughout the country, it is particularly prevalent in Native

American and other rural, remote, and culturally distinct communities (e.g., Hispanic, African

American). Here, the lack of access to education and training severely limits availability of qualified

staff and treatment programs in the very communities that suffer from the highest 

incidence of addiction.

EXTERNAL ISSUES. The risk for substance abuse treatment programs of losing reimbursement

from third-party payors is a significant motivator to increase the availability and quality of addiction education and training. Third-party payors may discontinue reimbursement if programs do

not comply with minimum educational requirements for staff. Private payors and other funding

agencies have variable education and training requirements. Although these requirements might be

similar at the level of basic training, advanced training requirements are different from payor to

payor. For the student, the demands of academic institutions further complicate this situation.

Individual academic programs set entry requirements for substance abuse-specific degrees, which

often results in considerable diversity in the requirements students must fulfill.

Various external education and training requirements have raised concerns for those staff who do

not have formal education or training in addiction. Mandatory education and credentialing may be

perceived as an insurmountable obstacle by some staff who are unable or unwilling to undertake a

formal addiction education program because of the cost or other factors.
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Credentialing

INTERNAL ISSUES. The absence of consistent, national, mandated standards and processes for 

the credentialing of addiction counselors has resulted in substantial variation in credentialing

approaches from State to State. A variety of approaches and criteria makes for considerable inconsistency, might limit the application of best practices in some States due to restrictive rules, and,

despite reciprocity arrangements for counselors, can make it difficult for counselors to practice in

other regions. Because there are also no national standards for education, no clear link exists

between systems for credentialing and those for education and training, which can result in some

curricula not appropriately preparing students for credentialing exams. Creating particular problems is the lack of nationwide standards to determine which counselors can treat clients.

The lack of progress toward development of a unified, national process for credentialing addiction

counselors might stem, in part, from the variety of possible approaches and the variety of interests

that exist. The role of staff in the workforce who have no formal education, or no formal education

in addiction, presents a particular challenge in the field’s efforts to define and require professional

qualifications and standards. A general lack of accessibility to education in addiction for counselors

and others exacerbates this situation. Practitioners in some disciplines, credentialed in their own

field, can obtain a specialty credential in addiction (i.e., registered nurses, psychologists, psychiatrists, social workers [master’s degreed]). If a specialty credential in addiction is unavailable for a

particular discipline, those professionals can obtain a credential as an addiction counselor.

EXTERNAL ISSUES. A major force behind the move toward credentialing substance abuse treatment

staff (and/or accrediting or otherwise approving treatment programs) is the managed care industry,

whose insurers and third-party payors often dictate the credentialing requirements for substance

abuse treatment programs and staff. Among those MCOs that include substance abuse treatment as

a reimbursable benefit, there are many different approaches to ensuring standards. To qualify for

reimbursement with some MCOs, substance abuse treatment personnel need specialized education

and training, including degrees in rehabilitation counseling, psychology, social work, and addiction

studies. Other MCOs have different requirements. Despite the obvious benefits of this emphasis on

credentials, the driving force should be the field itself, not outside bodies such as MCOs. This is

especially pertinent because these organizations are unlikely to remain as they are now but, rather,

will themselves change in the future. It is important for the field to regain the initiative and develop

its own solutions and systems to demonstrate standards and competency. Additionally, non-accredited programs may be delivering interventions that do not have proven outcomes. Without a

nationwide system of minimum credentialing standards, the field cannot intervene when the effectiveness of such programs is in question.

THE NATIONAL TREATMENT PLAN INITIATIVE
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Supply, Demand, and Distribution

INTERNAL ISSUES. Over the last several decades, many individuals entering the field with a personal history of addiction and recovery have facilitated, in part, the expansion of the substance abuse

treatment system. Regardless of this growth and other workforce expansion, supply and demand

constantly fluctuate. Currently, some employers suffer a lack of qualified staff, while other experienced mid-level staff are losing their jobs.

Availability of human resources is generally accepted to be a product of economic, political, geographic, social, and technical factors. This is true for the substance abuse treatment field, specifically in rural, isolated regions in which there are inadequate numbers of staff possessing certain skills,

mainly cultural competency. To be successful, treatment modalities must be based on traditions,

language, customs, and values. However, Native Americans, Hispanics, African Americans, Asians,

and recent immigrants often find that culturally sensitive treatment is unavailable, even in areas

with high concentrations of these population groups. This staffing shortfall is widely linked to lack

of investment in addiction education, lack of access to alternative education sources such as distance

learning, lack of appeal of a career in substance abuse treatment, and low salaries.

Indeed, limited revenue within substance abuse treatment programs represents a major factor affecting the supply of and demand for qualified staff, particularly in those areas that are identified as disproportionately affected by chemical dependency. These funding limitations include low salaries,

which discourage people from entering or staying in the field, and restricted recruitment and

staffing opportunities for program managers, whose agendas are frequently driven by funding availability as much as by clinical need. Often program administrators must choose between staff development and program development when deciding how to spend treatment dollars. Similar issues

contribute to staff losing their jobs where employers, seeking to cut costs and stretch finite revenues,

employ underqualified, non-credentialed, or inexperienced staff instead of more expensive, qualified

staff. Such daily management decisions affect the supply of and demand for staff nationwide.

Consequently, in some areas, the employment security of qualified addiction counselors might be

threatened by multiple calls on limited revenue.

There are anecdotal reports of private providers and, in some instances, county provider systems,

offering consistently higher salaries and more attractive benefits than independent or nonprofit

providers. In this environment, qualified personnel in public or not-for-profit providers routinely

leave to work for higher paying providers, particularly under circumstances in which they have not

received a pay raise for several years. The Panel believes that this threatens the supply and retention

of credentialed staff in certain sectors, which affects the ability of programs to meet client need.

Lack of salary parity with other healthcare professionals, who typically enjoy a higher income, exacerbates these circumstances, particularly in the public sector.
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It is anticipated that, in the future, more treatment staff will be required for key racial and ethnic

groups such as Native Americans, Puerto Ricans, African Americans, and Mexican Americans. More

treatment staff will also be needed for most age groups, including the children of substance abusing

parents, adolescents, and the elderly. Furthermore, staff trained in addiction counseling will be

needed in primary care, public health, and settings such as schools and colleges. Currently, how this

staff expansion will be achieved remains unclear. Within the academic field, it is also unclear how

the increasing numbers of retiring faculty will be replaced to train the workforce of the future.

Other Workforce Related Issues

INTERNAL ISSUES. The substance abuse treatment field lacks consistent, prescribed national treatment standards such as clinical practice guidelines, procedures, and protocols. Moreover, practice

guidelines that do exist might not reflect developments in knowledge, practice, and technology that

have taken place in recent years. In the past, staff worked well within this open environment;

however, with the increasing complexity of the client population, guidelines are becoming more

necessary. Although seemingly a treatment system issue rather than a workforce issue, lack of formalized practice guidelines results in potential for treatment system staff to implement inconsistent

approaches, use unproven treatment modalities, and work toward different treatment outcomes.

Of even greater concern is the impact on staff of other agencies that come into contact with substance abuse treatment clients (e.g., social services, criminal justice) because there are no requirements for them to meet minimum practice standards or standards of clinical competence. National,

formalized, mandatory practice guidelines, including minimum standards, are needed to provide

models of best practice and staff competency that are trans-disciplinary (i.e., working across professional boundaries) and interdisciplinary. Such guidelines and standards will also focus the substance abuse treatment workforce and other allied staff on optimizing clinical outcomes, underpin

the development of core curricula for staff education and training programs, and contribute to the

development of credentialing processes.

Panel members acknowledge that research results are not readily available in language and formats

that are accessible, comprehensible, or relevant to all treatment staff. During public hearings,

testimony indicated that some clinicians on the front line do not consistently understand the latest

research findings on new treatment practices or how the research was conducted. Treatment personnel are not widely involved in research activities, and research results are not disseminated in a

way that allows the workforce to develop or refine treatment practice in the field.

Some see the extent to which substance abuse treatment personnel interact with each other and

with staff of other health and human services-related services as an emerging issue of importance.

Due to its bifurcated nature, using a range of specialized professionals (e.g., child welfare,

HIV/AIDS, and other subspecialties) is a fragmented approach to treating substance-related 
REPORT OF PANEL V

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disorders. Tension exists between providing substance abuse treatment through a variety of different specialists and the alternative notion of taking a whole person approach. The field has yet to

determine how to develop and implement a treatment approach combining the best characteristics

of staff integration and staff specialization into an integrated model.

EXTERNAL ISSUES. The Panel believes that the lack of funding for substance abuse treatment in the

healthcare system interferes with the ability of treatment programs to maintain the required quality

of staff experience levels, qualifications, education and training.

The concept of viewing the client as a whole and meeting his or her needs holistically involves a

great deal of trans-disciplinary work with other health and human service providers to provide

seamless services. However, the Panel feels that clinical integration should not be taken to such

extremes that system integration leads to the substance abuse treatment workforce’s being subsumed

by another service.

III. Recommendations

In light of the qualitative analysis, the question emerges: “Given these trends, how can the substance

abuse treatment system establish and maintain sufficient numbers and quality in the workforce?” In

seeking an answer, the Panel has produced a composite of the ideal workforce of the future, generating

forward-looking statements that describe their vision for the treatment system and the workforce.

VISION STATEMENT

The Substance Abuse Treatment System

ACCESS. Substance abuse treatment system services will be readily accessible to the community at

large through multiple geographically convenient entry points. The treatment system will provide

timely, affordable, and comprehensive treatment on request and will be fully funded through a variety of public and private sources and reimbursement mechanisms.

TREATMENT ENVIRONMENT. The treatment system will be seamless (see Glossary) and will

include multiple evidence-based treatment modalities and options. It will provide a safe, flexible,

and accountable environment.

RANGE OF TREATMENT. The treatment system will provide integrated, comprehensive treatment

through a spectrum of qualified professionals. Treatment will benefit from state-of-the-art clinical

and information technology.
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RESPONSIVENESS. Serving the unique needs of each client, the treatment system will provide

client-focused care that responds to the needs of different population groups. It will be respectful

and empowering to the individual and free from stigma. The system will acknowledge and adapt to

the condition of each client’s individual social support and community-based support systems.

The Substance Abuse Treatment Workforce

CLINICAL PRACTICE. The substance abuse treatment workforce will use evidence-based practices

that are value- and outcome-driven.

STAFF RELATIONSHIPS. The treatment workforce will be team-oriented and interdisciplinary.

STAFF CLIENT RELATIONSHIPS. The treatment workforce will better reflect the variety of client

populations and demonstrate cultural sensitivity and competency.

STAFF SUPPORT INFRASTRUCTURE. The treatment workforce will be grounded in education,

training, clinical supervision, and credentialing processes that are defined by the complexity of

evolving client needs and treatment research. Additionally, the workforce will establish processes for

advancement, including career ladders, appropriate compensation, and increased responsibility

based on competency.

GOALS AND RECOMMENDATIONS

Visualizing the desired future has made it easier for the Panel to identify the most important issues

and the activities required to address them. To drive the development of workforce recommendations the Panel formulated three goals (see Figure 1, shown earlier) as follows:

• Provide a national platform to address workforce issues.

• Develop and strengthen a comprehensive infrastructure that attracts, supports, and maintains a

competent, diverse workforce, reflective of its client populations.

• Improve the competency of a diverse addiction workforce by providing didactic, clinical, and

experiential education and training based on a core body of the latest evidence-based knowledge.
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GOAL 1: PROVIDE A NATIONAL PLATFORM TO ADDRESS WORKFORCE ISSUES.

Recommendation 1.1: Establish a National Workforce Development Office at CSAT.

There exists a need for a Federal agency specifically dedicated to supporting the development of the

substance abuse treatment workforce at a national level. Of the previous recommendations on

workforce issues, none have addressed this requirement. A need exists, as well, for a nationwide

source of valid, comparable data on the workforce and use of that data to guide legislative and 

policy decisions regarding the workforce. Furthermore, it is important that addiction education and

training be based on addiction research findings.

CSAT will immediately establish a National Workforce Development Office, which will collaborate

with the Indian Health Service (IHS), the Health Research Services Administration (HRSA), the

Office of Minority Health, and other Federal agencies to implement the action steps.

Action Steps

The National Workforce Development Office should perform the following tasks:

• Develop a comprehensive report on the state of the workforce. (The National Workforce

Development Office will employ data from a comprehensive national report on the state of

knowledge in the addiction field and will be instrumental in encouraging or supporting individuals and/or bodies to undertake this research.)

• Provide leadership in the collection, use, and application of comparative nationwide workforce

data for decision-making at Federal, State, and local policy levels.

• Develop and monitor cross-disciplinary competency guidelines.

• Facilitate a multi-disciplinary process to develop a core curriculum (based on CSAT’s TAP 21),

which will form the basis for credentialing standards.

• Monitor the inclusion of basic addiction-related curricula in education and training programs.

• Monitor and facilitate the implementation of CSAT NTP Workforce Issues Panel recommendations.
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GOAL 2: DEVELOP AND STRENGTHEN A COMPREHENSIVE INFRASTRUCTURE THAT 

ATTRACTS, SUPPORTS, AND MAINTAINS A COMPETENT, DIVERSE WORKFORCE,

REFLECTIVE OF ITS CLIENT POPULATIONS.

Recommendation 2.1: Establish funding mechanisms to support workforce recruitment,

retention, and development initiatives.

The absence of adequate funding and other strategies to recruit, educate, and retain a diverse workforce

has meant a lack of staff with sufficient linguistic skills and cultural competence to meet the diverse

needs of all client populations represented in the substance abuse treatment system. Previous workforce-specific recommendations are applicable to this recommendation but lack specificity and focus.

Financial incentives might involve establishing loan forgiveness, scholarship, and stipend programs, particularly for individuals from targeted under-represented population groups. CSAT

should work with relevant agencies (e.g., SAMHSA, HRSA, the National Institute on Drug Abuse

[NIDA], the National Institute on Alcohol Abuse and Alcoholism [NIAAA] and the National

Institute of Mental Health [NIMH]), to identify and coordinate adequate funding opportunities to

support workforce development.

Action Steps

• Advocate for salary parity.

• Develop strategies and financial incentives to meet workforce supply shortfalls.

• Develop strategies and financial incentives to attract staff reflective of the treatment population.

• Identify and use innovative funding sources to expand training opportunities (particularly for

under-resourced population centers).

• Secure funding for a Workforce Development Mentoring Initiative.

Recommendation 2.2: Advocate for competency-based career ladder opportunities in 

addiction treatment settings.

Lack of professional and/or career opportunities for advancement in the addiction field and/or

treatment setting equates to an absence of a competency-based career path in the substance abuse

treatment system. There is a requirement for adequate support for staff attainment of basic through

advanced competencies. Previous workforce-specific recommendations have not addressed the 

need for a career ladder.
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149

The Workforce Development Office, created by CSAT, should take responsibility for developing the

competency-based career path for the substance abuse treatment system. Individual programs

might need to adapt the career ladder relevant to their treatment setting. Furthermore, staff have

the professional responsibility to pursue their own advancement by keeping up to date and seeking

opportunities for continuing education and training. Financial and other incentives may be secured

for workforce development at Federal, State, and local levels.

Action Steps

• Develop a competency-based career path in the substance abuse treatment system.

• Create and support opportunities for competency-based professional advancement.

Recommendation 2.3: Advocate for all health and human service-related accrediting and 

certifying/re-certifying agencies to require education and competence in addiction, and inclusion

of addiction questions on all credentialing exams.

There is a requirement for all healthcare professionals to possess basic competence — knowledge,

skills, and attitudes — for meeting the needs of clients with substance use disorders. Basic addiction knowledge, skills, and attitudes among the workforce must be common to all disciplines.

CSAT will convene a working group consisting of States, the National Association of State Alcohol

and Drug Abuse Directors (NASADAD), credentialing bodies, professional organizations, and treatment provider associations to implement this recommendation.

Action Steps

• Develop and disseminate model competency-based State credentialing standards for addiction

counselors as well as other health and human services disciplines.

• Collaborate with State and professional credentialing bodies, academic institutions,

and treatment providers.

Recommendation 2.4: Establish standards for didactic, clinical, and experiential education 

and training of addiction professionals and other health and human services providers.

Uneven quality of substance abuse treatment, a direct result of a number of variable standards for

education and training of addiction professionals, indicates a need for research on the most effective

methods for educating and training addiction professionals and other health and human services

providers, and a requirement to establish minimum standards for basic and continuing education 
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in addiction. Moreover, the need extends to national consistency among curricula, education, and

training approaches and access to education and training. Further evidence of the importance of

instituting national standards resides in the varying emphasis placed on client-centered care and

practica. Previous workforce-specific recommendations are applicable to this recommendation 

but lack specificity and focus.

CSAT should work with relevant Federal agencies, professional organizations, academic institutions,

and treatment providers. This work might involve the development of a think tank on academic/

treatment program partnerships and encouragement of collaboration between academic 

institutions and providers.

Action Steps

• Conduct research to determine the most effective methods for educating and training 

addiction professionals.

• Provide a clearinghouse for education and training information as well as trainers 

for onsite training.

Recommendation 2.5: Advocate for and encourage academic institutions to develop and offer

degree programs for addiction professionals at the undergraduate and graduate levels.

There exists a need to enhance and encourage formal academic education for the addiction 

workforce. CSAT will encourage and support the establishment of additional degree programs by

providing appropriate incentives such as faculty or curriculum development grants and contracts.

Action Steps

• Expand the number of available academic degree programs in addiction.

• Increase accessibility to these programs using distance learning and non-traditional strategies.

GOAL 3: IMPROVE THE COMPETENCY OF A DIVERSE ADDICTION WORKFORCE BY PROVIDING

DIDACTIC, CLINICAL, AND EXPERIENTIAL EDUCATION AND TRAINING BASED ON A CORE BODY

OF THE LATEST EVIDENCE-BASED KNOWLEDGE.
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Recommendation 3.1: Ensure the development of core curricula based on CSAT’s Technical

Assistance Publication 21, Addiction Counseling Competencies: The Knowledge, Skills, and

Attitudes of Professional Practice, for the education of addiction counselors.

There exists a need for comprehensive evidence-based curricula for addiction counselors.

Previous workforce-specific recommendations are applicable to this recommendation but lack

specificity and focus.

CSAT should work with HRSA, academic institutions, professional organizations, ATTCs, and 

education and training program networks to review existing curricula and establish a clearinghouse.

Core curricula can be produced within two years, with dissemination and promotion 

ongoing over a 10-year period.

Action Steps

• Review existing addiction curricula to identify gaps.

• Develop undergraduate and graduate curricula based on: (1) the existing needs and gaps;

and (2) substance abuse treatment field-endorsed competencies for basic, advanced, and 

discipline-specific curricula.

• Develop, update, and disseminate research-based curricula appropriate for addiction counselors

(based on CSAT’s TAP 21).

• Ensure all addiction treatment curricula and materials emphasize client-centered, respectful,

and client-empowering assessment and treatment.

• Require addiction-specific clinical rotations or practice-based learning in all education 

and training programs for addiction counselors.

Recommendation 3.2: Ensure inclusion of basic addiction-related curricula in all levels of

education and training programs for health and human services providers, that is appropriate

for their scope of practice.

Previous workforce-specific recommendations are applicable to this recommendation but lack

specificity and focus. At the same time, there is a requirement for all healthcare professionals to

possess basic competence — knowledge, skills, and attitudes — for meeting the needs of clients with

substance use disorders. It is essential that basic addiction knowledge, skills, and attitudes among

the workforce be common to all disciplines. Therefore, to improve the competency of a diverse

addiction workforce, substance abuse treatment and addiction curricula must be included at the

undergraduate, graduate, and post-graduate/continuing education levels, and client-centered care 

in addiction-related education and training curricula must be emphasized.
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CSAT should work with HRSA, academic institutions, professional organizations, ATTCs, and 

education and training program networks to review existing curricula and establish a clearinghouse.

Core curricula can be produced within two years, with dissemination and promotion ongoing 

over a 10-year period.

Action Steps

• Review existing general and discipline-specific addiction curricula to identify gaps.

• Develop core interdisciplinary undergraduate and graduate curricula based on: (1) the existing

needs and gaps; and (2) substance abuse treatment field-endorsed competencies for basic,

advanced, and discipline-specific curricula.

• Develop, update, and disseminate research-based curricula appropriate for various disciplines

(based on CSAT’s TAP 21).

• Ensure all addiction treatment curricula and materials emphasize client-centered, respectful,

and client-empowering assessment and treatment.

• Require addiction-specific clinical rotations or practice-based learning in all education and 

training programs.

Figures 2, 3, and 4, which follow, illustrate The Goals, Recommendations, and Action 

Steps discussed.
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153

Figure 2. Goal 1, Recommendation and Action Steps

Goal 1

Provide a national platform 

to address workforce issues.

Recommendation

1.1 Establish a National Workforce

Development Office at CSAT.

Action Steps

Develop a 

comprehensive

report on the 

state of the 

workforce.

Provide leadership in

the collection, use,

and application of

comparative nationwide workforce data

for decision-making

at Federal, State, and

local policy levels.

Develop and monitor

cross-disciplinary

competency 

guidelines.

Facilitate a multidisciplinary process

to develop a core 

curriculum (based on

CSAT’s TAP 21),

which will form the

basis for 

credentialing 

standards.

Monitor the inclusion

of basic addictionrelated curricula in

education and 

training programs.

Monitor and facilitate

the implementation

of this Panel’s 

recommendations.
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THE NATIONAL TREATMENT PLAN INITIATIVE Figure 3. Goal 2, Recommendations and Action Steps Develop and disseminate model competency-based State credentialing standards for addiction counselors as well as other

health and human services

Goal 2

disciplines. 

Recommendations 2.1 Establish funding mechanisms to support workforce recruitment, retention, and develop- ment initiatives. 2.2 Advocate for compe- tency-based career lad- der opportunities in addiction treatment set- tings. 2.3 Advocate for all health and human services-related accrediting and certifying/re- certifying agencies to require education and competence in addiction, and inclusion of addiction questions on all credentialing exams. 2.4 Establish standards for didactic, clinical, and experiential education and training of addiction professionals and other health and human servic- es providers. 2.5 Advocate for and encourage academic insti- tutions to develop and offer degree programs for addiction professionals at the undergraduate and graduate levels.

Advocate for salary 

parity. Develop a competencybased career path in the

substance abuse treatment system.

Expand the number of

available academic

degree programs in

addiction.

Develop strategies and

financial incentives to

meet workforce supply 

shortfalls.

Create and support

opportunities for 

competency-based 

professional 

advancement.

Provide a clearinghouse

for education and

training information 

as well as trainers for 

on-site training.

Increase accessibility to

these programs using

distance learning and

non-traditional strategies.

Action Steps Identify and use innova- tive funding sources to expand training opportunities (particularly

for under-resourced 

population centers).

Secure funding for a

Workforce Development

Mentoring Initiative.

Collaborate with State and

professional credentialing

bodies, academic 

institutions, and treatment

providers. 

Develop and strengthen a comprehensive infrastructure

that attracts, supports, and maintains a competent, diverse

workforce, reflective of its client populations.

Conduct research to

determine the most

effective methods for

educating and training 

addiction professionals.
REPORT OF PANEL V

155

Figure 4. Goal 3, Recommendations and Action Steps

Goal 3

Action Steps

Improve the competency of a diverse addiction workforce by providing

didactic, clinical, and experiential education and training based on a core

body of the latest evidence-based knowledge.

3.2 Ensure inclusion of basic addiction-related curricula in

all levels of education and training programs for health

and human service providers, that is appropriate for their

scope of practice.

Review existing addiction curricula 

to identify gaps.

Review existing general and discipline-specific addiction

curricula to identify gaps.

Develop undergraduate and graduate curricula based on:

(1) the existing needs and gaps; and (2) substance abuse

treatment field endorsed competencies for basic,

advanced, and discipline-specific curricula.

Develop core, interdisciplinary undergraduate and graduate 

curricula based on: (1) the existing needs and gaps; and 

(2) substance abuse treatment field-endorsed competencies for

basic, advanced, and discipline-specific curricula.

Develop, update, and disseminate research-based curricula

appropriate for addiction 

counselors (based on CSAT’s TAP 21). 

Develop, update, and disseminate research-based curricula

appropriate for various 

disciplines (based on CSAT’s TAP 21). 

Require addiction-specific clinical rotations or practicebased learning in all education and training programs. Require addiction-specific clinical rotations or practice- based learning in all education and training programs for addiction counselors.

Ensure all addiction treatment curricula and materials

emphasize client-centered, respectful, and clientempowering assessment and treatment. 

3.1 Ensure the development of core curricula based on

CSAT’s TAP 21 for the education of addiction counselors.

Recommendations
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Changing the Conversation

IV. Discussions: Opportunities for the Future

A. EDUCATION AND TRAINING

Panel members have identified a number of actions integral to developing an approach that will

improve the substance abuse treatment education and training system. Of primary concern is the

fundamental restructuring of the education and training system to direct and support the development of a core body of evidence-based knowledge. As part of this approach, panelists support

supervised clinical experience in all education programs. Scientific research comparing client outcomes from different modalities would also prove useful in helping practitioners to determine 

standardized treatment practices.

It is important to recognize that availability of and accessibility to this education and training

remain challenges for some. Strong incentives, loan forgiveness, fellowships, grants, and other forms

of financial support for pre-service and staff education would render education and training more

accessible, particularly in rural and other isolated and under-resourced areas. Provision of financial

incentives or other rewards and recognition can further encourage staff to undertake advanced

training or continuing education. More innovative and flexible approaches to educating staff with

available funding streams (e.g., State and Block Grant funds) represent additional ways to engage

interest and create opportunities for self-improvement among addiction personnel. In addition,

new technology will increase access to education and training for economically, socially, and geographically isolated communities through distance learning and by establishing new academic 

centers in needy areas.

Culturally appropriate education and training programs that address the varying levels of educational backgrounds of students and staff are necessary given that substance abuse treatment personnel come from diverse backgrounds, and many personnel lack formal education and training and/or

some personal experience with addiction and recovery. Core substance abuse treatment education

appropriate to their scope of practice should be routine for all health and human services practitioners who come into contact with substance abusing clients. Addiction education and training for

staff in other healthcare fields should be flexible and should not require more high-level study or

large time commitments.

B. CREDENTIALING

Conceiving and instituting uniform standards for the substance abuse credentialing system has

emerged as a principle concern for Panel members, who have identified a series of measures for pursuing that end. An initial action should be to convene a forum of divergent credentialing groups possessing different requirements, with the objective of jointly creating unified, or at least more similar,

approaches to credentialing nationwide. This forum can collaborate on developing and implementing

THE NATIONAL TREATMENT PLAN INITIATIVE
REPORT OF PANEL V

157

quality assurance mechanisms, using agreed-upon minimum standards (e.g., TAP 21). At the same

time, the field should support and promote innovative models and approaches to credentialing that

are flexible and able to grow and change with the needs of the clients and the workforce.

A credentialing system for substance abuse treatment counselors that is national will offer staff the

advantage of more geographic flexibility in where they work, sometimes a deciding factor when

planning a career and looking for employment. For this reason, such added advantages can make a

difference for recruitment efforts. With further respect to recruiting, an outcomes-based approach

to solving credentialing issues, which is based on defining the knowledge, skills, and attitudes necessary for obtaining required/expected client outcomes, is desirable. Administrators should identify

and recruit individuals that have these competencies.

The field must consider public protection through mandating a consistent approach to credentialing

and accountability across the whole field. To address accountability, a consistent, mandatory credentialing system, which includes penalties for non-credentialed staff demonstrating unethical or

poor practice, is essential for all staff groups.

The field also needs to address issues of “professional scope of practice” by embedding national 

standards in the recommendations for credentialing systems in order to reinforce substance abuse

treatment workers as valued professionals. Creating a “credentialed substance abuse treatment 

professional” in all States, who enjoys parity with other credentialed professionals, can only serve to

increase visibility of and foster respect for addiction personnel and the work they do.

Substance abuse treatment personnel should work toward developing a field-wide, shared understanding and expectation of recovering staff. Treatment personnel will need to clarify the degree 

of personal recovery expected from a member of staff in recovery, and to define the extent of

progress he or she must have made in dealing with his or her own issues and in taking on a 

“clean and sober” lifestyle.

Finally, the Panel feels that payors should reimburse credentialed substance abuse treatment 

counselors on equal terms with other credentialed professionals, and that the field must work

toward procuring fair treatment for its qualified members.

C. SUPPLY, DEMAND, AND DISTRIBUTION

Ensuring an adequate supply of staff is of utmost importance to improving both the availability and

the quality of substance abuse treatment. Panel members believe that the number of individuals

employed in the substance abuse treatment field will meet demand if the field takes steps to make

most effective use of existing staff and to attract new, qualified personnel. One way this can be

achieved is by developing creative approaches to make more substance abuse treatment personnel
158

Changing the Conversation

available to community-based primary care clinics, despite the lack of funding for such staff.

Also, practitioners must propose solutions and recommendations for workforce issues that promote,

reinforce, and build on the concept of the interdisciplinary healthcare team. In particular, physicians should be working closely and flexibly with substance abuse treatment staff as an integral part

of the client treatment team. Redistribution of available human and program resources to focus on

areas with insufficient staff to meet the increasing demand of disadvantaged populations (e.g.,

Native Americans, Puerto Ricans, African Americans and Mexican Americans) will also help deliver

care where it is most needed and currently least provided. Finally, implementation of strategies to

develop and maintain addiction faculty positions in academic institutions will lend credibility to

and increase respect for this burgeoning area of healthcare, thereby encouraging a flow of

competent individuals to the field.

D. FACTORS TO CONSIDER IN MOVING FORWARD

Client Population

The profile of the national population continues to change as a consequence of demographic and

social developments such as rising immigration, the prevalence of single-parent or other “nontraditional” family groupings, and growing numbers of elderly people. These national demographic

changes, as well as political developments and economic trends, contribute to the changing 

demographic profile of the substance abusing population.

The Panel has determined that, in recent years, numbers of clients who are sent for treatment as a

result of welfare reform, criminal justice sentencing, or legislation on the drug-free workplace have

increased. Also evident is an increase in the ethno-cultural diversity of client populations and,

particularly in the African American and Puerto Rican communities, an increase in numbers of

substance abusing mothers. In addition, more clients with co-occurring substance-related, cognitive,

physical, and developmental disorders are seen, as are more clients who abuse multiple substances.

The Panel feels that there is an increasing awareness of the negative impact of the social environment in which some individuals with or at-risk for addiction might find themselves. However, panelists have noted that staff are also seeing increasing numbers of individuals with substance use disorders who are able to hold stable jobs in the national workforce. (This includes the developing role

of clients and former clients in the substance abuse treatment workforce.) The substance abuse

treatment workforce is becoming increasingly aware of and sensitive to emerging population groups

in the addicted population, including the elderly, the disabled, the bi- and transsexual populations,

and those using emerging drugs.

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159

The impact of these changes on the substance abuse treatment system is seen in recent changes in

practice that impact the substance abuse treatment workforce. For example, the increasing prominence of outreach workers is attributed to the need to address the increasing occurrence of addiction within ethnic groups, and to bring these clients into the treatment system. Furthermore, the

increasing ethno-cultural diversity in the treatment population calls for a more ethnically and culturally diverse workforce or, at least, a workforce comprising staff familiar with and sensitive to the

cultural issues of the numerous, changing client groups. To achieve good treatment outcomes, staff

will have to work flexibly, adapt their approach to the needs of the individual client, and become

competent in addressing the needs and issues of the client’s emotional support network.

Health Industry Structure and Impact of Managed Care

MCOs emerged through a desire to control increasing health expenditures in the United States.

Therefore, their primary concerns are to ensure that providers are not providing “too much” or

“unnecessary” care and that services provided are competitively priced. The MCO system has used

several approaches to achieve these objectives, including external gatekeepers, restricted provider

networks, credentialing requirements, utilization and performance management, and quality of care

indicators. Some panelists believe that these managed care mechanisms have been particularly difficult to adopt in the substance abuse treatment field. The arrival of managed care in the treatment

system raised a variety of issues affecting the substance abuse treatment workforce. Some key issues

include the requirement for demonstrated competence, the link between credentialing and reimbursement and the resultant implications for non-credentialed staff in the workforce, the expansion

of outpatient treatment programs and the resulting restructuring, and the tension between financial

and clinical interests.

First, to secure reimbursement for their services from private health companies, the majority of

providers in the substance abuse treatment field have been required to implement significant organizational and structural change. The impact of credentialing requirements on staff and providers

has also been significant in recent years. To become legitimate providers within an MCO network,

substance abuse treatment providers had to secure and demonstrate program and/or individual 

credentialing standards. A fairly wide range of “standards,” including the Joint Commission on

Accreditation of Health Care Organizations (JCAHO), Medicaid, and State credentialing standards,

affected provider agencies as well as their workforce. However, many socially and geographically

isolated and/or other under-resourced communities have not had the capacity to address these

requirements, which has constrained substance abuse treatment providers in these communities

from generating revenue from MCO payor sources. Some Panel members were concerned that the

requirements of MCOs might have had a particularly marked impact in rural, remote, and culturally distinct communities that lack the resources necessary to develop the stable network of services

required by private payors. Their limited infrastructure has prevented them from building MCO

service capability or addressing the credentialing requirements of these payors.

REPORT OF PANEL V
160

Changing the Conversation

Second, MCO use of active gatekeeping strategies dramatically reduced the use of inpatient and 

residential treatment programs, and many counselors lost jobs during periods of hospital-based

and other residential program cutbacks and closings. The reduction in reimbursement and subsequent downsizing led treatment agencies to amalgamate to ensure survival. In inpatient settings,

substance abuse treatment programs were often subsumed within mental health/psychiatry departments. On the outpatient side, small providers merged or were acquired by larger agencies.

Finally, joint initiatives between substance abuse treatment providers and other agencies (e.g.,

Criminal/Juvenile Justice, Child Welfare, and Public Health departments) that come in contact with

individuals with addictions have become more prevalent. As these initiatives developed, new crossagency program configurations also emerged. Although these collaborative programs seek to optimize the resources of the agencies involved to preserve the best interests of the client, they are often

faced with differing philosophies, funding streams, and policies.

Substance Abuse Policy

Since the 1960s, Federal policy and legislation regarding the substance abuse treatment field have

included a variety of drug abuse treatment and control bills. These include provisions for increased

research in drug abuse, dependence, and prevention; policies for acceptable standards of care;

legislation regarding the rehabilitation of those with narcotic addiction; legislation legalizing and

regulating maintenance treatment; and a requirement for physicians who dispense methadone to be

registered. By implication, all such acts, legislation, and laws have implications for the workforce,

ranging from changes in education and training requirements, to developments in credentialing

requirements, to changes in the demand for staff.

Federal drug control approaches have emphasized the importance of restricting the supply of illegal

substances by conducting what has come to be known as the “War on Drugs.” The Panel feels there

remains an unmet need for funding to support addiction treatment programs and to support the

development of the workforce (see Panel I Report).

Other social policy legislation also impacts substance abuse treatment staff. Recent examples

include Welfare Reform and Drug Free Workplace legislation. With regard to Welfare Reform legislation, the incidence and prevalence of substance-related disorders among welfare program beneficiaries are fairly significant. The Panel feels that this will have a strong influence on the number, type,

and skill mix of substance abuse treatment providers required. As a result of Drug Free Workplace

legislation, growing numbers of employees are subject to random drug testing and are referred for

mandated rehabilitation. Therefore, when considering workforce issues it is also important to

understand Federal legislation that is not substance abuse-specific.

THE NATIONAL TREATMENT PLAN INITIATIVE
161

The Panelists believe that, too often, discussion of substance abuse issues at Federal and State levels

is not well connected. The number of policy discussions that take place at multiple levels impedes

cohesive debate on the problems of the substance abuse field. Further, the fragmentation of policy

discussions hinders the development of cohesive national approaches to support the profile and

objectives of the substance abuse field.

Although much of the general substance abuse policy and legislative agenda is relevant to or will

indirectly impact the workforce, shortage of quantitative workforce data to inform discussion hampers policy debates focusing specifically on workforce issues. As a result, legislative and policy decisions cannot be made on comprehensive empirical data, and workforce issues can only be addressed

using what experience tells us. Furthermore, there is no Federal office or department that has a

comprehensive, nationwide picture of the substance abuse treatment workforce or that has responsibility for workforce policy development.

Financing

The financial structure of the substance abuse treatment field has fluctuated as the healthcare environment has changed, funding from managed care organizations has become available, and government policy regarding illegal substances has developed. The principle funding streams2 for provision of public substance abuse treatment currently include the Substance Abuse Prevention and

Treatment (SAPT) Block Grant; Medicaid funds; treatment dollars from the Indian Health Service;

Federal funding for specific initiatives (e.g., the Department of Education’s Safe and Drug-Free

Schools program, and Drug Court and prison treatment funding from the Department of Justice);

and, finally, State and County General Funds. For private substance abuse treatment, funding

sources include insurers and/or third-party payors and self-pay clients.

All public funding streams have several characteristics in common. Funds are intended to resource

the delivery of substance abuse treatment in the field; therefore, there are no individual funding

streams that are intended specifically for the development of the workforce (and only a small portion of the Block Grant allocation is intended for workforce development). As a result, funding for

workforce initiatives (recruitment, retention, credentialing, training or continuing education) has to

come from treatment service dollars. To further complicate the picture, some of the funding the

field receives is categorical, which reduces the pool of available program funds that workforce initiatives can access. Indeed, Panelists noted that providers in rural, remote, and culturally distinct or

under-resourced areas might not be able to access private funding streams at all because their limited infrastructure has prevented them from building service capability and from addressing the credentialing requirements of these payors.

REPORT OF PANEL V

2 In some states, there also might be small amounts of income from specific State or local programs (e.g.,Temporary Assistance for Needy Families [TANF], Welfare to

Work programs) or monies specifically targeted at the dual diagnosis population and various trust funds. However, these income streams provide insignificant amounts of

revenue.
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Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

At the local level, the lack of a specific budget item for the workforce in treatment programs results

in the needs of staff competing with the needs of clients. The basic development needs of staff are

often threatened by multiple calls on limited revenue. For example, program administrators often

have to make prospective or retrospective decisions regarding how program dollars will be allocated.

In many cases, administrators can either invest in staff development or in other resources for the

program, but frequently expenditure on both is not viable. Consequently, many of the daily budgetary decisions that State substance abuse directors, program directors, and administrators make

affect the development of the substance abuse treatment workforce.

Technical and Clinical Developments

Technical developments prevalent in the substance abuse treatment field in recent years impact the

curricula, education, training, and clinical practice of substance abuse treatment staff. In Slaying the

Dragon, William L. White (1998) outlines some important technical developments in the substance

abuse field in the last 50 years. Specifically, with regard to improving access to the treatment system,

substance abuse treatment staff have made use of Employee Assistance Programs and formal family

intervention approaches, as well as further developing outreach services to link potential clients to

the system as early as possible.

Programs have made use of case management to manage all client needs including multiple diagnoses and/or high levels of acuity. Other patient management strategies have been implemented to

deal with the individual and social risks associated with addiction. The development of client

screening and assessment instruments to standardize diagnosis, referral, and treatment planning

processes has been significant in recent years. Further, there has been a growth in outcomes

research and other efforts to evaluate the clinical benefit and cost effectiveness of various treatment

modalities, interventions, and program combinations.

Some of the treatment modalities that have been seen in the last 50 years include the systematic

application of relapse prevention and relapse intervention technologies, the organic development of

a variety of different types of recovery homes for post-treatment clients, the use of therapeutic drugs

and other medications, and the formal incorporation of the family into treatment plans to strengthen

a client’s family support system. Overall, there has been a gradual transition from single treatment

modality programs to the use of multiple levels and types of care in a client’s treatment plan.

The introduction of computer- and web-based technologies to the substance abuse treatment field

has been noticeable in very recent years, including using computers for client screening and assessment and distance learning technologies for staff training and continuing education.

Although these developments range from changes in clinical practice to the introduction of management information systems, all have one characteristic in common: These technologies require
REPORT OF PANEL V

163

staff to learn new skills and competencies and to implement new practices. Thus, strategies and

processes for basic and continuing education, curriculum development, and credentialing requirements, as well as for the supply of and demand for staff should be influenced by recent technical

developments, where appropriate.

Workforce Attribute

The diversity of staff backgrounds and skills in the workforce results in a complex mix of staff characteristics, which confounds attempts to identify broad attributes for the field as a whole. However,

during the discussion and analysis, Panel members identified some specific attributes, which are

reproduced here.

One of the strengths identified early in the Panel process was the considerable knowledge and experience of those staff and faculty who have worked in the field for many years. The value of those

with more than 20 years of experience is immeasurable, and these individuals are the backbone of

the existing faculty of addiction professionals, providing valuable educational, clinical, administrative, and political leadership.

The unique contribution that recovering staff bring to the treatment field, both to clients and other

staff members, was identified repeatedly as an asset that must be preserved. This contribution

includes the ability to empathize and provide support from the recovery perspective, knowledge of

street culture and vernacular, experience with Alcoholics Anonymous and Narcotics Anonymous,

ability to serve as a role model, and extensive commitment and loyalty to the field.

Despite the lack of formal national standards for training, education, and credentialing the work

that was done on developing Technical Assistance Publication (TAP) Series 21, Addiction Counseling

Competencies: The Knowledge, Skills, and Attitudes of Professional Practice, is seen as a valuable

resource for the field. The TAP Series 21, is considered in some States to be the current customarily

accepted model of knowledge and skills required for competency. Its trans-disciplinary foundations

and broad relevance make it an invaluable reference for the substance abuse treatment team as well

as for all other professionals who work with clients with substance use disorders.

In the evolution of clinical practice, case managers and field staff who work in under-resourced,

rural, or isolated areas are developing more differentiated practice patterns. Staff are broadening

and increasing their skills, knowledge, and competency to function effectively at various levels of

practice. This evolution has been necessary to treat the diverse and complex needs of clients in

these under-resourced areas, which include different levels of client acuity, multiple co-occurring

disorders, and the complex social needs of the various client groups. As client needs become more

varied and multifaceted, this flexible and multi-skilled staff model is extremely useful.
164

Changing the Conversation

V. Selected Bibliography

The sources listed reflect those used by the panel members based on the data current at that time.

Subsequent sources were not incorporated into the individual reports, but may be in the companion

report, Changing the Conversation, Improving Substance Abuse Treatment: The National Treatment

Plan Initiative.

Adams, R.J. and S.L. Gallon, Entry-Level Addiction Counselor Competency Survey, National Results

(Portland, OR: Northwest Regional Educational Laboratory, 1997).

Addiction Technology Transfer Centers, “State Credentialing Bodies Information: Licensure or

Certification,” 1999, Online, <http://www.nattc.org/certification/states>, Oct. 1999.

Calsyn, D.A., A.J. Saxon, P. Blaes, and S. Lee-Meyer. “Staffing Patterns of American Methadone

Maintenance Programs,” Journal of Substance Abuse Treatment 7(4), 1990. pp. 255–9.

Department of Health and Human Services, Addiction Counseling Competencies: The Knowledge,

Skills, and Attitudes of Professional Practice, TAPS No. 21 (Rockville, MD: CSAT, 1995).

Fang, W.L., S.N. Applegate, R.M. Stein, and J.A. Lohr. “The Development of Substance Abuse

Curricular Content by Five North Carolina Schools,” Academic Medicine 73(10), 1998.

pp. 1039–43.

Fazzi, R.A., Future Perspectives in Mental Health (Holyoke, MA: Human Resource Association of the

Northeast, 1990).

Gustafson, J.S., “Do More . . . and Do It Better: Staff-Related Issues in the Drug Treatment Field

That Affect the Quality and Effectiveness of Services,” NIDA Research Monograph 106, 1991.

pp. 53–62.

Hall, M.N., H.J. Shaffer, and J. Vander Bilt, “Measuring Substance Abuse Treatment Provider

Training Needs: Developing an Index of Training Needs,” Journal of Substance Abuse

Treatment 14, 1997. pp. 593–606.

Health Resources and Services Administration, Policy Report of the Physician Consortium on

Substance Abuse Education, Publication No. HRSA-P-DM-91-3 (Washington, D.C.:

HRSA, 1991).

———, Substance Abuse and Addiction: The Interface of the Health and Criminal Justice Systems,

Second report of the Physician Consortium on Substance Abuse Education (Washington,

D.C.: HRSA, 1998).

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REPORT OF PANEL V

165

Institute of Medicine, Bridging the Gap between Practice and Research: Forging Partnerships with

Community-Based Drug and Alcohol Treatment (Washington, D.C.: National Academy Press,

1998) pp. 43–5; 120; 164–5.

———, Dispelling the Myths about Addiction: Strategies to Increase Understanding and Strengthen

Research (Washington, D.C.: National Academy Press, 1997) pp. 95–113.

International Certification and Reciprocity Consortium/Alcohol and Other Drug Abuse, Inc., Role

Delineation Study for Alcohol and Other Drug Abuse Counselors (Raleigh, NC: Columbia

Assessment Services, Inc., 1996).

Kirk, C. and K.R. Amaranth “Staffing Issues in Work with Women at Risk for and in Recovery from

Substance Abuse, Women’s Health Issues 8(4), 1998. pp. 261–6.

Koyanagi, C. and H. Goldman, Inching Forward: A Report on Progress Made in Federal Mental

Health Policy in the 1980s (Alexandria, VA: NMHA, 1991).

Legal Action Center, Blueprint for a New and Effective National Drug and Alcohol Strategy, Rev. ed.

(New York: LAC, 1993).

Lewin Group, The, Substance Abuse Training Needs Analysis (Fairfax, VA: The Lewin Group, 1994).

Mactas, D.J., V.H. Jackson, and D. Trout. “Provider Licensing: A Requirement in Public/Private

Partnerships,” Behavioral Healthcare Tomorrow 5(2), 1996. pp. 40–6.

Murphy, S.A., C.S. Scott, and L.P. Mandel. “Clinical Knowledge and Skill Priorities in Substance

Abuse Education: A Nursing Faculty Longitudinal Survey,” Journal of Nursing Education

35(8), 1996. pp. 356–60.

National Association of Alcohol and Drug Abuse Counselors, Education and Research Foundation,

Salary and Compensation Study of Alcohol and Drug Abuse Professionals (Washington, D.C.:

Fetzer-Kraus, Inc., 1993).

Office of National Drug Control Policy, Performance Measures of Effectiveness: A System for

Assessing the Performance of the National Drug Control Strategy (Washington, D.C.: ONDCP,

1998).

———, The National Drug Control Strategy, 1998: A Ten Year Plan (Washington, D.C.: ONDCP,

1998).

Peterson, P.D. and R.C. Lippincott, “State Mental Health Directors’ Priorities for Human Resource

Development,” Hospital and Community Psychiatry 44(8), 1993. pp. 788–90.
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Shaffer, H.J., M.N. Hall, and J. Vander Bilt, Program Evaluation: A Practical Guide to Discovering

What Works, ATTC-NE Technical Report No. EV-122297 (Boston: Harvard Medical School,

Division on Addiction, and Brown University, Addiction Technology Transfer Center of New

England, 1997).

———, Training Needs Among New England Substance Abuse Treatment Providers, ATC-NE

Technical Report No. 040395-NA100 (Boston: Harvard Medical School, Division on

Addiction, and Brown University, Addiction Training Center of New England, 1995).

Substance Abuse and Mental Health Services Administration, National Drug and Alcohol Treatment

Unit Survey (Rockville, MD: SAMHSA, 1993).

———, Office of Applied Studies, Uniform Facility Data Set: Data for 1996 and 1980–1996

(Rockville, MD: SAMHSA, 1997).

———, The Uniform Facility Data Set: Past, Present and Future, Background paper for Feb. 2, 1999,

UFDS Review Meeting (Rockville, MD: SAMHSA, 1999).

Vander Bilt, J., M.N. Hall, H.J. Shaffer, and J.C. Higgins-Biddle, “Assessing Substance Abuse

Treatment Provider Training Needs: Screening Skills,” Journal of Substance Abuse Treatment

2, 1996. pp. 163–71.

Vander Bilt, J., M.N. Hall, H.J. Shaffer, S. Storti, and O. Church, “An Assessment of Substance Abuse

Treatment Training Needs Among Nurses: II,” International Journal of Substance Misuse 2,

1997. pp. 184–90.

———, “An Assessment of Substance Abuse Treatment Training Needs Among Nurses: Volume I,”

International Journal of Substance Misuse 2, 1997. pp. 150–7.

White, W.L., Slaying the Dragon: The History of Addiction Treatment and Recovery in America

(Bloomington, IL: Chestnut Health Systems Publications, 1998).
167

VI. Participants PANEL MEMBERS

Paula Horvatich, Ph.D. (Chair)

Director

Mid-Atlantic Addiction Technology 

Transfer Center

Virginia Commonwealth University

Richmond,VA

Ana Anders, LCSW

Senior Advisor on Special Populations

National Institute on Drug Abuse 

Bethesda, MD

Robert Bailey, M.Ed.

Director

Northern Cheyenne Recovery Center

Lame Deer, MT

Deb Beck, M.S.W.

President

Drug and Alcohol Service Providers 

Organization of Pennsylvania

Harrisburg, PA

Vivian Brown, Ph.D.

President and CEO

PROTOTYPES, Centers for Innovation

In Health

Mental Health and Social Services

Culver City, CA

Bill B. Burnett

Director of Treatment

South Carolina Department of Alcohol 

and Other Drug Abuse Services

Columbia, SC

Mary Cesare-Murphy, Ph.D.

Executive Director

Behavioral Health Accreditation Services

Joint Commission on Accreditation of

Healthcare Organizations 

Oakbrook Terrace, IL

Bishop Chears

Illinois State Coordinator

One Church One Addict

Governors State University

College of Health Professions

University Park, IL

Barbara Cimaglio

Director

Office of Alcohol and Drug 

Abuse Programs

State of Oregon Department of

Human Resources

Salem, OR

David A. Deitch, Ph.D.

Clinical Professor of Psychiatry

Director 

Addiction Technology Transfer 

Center 

University of California, San Diego

La Jolla, CA

Thomas Durham, M.A., LADC

Director

Military Services Unit

ETP, Inc.

East Hartford, CT

Patricia Fazzone, D.N.Sc., M.P.H.

Assistant Professor

University of Kansas School of Nursing

Kansas City, KS

Angela Gonzalez-Willis, Ph.D.

Senior Program Management Officer

Center for Quality Improvement

Bureau of Health Professions

Health Resources Services 

Administration 

Rockville, MD

Arturo Niño Gutierrez, M.P.A.

Texas Addiction Technology Transfer

Center Coordinator

Texas Commission on Alcohol 

& Drug Abuse

Austin, TX

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Changing the Conversation

THE NATIONAL TREATMENT PLAN INITIATIVE

Karen Kelly, Ph.D., MAC

President and CEO

Circle of Recovery, Inc.

Decatur, GA

Judith Lewis, Ph.D.

Interim Chair

Division of Health Administration 

and Human Services

Governors State University

College of Health Professions

University Park, IL

Bruce Lorenz, CADC, NCACII

Director

Threshold, Inc.

Georgetown, DE

Kathleen Malliarakis

Branch Chief

Specific Drugs Office

Executive Office of the President

Office of National Drug Control 

Policy 

Washington, DC

Neal McGarry

Executive Director

Certification Board for Addiction 

Professionals of Florida

Tallahassee, FL

David Mee-Lee, M.D.

DML Consulting

Davis, CA

Elvin Bernard Parson, M.D.

Medical Director

Metropolitan Hospital Center

Methadone Treatment Program

New York, NY

Gerry Schmidt, M.A., LPC, MAC

COO

Valley HealthCare System

Morgantown, WV

David Smith, M.D.

President & Founder

Haight Ashbury Free Clinics

San Francisco, CA

Susan A. Storti, R.N., M.A.

Director

Addiction Technology Transfer Center 

of New England

Brown University

Center for Alcohol and Addiction Studies

Providence, RI

Lala Ashenberg Straussner, D.S.W.,

CEAP, CAS

Professor

New York University

Ehrenkranz School of Social Work

New York, NY

Michael Taleff, Ph.D., CAC, MAC

Assistant Professor and

International President of INCASE

The Pennsylvania State University

University Park, PA

CSAT STAFF (ROCKVILLE, MD)

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community 

Assistance

CDR David Griffith, R.N.

Branch Chief

Performance Partnership Grant 

Program Branch

Division of State and Community

Assistance

CDR Susanne Rohrer, R.N., M.B.A.

Public Health Analyst

Office of Evaluation, Scientific Analysis 

and Synthesis
169

REPORT OF PANEL V

STEERING GROUP

Linda Kaplan, M.A., CAE

Project Director

Danya International, Inc.

Chevy Chase, MD

CONSULTANTS: THE LEWIN GROUP

(FALLS CHURCH, VA)

Melanie Barraclough

Senior Associate

Christina Hughes

Associate

Sandy Smith

Vice President

(Visioning Facilitator)

PANEL MEETING SPEAKERS AND

CONTRIBUTORS

Karen Allen

President 

National Nurses Society on Addictions 

St. Joseph, MI

Carolyn Aoyama

Deputy Branch Chief for Clinical 

Management and Professional 

Development 

Division of Community Bureau of

Health Care 

Health Resources Services Administration

Rockville, MD

Susan Blacksher

Executive Director

California Association of Addiction 

Recovery Resources

Sacramento, CA

Janice F. Kaufman, R.N. M.P.H., C.A.S.

Vice President

American Academy of Health Care 

Providers in the Addictive Disorders 

Cambridge, MA

Ian M. Shaffer, M.D., M.M.M.

Executive Vice President, Quality 

and Outcome Strategies

ValueOptions

Falls Church, VA

Mary Lynn Stainton

Chief Operating Officer

Operation PAR

Pinelas Park, FL

Flo Stein

Chief

Substance Abuse Services

Division of Mental Health, Development 

Disabilities, and Substance Abuse Services

Department of Health and Human Services

Raleigh, NC
170

VII. Glossary

CLIENT-FOCUSED: Treatment that addresses the client’s clinical needs, plus the client’s perceived

needs, goals, and agenda.

COMPETENCY: Knowledge + Attitudes + Skills. Implies application (i.e., counselors might be 

competent but fail tests; physicians might be knowledgeable but not competent).

CREDENTIALING: Licensing, certification, or registry process by which an individual can provide 

services in a specified professional capacity.

HEALTHCARE TEAM: Counselors (recovering staff and others), addiction physicians, addiction

nurses, case managers, social workers, psychiatrists, psychologists, pharmacists, and other direct care

and service providers.

RECOVERING STAFF: Degreed or non-degreed counselors working in the substance abuse treatment field who are in recovery.

PROFESSIONAL VS. OTHER STAFF: Professional Staff: Trained, educated, credentialed individuals 

treating addiction. Other Staff: Non-credentialed individuals, providing services to individuals 

with addiction.

STANDARDS: Statement or criteria that defines: (1) the level of requirement, excellence, or attainment, and (2) recommended minimum practice. Commonly used and accepted as an authority in a 

professional field. (Some might conform to an established norm.) Adherence to standards can 

serve as a measure of quality.

SEAMLESS: Treatment system without gaps or breaks in service, such that clients transition

smoothly and with ease from one treatment component to another.

SUBSTANCE ABUSE: Problematic use of a substance to modify or control mood or state of mind in 

a manner that is illegal or harmful to oneself or others.3

WORKFORCE: Practitioners in a variety of related disciplines, for example, counselors, physicians,

nurses, psychologists, social workers with varying levels of education, training, experience, and 

credentialing, who intervene in the lives of people with substance use disorders.4

3 http://www.nida.nih.gov/Diagnosis-Treatment/Diagnosis2.html

4 Ibid.
Changing the Conversation

Section II: 

Public Hearing Summaries

171

PUBLIC HEARING SUMMARIES

THE NATIONAL TREATMENT PLAN INITIATIVE

Changing the Conversation

173

Changing the

Table of Contents

I. OVERVIEW. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

II. HEARING SUMMARIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175

A. Arlington, VA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .175 

B. Hartford, CT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .177

C. Chicago, IL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .183

D. Washington, DC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .188

E. Portland, OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .192

F. Tampa, FL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .198

III. WRITTEN TESTIMONY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206

PUBLIC HEARING SUMMARIES

THE NATIONAL TREATMENT PLAN INITIATIVE
I. Overview

As part of the National Treatment Plan Initiative (NTP), the Center for Substance Abuse Treatment

(CSAT) convened six public hearings in order to ensure the incorporation of community perspectives in the NTP efforts to improve the availability, accessibility, and quality of substance abuse

treatment services across the nation. The hearings were held in geographically diverse areas in

order to receive testimonies, both oral and written, from a wide variety of individuals and organizations involved with and affected by alcohol and drug problems. Over 400 testimonies were heard

from individuals from 31 States. Hearings took place in Arlington, Virginia; Hartford, Connecticut;

Chicago, Illinois; Washington, DC; Portland, Oregon; and Tampa, Florida, between June and

November, 1999.

The public hearings provided an opportunity for CSAT and all agencies involved in the NTP 

Initiative to listen to issues of concern to clients, staff, and other stakeholders in the substance abuse

treatment system. Major themes included:

• The need for the field to consider the impact of multiple and overlapping stigmas and to educate

the public about the disease of addiction.

• The need for an increase in funding to support the improvement of treatment.

• The need for integration with other systems, such as the primary care, mental health, child 

welfare, justice, and social services systems.

• The need to: (1) develop common language around alcohol and drug problems among criminal

justice, mental health, and substance abuse communities; (2) classify addiction as a disease; and

(3) reimburse treatment expenses as a medical condition.

• The need for better access to treatment in order to ensure that treatment is administered at

defined quality standards. The need for increased communication between the service delivery

and research communities to ensure the dissemination of best treatment practices.

• The need for training and education in substance abuse treatment to be evidence-based and 

culturally competent, and that trained and educated staff are certified and licensed using a unified, national system.

• The need to address workforce shortfalls by making substance abuse treatment salaries commensurate with other health professional fields, by supporting the education of new and existing

counselors with scholarships, stipends, and loan forgiveness, and by establishing a career ladder

within the field.

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THE NATIONAL TREATMENT PLAN INITIATIVE
1 Hearing Summaries were prepared by ROW Sciences, Inc. under contract to CSAT. The content of this document represents the ideas of those who presented testimony and

does not necessarily reflect those of CSAT or SAMHSA. Lists of participants and affiliations of hearing panelists are included in Section III, Participant Acknowledgements.

175

II. Hearing Summaries1

A. ARLINGTON HYATT, ARLINGTON, VIRGINIA, JUNE, 30, 1999

On the evening of June 30, 1999, the Center for Substance Abuse Treatment (CSAT) — a component of the Substance Abuse and Mental Health Services Administration (SAMHSA) — held a hearing in conjunction with a four-day grantee meeting. This short hearing was a prelude to a series of

one-day public hearings that constitute a crucial component of CSAT’s initiative, Changing the

Conversation: The National Treatment Plan Initiative (NTP). Input from these hearings, combined

with recommendations from expert panels, will serve as the foundation for the NTP that will guide

national programs and policy. The hearing was organized into the same five domain areas

addressed in the NTP Initiative: closing the treatment gap, reducing stigma and changing attitudes,

improving and strengthening treatment systems, connecting services and research, and addressing

workforce issues.

Johnny Allem moderated the hearing, and H. Westley Clark, Camille T. Barry, Andrea Barthwell,

and Susan Thau served as expert panelists. Twenty individuals presented testimony, some testifying

on more than one domain. The following summarizes their recommendations, concerns,

and other comments.

Closing the Treatment Gap 

Generally, those who testified expressed a need for increased access to treatment across the continuum of care and for funding that is commensurate with the need for treatment. People commented

repeatedly on the way in which managed care has constricted treatment provision. In addition,

some argued that treatment should be available on demand and that anyone who is Medicaid-eligible should have access to treatment services. Some also called for increased attention to the needs of

special populations, including those involved in the criminal justice system, people with disabilities,

Native Americans, transgender clients, lesbian and gay clients, and adolescents. One person recommended that recovery support services be recognized as a distinct part of the continuum of care and

called for increased availability of such services provided by persons in recovery. Another person

commented that planning for the services across the continuum of care could be improved by more

thorough needs assessments.

PUBLIC HEARING SUMMARIES
Reducing Stigma and Changing Attitudes 

According to those who testified, the public tends to view addiction as a moral issue rather than as a

disease. Suggestions for shifting this perception included educating the public about research on

brain chemistry; developing a “common language” among the Department of Justice, mental health

agencies, and the substance abuse community; and replacing the term “substance abuse” with a

term that more accurately reflects the nature of the disease, such as “addiction.” One person who

testified stressed that effective recovery must address issues concerning stigma and the client’s

shame and low self-esteem.

Improving and Strengthening Treatment Systems 

Testimony indicated that CSAT’s block grant funding mechanism does not facilitate coordination

and collaboration at the local level and, therefore, should be modified. In addition, it was suggested

that CSAT form partnerships with the Indian Health Service to assist tribal governments in obtaining additional money to maintain and increase the number of treatment beds for Native Americans.

Connecting Services and Research

One person who testified called for ethnographic case studies and additional surveys targeting consumers and families. Another recommended enhancing the user-friendliness of research so that

findings can be shared with and understood by a broad audience. Other testimony suggested that

people in recovery should be consulted when programs are considering how to apply treatment

approaches that appear to have been effective in research settings.

Addressing Workforce Issues 

According to some who testified, the number of people in recovery who are providing services is

decreasing because of changes in certification and licensing requirements and the shift to managed

care. Recommendations to CSAT for reversing this trend include using block grant money to influence the staffing of treatment programs and advising programs about how to maintain a balance

between professional staff and staff who are in recovery. In addition, policymaking decisions and

grant implementation should include front-line staff.

A recurring theme throughout the hearing was that CSAT and the treatment field should respect the

voices of people in recovery in the development of the NTP. Moreover, those in recovery should 

be surveyed for their thoughts on addiction and recovery and should be included in policy- and 

decision making processes. One person who testified recommended that CSAT provide recovery

organizations with the opportunity to carefully review the body of work that evolves during the

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177

development of the NTP. Another person expressed concern that the public hearings were not

scheduled in locations accessible to members of treaty tribes. A solution to that problem would be

that CSAT provide a forum for contributions from treaty tribe members.

B. STATE CAPITOL, HARTFORD, CONNECTICUT, JULY 8, 1999

On July 8, 1999, CSAT held a one-day public hearing to offer the general public the opportunity to

contribute to the NTP Initiative. Dennis McCarty moderated the hearing, and H. Westley Clark,

Albert J. Solnit, Thomas A. Kirk, Camille T. Barry, Linda Kaplan, Thomas Edwards, Jr., José A.

Rivera, Constance Horgan, Lisa Nan Mojer-Torres, John Coppola, Ronald White, and Andrea

Barthwell served as expert panelists. Seventy-six individuals presented testimony, some testifying 

on more than one domain. The following summarizes their recommendations, concerns, and 

other comments.

Closing the Treatment Gap

Of the issues that emerged during the testimony on closing the treatment gap, perhaps the most

pervasive involved the needs for expanded treatment capacity, including more treatment slots and

longer lengths of stay for all people, but, especially for special populations including youth, criminal

offenders, and women with children. A substantial focus was placed on managed care’s contributing

to the gaps in treatment and the degree to which treatment is unavailable. Solutions for increasing

capacity included increased funding for treatment and passage of legislation for substance abuse

treatment parity.

Several of those who testified called for increased funding for and availability of recovery support

services and recognition of these services as a distinct part of the continuum of care. Recovery support services, which include assistance in entering various levels of treatment, locating housing, and

securing employment, bridge the gap between treatment and the community.

Testimony indicated that gaps in treatment are especially problematic for certain populations who

need access to multiple systems of care or who are at high risk of relapse. For these individuals, a

multi-system, multidisciplinary approach was suggested as the way to provide comprehensive 

treatment. For example, effectively addressing the specific needs of women with children may

require close collaboration between a caseworker from the State’s department of children and families and a substance abuse treatment provider, along with involvement of a counselor — who can

address issues related to physical abuse — and a physician who can provide primary care.

Comprehensive treatment for the family may require job skills and parenting skills training, child

care, treatment for related issues (e.g., low self-esteem), and housing and transportation.

PUBLIC HEARING SUMMARIES
Some people testified that the gaps between systems could be minimized by initiating a coordinated

approach for addressing substance abuse on the Federal level.

Several recommendations were presented for specific populations:

• For adolescents, create a continuum of care that addresses their development and the family crisis that results from addiction; develop and adopt criteria specific to teens that can be used as

standards for residential care; provide respite care for adolescents away from their families; educate parents, communities, and health professionals about drugs and addiction; encourage

schools to confront substance use and abuse by students; and establish an accessible information

and emergency counseling hotline.

• For homeless clients, some of whom also have mental illness, increase access to transitional

housing and permanent supportive housing to help them move from emergency 

shelters to treatment and from treatment to recovery.

• For women and women with children, increase the special programs and education, research,

and treatment that address their specific needs; increase the availability of safe, affordable 

housing and recovery homes; and fund programs that use family-focused interventions.

• For criminal offenders, increase the number of diversionary treatment programs; educate 

correctional officials about the efficacy of treatment; and eliminate statutory, programmatic,

and economic barriers that make incarceration the first course of action to manage substanceabusing offenders instead of treatment.

• For “the working poor,” ensure that they have adequate access to services. This group is rapidly

losing insurance, and those that are able to purchase services themselves rarely buy packages that

include a behavioral component.

• For undocumented clients, ensure that they have access to services regardless of their 

immigration status.

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179

Reducing Stigma and Changing Attitudes

People testified that the stigma against individuals with addiction contributes to denial, prevents

individuals from receiving the treatment they need to recover, forces persons in recovery to live in

fear of “being discovered,” and impedes appropriate siting of needed treatment programs, especially

methadone programs.

The primary recommendation for reducing stigma was to implement a multiyear, multilevel public

education campaign to share facts about addiction. According to those who testified, the most

important messages to share are that addiction is a disease, not a moral problem, and that addiction

can happen to anyone. Addiction is treatable, and relapse is a part of the disease. Another important message to share is that substance abuse, mental health, and HIV/AIDS are tied to poverty.

Suggestions for the public education campaign included modeling the campaign after product

advertising, infusing drug education into all parts of the school curricula at all levels, and posting

drug information on Government and school Web sites. In addition, there was agreement that 

people in recovery have a role in reducing stigma by telling their own stories, which “puts a face 

on addiction.” People in recovery could share their stories in classrooms, public service announcements, and chat rooms. In addition, people in recovery should take a greater role in advocacy 

and political activism.

Several policy approaches were recommended for reducing stigma. The most important one was

passing the substance abuse parity act. In addition, some recommended enacting welfare reforms

that treat rather than punish those with addiction and that recognize the long-term efficiency of

early identification and treatment, removing legal restrictions to treatment, and enhancing the 

ability to prevent and deal with the consequences of tragedies related to substance abuse.

Some people who testified charged the field with reducing stigma. They suggested that, first, those

in the field should avoid using language that contributes to stigma, such as the term “substance

abuse,” which supports the idea that addiction is caused by willful misconduct. Second, treatment

providers should avoid criticizing treatment approaches used by other providers, because such 

criticism diminishes the credibility of the whole field. Mandatory training and education about 

the physiology, psychology, and sociology of addiction were recommended for program staff.

Finally, people called for more research that demonstrates the efficacy of treatment as a way to

decrease stigma. Data on what works and for whom should be made available to the publicat-large, including families and policymakers. Data also should be shared with other systems,

especially the criminal justice system, which does not adequately embrace treatment as an important crime fighting and disease-reduction tool.

PUBLIC HEARING SUMMARIES
Improving and Strengthening Treatment Systems

In the words of one person who testified:

“Substance abuse treatment works best when it is coordinated and when it becomes a system of care

which is capable of addressing the often complex needs of the total individual. It is rare that a 

single entity has the resources and expertise to address the medical, psychological, housing, vocational, educational, transportation, access, and cultural needs of any particular client. The challenge . . . for substance treatment providers is to build a system of care through collaborations with

other providers that can address the very needs of clients without making them negotiate multiple

layers of bureaucracy.”

This theme was echoed throughout the day of testimony. Other testimony indicated that because

systems often coexist in isolation, treatment dollars are not used effectively and the quality of treatment suffers. Connecting systems can be extremely important for clients with co-occurring addiction

and mental illness, drug-involved criminal offenders, homeless clients, and women with children. It

also was suggested that integration of services across systems would be enhanced by independent case

management and by a policy that ensures that patient records can be shared adequately and effectively

across all systems.

A primary recommendation for integrating services was that State and Federal governments should

encourage collaborations in both the public and private sectors through funding mechanisms (e.g.,

funding collaborative efforts, avoiding the use of funding mechanisms that require agencies to 

compete with one another). In addition, these governments should change laws or policies that

obstruct the development of these systems of care. Effective collaborative efforts could be promoted

as models in other States.

In spite of the need to collaborate across systems, some people argued against merging the funding

streams for substance abuse and mental health services to avoid a possible decrease in substance

abuse treatment services and a loss of identity for the field. In addition, some recommended using

caution in making “sweeping” changes.

Examples of other recommendations are the following:

• Improve cultural competence in all behavioral health services at the service delivery, administrative, and policymaking levels.

• Take a more comprehensive approach to data gathering that includes providers of services in

both the public and private sectors.

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181

• Develop a national consensus among the private and public sectors regarding treatment definitions and measurements of results.

• Increase the accuracy and consistency of data on patient census and waiting lists.

Connecting Services and Research

According to testimony, there is and has been a “disconnect” between those who conduct research

and those who put it into practice. Generally, efforts are needed to ensure that new knowledge

gained in research is disseminated and implemented effectively in the clinical setting. Likewise,

efforts are needed to ensure that the most pressing challenges and most promising practices in 

treatment programs are being studied by researchers. It also was suggested that practices shown to

be effective and cost-saving be communicated to lawmakers.

Several people who testified described projects that address the implementation of research, including practice/research collaborations and Connecticut’s Statewide Clinical Treatment Innovations

Network, which systematically assesses whether treatments shown to be effective in “ideal” settings

can be effective when applied more generally by clinicians. One person who testified recommended

that CSAT consider the development of State university academic partnership grants to develop

partnerships between university-based researchers who conduct research on treatment and single

State agency directors who disseminate and implement research findings.

Several people who testified commented on the application of specific areas of research (including

research on office-based methadone maintenance) and the need for specific types of research (such

as research on the cost-benefit of treatment and research on the effect of new atypical anti-psychotic

drugs on the treatment of severely addicted individuals).

Some other suggestions from testimony included the following:

• Outcomes measures should account for factors related to economic resources that are available

to individuals — especially women — after treatment, such as jobs at a living wage, child care,

affordable housing, transportation, and medication.

• A standardized set of measures for collecting data should be developed.

• Some of the funding available for scientific research should be directed toward application 

of research in the field.

• Demonstration grants and other funding for model programs need to encourage attention to

anticipated major changes that will affect the substance abuse treatment system.

• Caution should be used in interpreting and translating research.

PUBLIC HEARING SUMMARIES
Addressing Workforce Issues

Three main areas of testimony were presented that related to workforce issues: the type of people

providing treatment, the education of health care practitioners to increase substance abuse screening in the medical setting, and workplace policy and treatment for employees.

Those who testified frequently commented on their concern about the decreasing number of

persons in recovery who are working as counselors in substance abuse treatment programs due to

changes in certification and licensure, as well as the shift to managed care. One person recommended that CSAT direct funds from block grants to the States in such a way as to encourage State

and individual treatment programs to increase the number of persons in recovery on their programs’ staff. Another issue facing programs is the insufficient number of Spanish-speaking clinicians, nurses, physicians, and psychiatrists to respond to the number of Spanish-speaking clients

who are served in treatment programs. It was suggested that CSAT support educational initiatives

that would allow Spanish-speaking people to earn degrees in the helping professions. Another person who testified recommended that Federal standards for alcohol and drug counseling be instituted in order to protect consumers.

Some people testified that although alcohol and other drugs frequently contribute to injuries that

are treated in emergency care and surgical practice, health care practitioners often fail to recognize

and address alcohol and other drug problems in their patients. Therefore, it was suggested that

health care practitioners’ knowledge, beliefs, and attitudes must be changed with education and

training about addiction and how to address the disease.

Testimony was also heard regarding the need for developing workplace programs that prevent substance abuse and achieve drug-free workplaces. Addressing substance abuse issues is especially difficult for small businesses, which require educational and training opportunities to increase awareness. Testimony also reflected the importance of businesses having not only an employee assistance

program but also appropriate insurance so that employees have access to needed services.

Other Issues

A recurring theme throughout the hearing was that CSAT and the treatment field should listen to

the voices of people in recovery in the development of the NTP and, more generally, develop a

process by which consumers can be consulted regularly as full partners in the recovery process.

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C. LOYOLA UNIVERSITY, CHICAGO, ILLINOIS, SEPTEMBER 16, 1999

On September 16, 1999, CSAT held a one-day public hearing in Chicago, the third in a series 

of hearings providing input to the NTP Initiative. Testimony was heard in five NTP domains 

related to substance abuse treatment: closing the treatment gap, reducing stigma and changing 

attitudes, improving and strengthening treatment systems, connecting services and research, and

addressing workforce issues.

Melody Heaps moderated the hearing, and H. Westley Clark, Lura Lynn Ryan, Nick Gantes, Susan

Weed, Camille Barry, Michael Couty, George Gilbert, Benjamin A. Jones, Judith Lewis, and Chilo

Madrid served as expert panelists. Sixty-five individuals presented testimony, some testifying 

on more than one domain. The following summarizes their recommendations, concerns, and 

other comments.

Closing the Treatment Gap

The foremost issue discussed during the hearing was the paucity of treatment available for those

who need it. The inadequacy of resources, not only for providing treatment but also for ensuring

quality treatment, also was cited. There were comments on the “disconnect” between the nature of

addiction as a chronic brain disease and the fact that available treatment often consists of only of a

few sessions in outpatient care.

A negative effect of managed care and health maintenance organizations (HMOs) on the ability 

to provide adequate treatment was mentioned by several speakers. They suggested that these organizations should give more consideration to symptomatology than to cost factors. Additionally it was

suggested that outpatient treatment, which is the most intensive treatment that insurers will pay for

under many health insurance plans, is not adequate for many patients, especially homeless persons.

The importance of providing services in recovery homes was mentioned by several people who testified. It was also noted that recovery services can be an important bridge between treatment and

the community, especially for people whose homes and communities are not conducive to their

recovery. Testimony included recommendations about the kinds of services that need to be provided during a long-term recovery period of up to 18 months, including aftercare and training in parenting, communication, and job skills. The importance of establishing recovery homes for teenage

girls was emphasized. More than one speaker suggested that health insurance coverage be provided

for persons requiring care in recovery homes.

Speakers indicated specific gaps related to treating women. According to some, there is a pressing

need for services to treat women with their children and to provide care for infants and children

who need special services because of parental addiction. An expansion of funds was recommended

PUBLIC HEARING SUMMARIES
for the treatment of women and children that would include parenting and other education, vocational training, housing, and case coordination. Another speaker noted that many women need

childcare to be able to take part in treatment. In addition, it was suggested that alternatives to

incarceration are needed, particularly for female offenders.

Various testimonies suggested that new and different models are needed for treating adolescents,

including those with co-occurring disorders; for coordinating their care; and for following through

to ensure that their needs are met. Other populations for which treatment should be improved

included dually diagnosed and offender clients, functional abusers who do not seek treatment,

homeless people who cannot participate effectively in outpatient treatment, and welfare-to-work

clients who need treatment during evening hours and on weekends due to their work schedules.

Another speaker called for improved approaches for the treatment of male African American

patients, including making recovery homes available to them.

Attention was given to the need to treat the medical conditions of many patients, especially those

with sexually transmitted diseases (including HIV and AIDS) or hepatitis, and to the need for the

primary health care system to take part in providing their care. Some people who testified called for

increased awareness of the gang situation in Hispanic communities across the country and its relationship to drug problems, as well as the need for treatment staff who are Hispanic or from other

ethnic minority groups.

The importance of the continuum of care and the ability of any individual in need to receive all 

levels of care was also emphasized. Testimony addressed the need for shared patient information

across providers and systems (e.g., ancillary service providers, criminal justice). The view was

expressed that incarceration in the correctional system should not be the prescription for people

who are nonviolent; treatment alternatives can be offered to these people with addictions.

Reducing Stigma and Changing Attitudes

Numerous speakers highlighted the power of recovery and the need for members of the recovery

community to speak about addiction and their experiences in an effort to help others understand

the nature of the disease. The belief was expressed that the recovery community can play a very

important role in changing attitudes about addiction and about people with addiction.

Appeals from various speakers showed how stigma distorts public policy, can contribute to the 

inappropriate incarceration of people with addiction, and can have a negative effect on child welfare

when parents are separated from their children. People in recovery clearly described the stigmas

and societal attitudes they faced in seeking treatment and remaining in recovery.

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According to some speakers, there is an urgent need to address the impact of racism, sexism, and

economic oppression on public policies regarding treatment. Speakers noted the differences

between communities in which addiction is addressed through the criminal justice system and 

communities in which it is addressed by health care. Unfortunately, they said, current public policy

accepts that people who have money and stable jobs have disproportionate access to the rare inpatient treatment programs.

Several speakers saw a need for CSAT and other government spokespersons to provide information

about addiction and treatment that would change attitudes among several key groups: treatment

providers, regulators, physicians, administrators of health insurance and managed care systems,

and members of the criminal justice system. Key messages should include that treatment works and

that addiction is a chronic and relapsing brain disorder. Government spokespersons also should

advocate for substance abuse training for individuals in medical schools, nursing schools, and 

other professional schools.

Testimony suggested a particular need to publicize the effectiveness of methadone treatment for

people addicted to heroin. Speakers suggested that when members of professional groups and

administrators of health insurance and managed care organizations limit substance abuse treatment, they negatively influence public thinking about effective treatment and what it should entail.

One speaker believed that participants in the War on Drugs and the criminal justice system should

focus on positive attitudes.

Improving and Strengthening Treatment Systems

Testimony was presented about the need to understand how to treat clients who have multiple needs

on the basis of factors such as gender, culture, and health status. CSAT can provide leadership to

treatment providers with respect to the treatment of patients with co-occurring disorders and complicated medical problems, as well as other special populations. The treatment system must be able

to respond to their needs.

Some people testified that substance abuse treatment should be considered the same as treatment

for any other medical illness by insurers. They suggested that CSAT monitor and evaluate managed

care to help its practitioners change their decision-making logic.

Speakers emphasized the importance and need for linkages across systems. Treatment staff need to

be engaged in developing systems integration strategies. In addition, some speakers called for

improved wraparound services as a major focus in treatment. They talked about including empowering, strengths-based approaches in treatment programs and including housing, employment, education, and parenting services as central, not peripheral, components to treatment. Bridges among

disciplines are needed, and it was suggested that CSAT help to establish them.

PUBLIC HEARING SUMMARIES
Others suggested that CSAT develop a prototype of an interdisciplinary, comprehensive system of

care for adolescents, generating research data, replication, evaluation, and continued funding. CSAT

also should provide information on adolescent care to policymakers to improve their understanding

of effective treatment and recovery services for this population.

Testimony was presented on legalization and regulation of drugs for adults, and harm reduction was

discussed. Speakers noted that some people who can benefit from treatment may not be ready for

abstinence. However, they recommended that these individuals be permitted to enter treatment;

their early stages of treatment could concentrate on building motivation for further change.

Two speakers suggested that the role of preventionists should be expanded and that they should be

educated to identify clients for treatment. In particular, preventionists can serve as outreach 

workers to identify youth and refer them for assessment and treatment. With adequate funding,

preventionists can promote positive peer interaction, social skills development, conflict resolution,

and positive alternative activities for youth.

The importance of identifying and applying best practices was emphasized. With respect to best

practices, one speaker suggested that seven- to ten-day detoxification be provided for late-stage alcoholics and addicts. Once the patient enters treatment, treatment needs to be available for relapses,

accidents, infections, and cirrhosis. A physician pointed out that the restoration of health during

treatment and recovery will help eliminate the costs of later complications. There were many 

comments on methadone maintenance and how stigma influences its administration, there by 

preventing the implementation of known best practices. The concept of making methadone maintenance part of mainstream medical care and the problems inherent in doing so were discussed.

Connecting Services and Research 

Testimony indicated that clinicians on the front line in treatment programs need to understand 

the latest research findings and how research is conducted. Mechanisms and funding need to exist

to facilitate staff training to advance their knowledge in these areas. Currently, staff are limited in

their ability to participate in training because programs are reimbursed only for time spent 

providing direct service.

Barriers to conducting research on best practices were identified. To connect research with practice,

research needs to be conducted with poly-drug users and those with multiple dysfunctions or disabilities, who are typically seen in real-world settings. Others stated that it is important for

researchers to consider the pattern of clients’ entire lives.

Other testimony indicated that community-based agencies and practitioners need to take part in

identifying appropriate research questions to ensure that research produces findings that they can

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apply in their work. The need to establish mechanisms to involve treatment personnel in the formulation of research goals, and the parallel need to improve the dissemination of research results 

to them, was addressed several times.

Some speakers called for funding for creative and innovative research that leads to new approaches

in treatment. The idea was presented of an “imagining” center that would conduct research on the 

possible range of medical, neuropsychological, and psychological services. In addition, a great need

exists for an infrastructure for substance abuse research that is based on the medical model of research.

Finally, it was suggested that certification and licensing bodies examine ways to ensure that 

clinicians and programs are keeping informed about and are implementing best practices.

Addressing Workforce Issues

Testimony was presented along two tracks. The first track related to the ways in which small businesses, large companies, and industries deal with people who use alcohol or other drugs or who are in

recovery. This testimony spoke to the need to establish company policies that encourage Employee

Assistance Programs (EAPs) and treatment interventions. In addition, it was suggested that companies should be better educated about how EAPs and substance abuse programs can improve productivity. There is a need to gather new data regarding substance abuse in the workplace and a need to

carry a succinct message to employers about their role in helping their employees.

Speakers presented their understanding that the country’s dysfunctional workforce derives in part

from the fact that substance abuse goes untreated. However, the workplace represents an opportunity

for intervention; the substance abuse treatment field should support and seize this opportunity. The

need to address the dysfunctions of the workforce that are related to substance abuse and resulting

problems applies not just to business, industry, and retailers, but to human service agencies as well.

The second track addressed issues in the workforce composed of providers in the substance 

abuse treatment and prevention systems. Radical changes have occurred in substance abuse and

treatment over the last 10 to 15 years, and treatment personnel are not necessarily trained to

address these changes.

Speakers stressed the need to ensure that treatment programs have an appropriate staff in place.

Program staff must have the expertise required to receive funding and reimbursement for services,

must be appropriately multicultural and multilingual, and must be aware of myriad psychosocial

and interdisciplinary treatment approaches. Training and other educational opportunities must be

made available to both professional and nonprofessional staff members.

One issue raised is the need for a role for nonprofessional community people, who may enhance

many clients’ treatment or recovery but lack formal training.

PUBLIC HEARING SUMMARIES
D. METROPOLITAN WASHINGTON COUNCIL OF GOVERNMENTS,

WASHINGTON, DC, OCTOBER 18, 1999

On October 18, 1999, CSAT held a one-day public hearing in Washington, DC, the fourth in a series

of hearings that constitute a crucial component of CSAT’s NTP Initiative. Testimony was heard for

each of the five NTP domains: closing the treatment gap, reducing stigma and changing attitudes,

improving and strengthening treatment systems, connecting services and research, and addressing

workforce issues.

Peter F. Luongo moderated the hearing, and H. Westley Clark, Camille T. Barry, Guardia E. Banister,

Alpha Estes Brown, Karen Dale, Thomas Davis, John Gregrich, Patricia D. Hawkins, Elvin Bernard

Parson, Melanie Randall, Dedra Roach, Michael C. Rogers, and Sue Thau served as expert panelists.

Seventy-five individuals presented testimony, some testifying on more than one domain. The following summarizes their recommendations, concerns, and other comments.

Closing the Treatment Gap

The comments provided by the first person who presented testimony set the tone for the rest of the

hearing, stating that substance abuse treatment is in search of recognition and acceptance in public

policy and advocacy at the highest levels of Government. Every one of the Nation’s social systems is

affected by the continuing epidemic of substance abuse, a problem that is exacerbated by the paucity of substance abuse treatment. He found it hard to believe that treatment is not a top

Government priority.

Speakers in this domain noted that treatment is not available or accessible to hundreds of thousands

of people who need it, many thousands of whom reside in the Washington metropolitan area alone.

CSAT was asked to address particular gaps in programming, including treatment programs for adolescents; programs integrating substance abuse and mental health treatment for persons with

co-occurring disorders; programs for women and their children; programs for persons with both

HIV infection or AIDS and substance abuse disorders; programs addressing the needs of people

with substance abuse problems who are dealing with issues of sexual abuse and violence; and comprehensive programs, such as therapeutic communities. Particular attention was directed to the

need for specialized substance abuse treatment programs for adolescents, as well as the need to find

ways to make adolescent treatment more affordable to families.

One glaring gap in treatment that was noted was the lack of programs that serve people who are

deaf and have substance abuse problems and the lack of treatment staff who can understand and

proficiently use sign language.

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Speakers highlighted the gaps in auxiliary services related to substance abuse treatment, including

family services, violence intervention, services related to sexual abuse, housing, parenting, and

employment. Attention was directed to the need for additional services addressing transitional

housing, job preparation, and the employment needs of clients during the important recovery 

period immediately following treatment. Also emphasized were the needs of welfare-to-work clients

who are able to find only minimum-wage jobs and need drug-free transitional housing during

recovery so they can avoid returning to their old neighborhoods and communities, which may not

support their sobriety. Others commented on the difficulties faced by single women who must pay

for child care during the search for jobs and initial employment, often at meager wages, while staying free of drugs and alcohol. Testimony suggested that CSAT might facilitate co-location of substance abuse treatment services with the offices responsible for welfare-to-work programs, since

substance abuse is commonly present in the welfare-to-work population.

The establishment of community-wide systems for accessing treatment and community-wide 

referral systems was recommended, with a single agency coordinating entry to treatment and 

facilitating referrals.

Problems with insurance carriers limiting access to treatment, such as the refusal of some insurers

to pay for certain treatment modalities, were described, along with the need for full parity of

treatment for substance abuse with treatment for other physical conditions in insurance plans.

CSAT was asked by several speakers to help increase the skills of treatment providers in supporting

the newly emerging recovery community, helping it develop the advocacy skills needed to draw

attention to the need for treatment. Some speakers suggested that the Recovery Community

Support Program be expanded. A related theme throughout the hearing was the importance of

involving people from the recovery community in the design of treatment approaches.

Testimony addressed the growing rate of Hepatitis C among the substance abuse treatment workforce

and among clients. Testimony called upon the National Institutes of Health, SAMHSA, and other

appropriate resources of the Department of Health and Human Services to confront this epidemic.

According to the testimony, it is very important that people be able to enter treatment when they

determine that they need it. In many geographical areas this is impossible. In some cases, no 

programs have treatment slots available. In other cases, insurance carriers prevent access to treatment because they only pay for specified modalities or they misunderstand issues such as relapse.

PUBLIC HEARING SUMMARIES
Reducing Stigma and Changing Attitudes

A major theme that emerged in the testimony was the need to overcome practices of treatment

providers that promote rather than help remove the stigmas attached to substance abuse, such as

perpetuation of the idea that treatment is punishment and that persons with this illness are “bad,”

rather than sick. A related suggestion was to eliminate the term “substance abuser,” which is seen as

dehumanizing, political terminology. Medical terminology is needed that more accurately describes

the illness and the ill person.

One speaker suggested that a Federal commission root out policies and laws mandated in all 

Federal agencies that are based in stigma. Interstate and national programs and media campaigns 

to advocate for the field were recommended to educate the public about the need for changed

thinking regarding stigma. In addition, the inclusion of communications specialists within the field

should be considered.

Another speaker suggested that a New Jersey model of State councils be implemented to advocate

for the treatment field and influence policy and legislation. One reason it was easy for managed

care organizations (MCOs) to remove substance abuse treatment from coverage was because the

public was not sure substance abuse treatment was needed, and State councils could help the public

better understand substance abuse and treatment. Treatment providers are now shouldering

responsibility for public education, and their attention needs to be devoted to clinical and administrative issues, particularly in a time when managed care requires so much administrative attention.

Speakers also noted the difficulties in finding employment that are faced by persons who have been

incarcerated for substance-related offenses and have completed their sentences, and they asked for

help in addressing this issue by directing attention to the successful rehabilitation of such persons.

Other testimony addressed the stigma that exists against traditional counselors who are in recovery

and who have contributed to the care of persons in treatment. These persons should be heard from

regarding the establishment of educational and credentialing programs for counselors.

Another speaker highlighted the institutional stigma that keeps emergency room and trauma 

centers from testing injured patients for the presence of alcohol and drugs and from using a positive

finding as a basis for intervention.

Improving and Strengthening Treatment Systems

Several areas for improvement were highlighted: treatment of dually diagnosed patients, treatment

of clients returning to work from welfare, culturally sensitive treatment for Latinos and other

groups, methadone maintenance, treatment for patients with HIV/AIDS, and treatment for people

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who have been sexually abused. In addition, speakers called for removal of bans against needle

exchange programs, which can prevent AIDS without increasing substance abuse.

CSAT and the Center for Mental Health Services (CMHS) were called on to collaborate in finding

ways to enable providers in their two fields to integrate their services and work jointly with individual patients; a mandate from the two agencies requiring collaboration was suggested. Similarly,

CSAT was asked to work with other agencies to ensure that comprehensive services, including substance abuse treatment, are available for people who are on welfare and are moving out of welfare.

The need to educate treatment providers about dual diagnosis was noted. This includes the need to

educate mental health providers about substance abuse treatment.

Others remarked on the discrepancy between scientific knowledge about the successful use of

methadone in treating opioid addiction and practices in the field. CSAT was asked to direct attention to this issue.

Programs in which community residents have helped design culturally sensitive treatment, particularly in Latino communities, were described, and the replication of this approach was recommended.

The use of telecommunication systems to provide continuing education for workers in rural areas

and to present educational components of treatment in these areas was suggested.

Speakers mentioned other areas that need to be improved and strengthened, including insurance

parity, outcomes research, and length of treatment stay. Another recommendation was to conduct

research on breathwork, a novel approach to treatment that has been studied and shown successful.

Connecting Services and Research

CSAT was asked to continue its interactions with the National Institute on Drug Abuse (NIDA) and

the National Institute on Alcohol Abuse and Alcoholism (NIAAA) to ensure that their research findings are made available to treatment providers. In particular, information on research results need

to be made available to counselors. Testimony indicated that CSAT also can play a major role in

ensuring that research results are implemented locally. One speaker advocated for a comprehensive

Federal training and technical assistance program to advance research utilization, extending beyond

the scope of Addiction Technology Transfer Centers.

Grassroots research, in which local programs participate, was recommended. One person called 

this “in-field” evaluation that could be supported by temporarily stationing researchers in 

community-based organizations.

PUBLIC HEARING SUMMARIES
Addressing Workforce Issues

Recommendations pertained to the treatment workforce, education about substance abuse problems in the Nation’s workforce, and problems of women on welfare entering the workforce.

It was suggested that CSAT provide technical assistance and training to enable the substance abuse

treatment workforce to keep abreast of advances and new findings in the field. Other speakers 

recommended that attention to standards of care not exclude recovering staff who can assist clients

in recovery or prevent people from entering the field as entry-level counselors. Scholarships and

grants for the education and training of traditional counselors could be provided, and attention

could be directed at better integrating counselors into the health care system.

It also was suggested that, to address the shortage of trained professionals in substance abuse treatment, a strategic planning process should be initiated that includes the private vendor sector. In

addition, there should be a sharing of resources between the private vendor sector and Government

agencies with respect to expertise and technology.

Many people leaving welfare rolls to seek employment need substance abuse treatment, and it was

noted once again that their needs for treatment and auxiliary services should be met. The need for

treatment models oriented to helping women prepare to return to work was stressed; counseling

that deals with their work-related issues was recommended.

Speakers called attention to legislation in Virginia that would keep recovering addicts with certain

criminal histories from working in substance abuse treatment programs. Vigilance is needed in

addressing this problem and in influencing discussions of such legislation proposed elsewhere.

E. THE PORTLAND BUILDING, PORTLAND, OREGON, OCTOBER 26, 1999

On October 26, 1999, CSAT held a one-day public hearing in Portland, OR, the fifth in a series of

hearings that constitute a crucial component of CSAT’s NTP Initiative. Testimony was heard on the

five NTP domains: closing the treatment gap, reducing stigma and changing attitudes, improving

and strengthening treatment systems, connecting services and research, and addressing workforce

issues.

Victor Capoccia moderated the hearing, and Camille T. Barry, Mady Chalk, Barbara Cimaglio,

Amalia Gonzalez Del Valle, Lewis E. Gallant, Steven L. Gallon, Melody M. Heaps, Alan Melnick, Rod

K. Robinson, Kenneth D. Stark, and Flo Stein served as expert panelists. Eighty-seven individuals

presented testimony, some testifying on more than one domain. The following summarizes their

recommendations, concerns, and other comments.

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Closing the Treatment Gap

The universal need for more treatment resources was best exemplified by the Director of the Oregon

Department of Human Services, who stated that his department’s staff of 10,000 could be reduced

by 50 percent if the problem of addiction could be eliminated. Addiction is the most serious problem

affecting clients, from prenatal to geriatric, in all the social services provided by the agency.

Lack of treatment programs is only part of the treatment shortfall. Gaps in resources needed to

provide effective service are caused by numerous factors, including the failure of managed care

providers to adequately reimburse, if at all, for substance abuse treatment. Individuals testifying

stated that paperwork and bureaucratic requirements of managed care organizations take resources

away from treatment and reduce the number of clients who can be served.

There was a call for CSAT to work with other parts of the United States Department of Health and

Human Services (DHHS) to change the Medicaid requirement stating that funds for substance

abuse treatment can only be provided for patients in facilities with 16 or fewer beds. This requirement keeps many patients from receiving treatment who would otherwise be eligible for it.

Speakers also called on CSAT to educate insurers regarding: (1) the rationale for parity of substance

abuse with other conditions requiring medical care, (2) the need for higher reimbursement rates,

(3) the need for employer health policies that cover more comprehensive services, and (4) the willingness of insurers to provide requested information about coverage to employees in these plans.

Insurers also need to understand that reimbursing services only for individuals, despite the scientific

evidence for the importance of family treatment, can reduce the effectiveness of treatment.

Numerous testimonies highlighted gaps in specific services, including methadone maintenance,

services for numerous vulnerable populations such as minorities and persons with disabilities,

outreach to Asian and Pacific Islander communities, adolescent substance abuse, and outreach to

incarcerated and homeless Native Americans. Other gaps were noted in maintenance care following

treatment, services for women with their children, treatment of co-occurring disorders among

minority citizens, services for women in welfare-to-work programs, care of hepatitis C among

addicted and recovering people, and culturally based inpatient and outpatient services for Native

Americans as well as services targeted to women and children on reservations. Another area of

concern, introduced in this domain and referred to in others as well, is the gap created by shortages

in the substance abuse treatment workforce.

Discrete gaps in the design of programs also were highlighted. For example, released felons who

have completed treatment successfully while incarcerated are not permitted legally to associate in

their communities with other felons who were incarcerated with them. This breaks up the support

groups that worked effectively for prisoners before their release. Improvements in treatment provided in correctional institutions are needed.

PUBLIC HEARING SUMMARIES
Attention was called to inhalant use among 11- to 13-year-olds and the lack of information about

the deaths that can occur because of its effects on the heart. Statistics on inhalant use among youth

were called “frightening,” yet no treatment programs seem to address this substance.

The need for treatment on demand, as for patients with other chronic diseases, was mentioned 

by several speakers, along with the need to integrate substance abuse treatment into mainstream

medicine. Acupuncture was recommended as a way to provide immediate treatment; increased

funding for this method was requested.

The importance of drug-free housing following treatment also received much attention. Speakers

felt that this type of housing, with strong facility management guidelines including clear policies on

the eviction of residents who use substances, is a treatment intervention. It preserves the benefits of

the treatment experience for people leaving treatment who do not have supportive, drug-free environments awaiting them.

Reducing Stigma and Changing Attitudes

People testifying at the public hearing concentrated their attention on what could be done to overcome stigma. CSAT representatives heard the call for its energies to be devoted to educating the

public on numerous issues: (1) the importance of methadone as a legitimate medication for heroin

addiction; (2) the cost effectiveness of methadone treatment compared to accepted treatments for

other diseases; (3) the fact that addiction is a treatable disease; (4) the efficacy and cost effectiveness

of treatment; (5) public health dangers connected with the use and abuse of alcohol and drugs; and

(6) replacing myths about addiction with facts. Information should be disseminated in ways that

make it readily acceptable to racial, ethnic, and cultural minority groups.

Speakers had very concrete suggestions for overcoming stigma among professionals, who could

more effectively provide services for addicted persons if their attitudes toward them were different.

CSAT could foster and contribute funding to provide training for members of the medical profession and develop continuing education courses for them and other professional groups. Workers in

social agencies need information about working with clients who are or have been felons. Many

fear them and resist providing services; this creates a problem for the substance abuse treatment

field, since many of its clients who need supportive services from other agencies received 

treatment while imprisoned.

Similarly, education from the Federal level can help officials in Federal agencies understand the need

to change attitudes toward recovering persons employed by or seeking work with Federal agencies.

Attitude change is needed even in agencies providing services designed to assist people with addiction and those in recovery.

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The increase in incidence of hepatitis C raised concerns because treatment is often less than optimal

if the patient is thought to be addicted. The situation parallels HIV/AIDS and the associated stigma

and needs an informed public to deal with what may become epidemic.

A fundamental change that speakers believed could begin within CSAT is the reformulation 

of terminology used to refer to addicted people. “Substance abuser” reinforces stigma, puts the blame

on the individual, and actually condones drug and alcohol use that falls short of abuse. It fails to suggest that addicted people are ill and need treatment. “Drunken Indians” was another term highlighted.

Numerous speakers emphasized the importance of people in recovery acknowledging to friends 

and associates that they are in recovery and that treatment works. Similarly, CSAT was asked to

communicate successes in treatment to the public.

CSAT can help remove stigma against treatment providers, particularly those who manage or work

in methadone maintenance programs. One social worker said she “could feel other professionals

move away from her” when she told them she worked in a methadone maintenance clinic.

Stigma of another sort was mentioned by a Native American speaker who described the problems

faced by persons who return to the reservation after successful treatment in a dominant-culture

program. Working outside the Tribal culture arouses suspicion, and nontraditional ideas such as

12-Step concepts are viewed negatively by peers.

Improving and Strengthening Treatment Systems

Integration of services was recognized by most speakers as essential to improve and strengthen

treatment systems. However, to help achieve this aim, leadership was requested from CSAT in

enabling treatment providers to sort out the maze of categorical funding restrictions, administrative

rules, and directives from different Federal, State, and county or local agencies that make it difficult

to blend service funding streams and develop integrated service strategies.

Speakers indicated that treatment programs should operate as part of multiservice centers or be able

to provide “one-stop shopping” themselves. This is essential in maximizing resources, reducing duplication of services, and showing positive outcomes for clients. CSAT leadership can help them achieve

this goal. Staff need training in multiple treatment approaches and in doing interagency planning.

Arguments were made for recasting addiction treatment as a chronic disease treatment system.

Such a system would recognize the critical importance of housing, recovery support services,

employment preparation assistance, and services that acknowledge range-of-life problems, including

aging. CSAT can help establish standards and benchmarks to let programs know to what extent

they are providing the full range of services that need to be part of chronic disease treatment.

PUBLIC HEARING SUMMARIES
Native American speakers asked CSAT to foster initiatives that recognize the isolated, rural nature 

of life on reservations; the mortality rate among youth that is 17 times the rate for white American

youth; the relationships between addiction and suicide; and the extent of dual diagnoses among

Native populations. Speakers suggested that a Federal approach to improving treatment among

Native Americans should be built around consideration of these factors.

Speakers suggested that Tribal leaders in the substance abuse treatment field also need access 

to a robust training system from which they can learn new approaches to integrate with Native

approaches to treatment. The need for new and renovated facilities in which to provide treatment

is acute. One speaker suggested that, because of the high rates of addiction among Native

Americans, a “disease burden” weight factor should be used when making funding decisions 

about grant applications from them. Another urged that CSAT work collaboratively with the 

Indian Health Service (IHS) to help ensure that substance abuse treatment is included in 

health programs it funds.

People in recovery and members of families with a recovering addict or alcoholic argued for more

attention to the need for including family members in treatment; providing employment preparation as a matter of course, with practicum or real job experience during the treatment process; and

establishing more social-model programs.

Service providers felt the field could be strengthened by the establishment of standard and uniform

outcome measures, analogous to those of the Joint Commission on Accreditation of Healthcare

Organizations. Treatment programs need computers and related technology.

Numerous speakers addressed the need to educate treatment staff about hepatitis C and prepare

them to educate clients about the disease and its transmission, as well as assist in finding treatment

if they have already been infected. Some argued for the need to return to a collaborative approach

to treatment as opposed to a competitive marketing approach focused on profit.

Connecting Services and Research

Changing the conversation to develop a culture built on trust and collaboration among the wide

variety of research and services organizations is an important precursor to bridging the gap between

research and treatment. Two researchers suggested that CSAT work to change the traditional model

in which a central research organization collects information from the field and disseminates findings back to the field for implementation, commenting that research also occurs in the field where

practitioners accumulate experience with treatment approaches. Their experiences, or findings, need

to be communicated among sites as well as with the central research organization. Methods need to

be found for such communication via the Internet, conference calls, and site visits. One group

encouraged CSAT to consider partnerships with higher educational institutions to train future 

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professionals in a combination of research and treatment and prevention skills. Two speakers mentioned that policy formation should be equally connected to empirical evidence-based information.

One speaker, who noted that practitioners need research results in small increments, suggested that

this can be accomplished by “stepping from one rock to the next” rather than having to wait until a

huge bridge can be built. Treatment providers should have the funds and resources necessary to

implement research findings; they should not be expected to carry any extra burden without some

form of compensation. CSAT should find ways to reward incorporation of demonstrated best practices. A resource pool of skilled change agents should be available to review progress and provide

consultation in the implementation of research findings.

One speaker asked that CSAT make funds available to States for research; States are asked to provide

up-to-date statistics on trends, determine the need for public treatment, and identify treatment capacity and costs associated with closing the treatment gap, even though they have few resources to do so.

States also need assistance from CSAT in funding research on medication efficacy so that treatment

providers have outcomes information that they can use in making decisions regarding medications.

Two Native American representatives advocated for research targeted at finding the most effective

ways, including Native treatment methods, to provide treatment to Native populations. Too often, it

is assumed that the IHS or the Bureau of Indian Affairs funds research, but this has never been the

case. One psychologist noted the need for research on the best processes for identifying and 

treating persons with alcohol-related neurological deficits. Acting-out behaviors, such as lateral violence and abuse and suicide, are common, and research is needed that will lead to the integration of

culturally relevant Tribal coping and healing methods with modern Western methods of treating

dual diagnosis. Tribal representatives should be included on institutional review boards. When

research results are obtained, they need to be communicated with Tribal officials. Speakers noted an

urgent need for information on state-of-the-art treatment methods for application within Native

American communities.

Two other main concerns were raised: (1) the need for research to identify the best methods of substance abuse treatment with different minority groups, and (2) the need for national, State, and

local dialog between researchers and practitioners. One speaker urged CSAT to model approaches

used by NIDA in national conferences and local dialogs to inform practitioners of research results

and enable them to interact directly with researchers.

Addressing Workforce Issues

Speakers emphasized, above all else, the shortage of counselors, and suggested that CSAT explore

ways of marketing and attracting professionals to the treatment field either by training new counselors or supporting education for existing counselors. These steps could be accomplished with

PUBLIC HEARING SUMMARIES
scholarships and continuing education programs. These programs could target diversity and geographic needs and secure a strong workforce by supporting increased earning power.

The particular need for counselors with the skills to serve an increasingly diverse clientele was

noted. Bilingual counselors are needed. Gender inequity of counselors is another issue. Because 

of the low wage scale, it is difficult to attract men into counseling. One speaker noted the workers’

need for a strong base of skill and knowledge that ensures treatment competency. Training should

include the development of cross-system competencies among workers in substance abuse treatment and allied fields, especially with respect to hepatitis C, services to people with low incomes,

and patients with disabilities.

One speaker argued that the emphasis on finding credentialed counselors and raising credentialing

standards may be weakening the field, depriving it of counselors with an overarching desire to help

people recover from addiction. The lack of counselors is compounded by State licensure laws that

are not competency based and exclude large numbers of counselors from eligibility for reimbursement by managed care organizations. A partnership among CSAT and national organizations was

urged to foster consensus among disciplines that individuals engaged in the practice of addiction

treatment services must practice within the confines of a recognized discipline shaped by competency-based standards.

CSAT also was urged to work with other Federal agencies to broker relationships that address the

workforce shortage; for example, the National Health Service Corps could be encouraged to fund

college education for chemical dependency counselors.

F. COUNTY CENTER, TAMPA, FLORIDA, NOVEMBER 8, 1999

On November 8, 1999, in Tampa, FL, CSAT held the final public hearing, the sixth in the series.

Testimony was heard regarding the five NTP domains: closing the treatment gap, reducing stigma and

changing attitudes, improving and strengthening treatment systems, connecting services and research,

and addressing workforce issues.

Shirley D. Coletti moderated the hearing. Serving as expert panelists were H. Westley Clark,

Camille T. Barry, Kenneth A. DeCerchio, Donald Evans, Bill Janes, James R. McDonough, Neal

McGarry, Stacia Murphy, Carole Otero, Thomas Scott, and Ronald Williams. Fifty-nine individuals

presented testimony, some testifying under more than one domain. This report summarizes their

recommendations, concerns, and comments.

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Closing the Treatment Gap

Integration of treatment systems was a prominent issue. Many speakers cited the need to eliminate

barriers and funding competition among different service areas with overlapping clientele. In addition, better relations and partnerships were called for between the public and private sectors.

The need for quality drug testing was mentioned by numerous speakers, particularly those in the

criminal justice system. Third-party payors were cited as too often dictating the course of treatment, to the detriment of clients; many speakers called for parity for substance abuse and mental

health services and removing the limitations on health plan coverage of these services. Vocational

training and family-based treatment were additional areas of concern. Several testifiers also spoke

of the need for better transitional treatment for offender populations reentering the community.

One speaker recommended legalizing marijuana so that people using it for medical reasons would

not occupy treatment beds.

Other recommendations concerning specific populations included:

• Persons with disabilities. Establish mechanisms within SAMHSA and CSAT to identify and 

examine the most promising treatment models for persons with disabilities; require all SAMHSA

and CSAT grantees to provide detailed plans for serving persons with disabilities within their

federally funded programs; form a disability compliance workgroup to assist CSAT in formulating policy and practices in this area.

• Individuals with dual diagnoses. Incorporate into existing treatment programs service components that assist dually diagnosed individuals with relapse prevention, housing, child care, education, vocational rehabilitation, parenting, and health care; develop aftercare programs to help

them maintain sobriety; increase current funding of services to this population; end the competition for funds among different service agencies treating this population.

• Ex-offenders. Legislation could help meet the needs of offenders with substance abuse problems

by extending the period (typically six months) and improving the structure of intensive treatment. Intensive treatment should be followed by a transitional modality such as a halfway house

to better equip offender addicts to reenter the community.

• Elderly populations. Allocate funds to raise the awareness of the general public and treatment

professionals concerning the problem of addiction in the elderly; develop appropriate screening

instruments for older adults; educate clinicians about discussing the topic of substance abuse

with their older patients.

PUBLIC HEARING SUMMARIES
• Adolescents. Focus on early intervention with young people who have addiction problems and

are entering the juvenile justice system for the first time; establish juvenile assessment centers to

perform early intervention, identify at-risk youth, and refer them to appropriate treatment programs before they become involved at higher levels of the criminal justice system; ensure that

treatment is age, gender, and culturally appropriate for the client; establish methods of effective

knowledge transfer so that successful programs can be embedded in and adapted to communities; include families in both treatment and prevention programs aimed at adolescents.

• Women. Create programs for women to enable them to keep their children with them while they

receive treatment; establish women-only groups within treatment programs.

• Homeless populations. Establish publicly funded substance abuse and mental health treatment in

managed-care and performance outcome-based environments.

• Clients in rural communities. Develop long-term, inpatient treatment for drug-addicted 

indigent consumers in rural areas, particularly women.

• Domestic violence offenders. Include domestic violence offenders in targeted populations in drug

courts; modify the eligibility criteria for Federal funding for drug courts to include domestic violence offenders who also have a substance abuse problem.

Reducing Stigma and Changing Attitudes

Many speakers testified to the persistent stigmatization of people with substance use disorders, particularly those with criminal records. Although attitudes have begun to change, especially with the

increasing view of substance abuse as a chronic, relapsing, and remitting disease, addiction is still

often seen as something that happens to others due to their own willfulness, stupidity, or lack of

good sense. Although it is less shameful today to be known as a recovering alcoholic or drug addict,

it is more difficult in many respects to get the help that is necessary to maintain recovery. Even

when addicted people do get help, treatment is often seen as a failure — by insurance companies as

well as friends and families of the addict — when they have a relapse.

Recommendations included the following:

• Providers should be educated to change their attitudes toward substance abusers. In particular,

mental health professionals and substance abuse professionals should endeavor to overcome

their negative attitudes about each other’s clientele and procedures and learn to work together.

Physicians should accept substance abuse as a disease and provide appropriate treatment 

and referrals.

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• Health insurers should be encouraged to provide coverage for substance abuse and mental illness

equal to that provided for other illnesses.

• Consumers need to organize and become more involved in education about and program 

development for substance abuse treatment.

• The definition of addictive illness should be broadened to include nicotine.

• Treatment providers and consumers alike should be more outspoken about the fact that treatment works and should engage in more public discussion of the commonality of the disease and

options for treatment.

• A human face should be put on addiction; the anonymity associated with self-help groups 

contributes to attitudes of shame and stigma.

• CSAT should encourage the formation of advocacy organizations devoted to ending the stigma

surrounding addictive disorders.

• Criminal offenders, even those in recovery with proven records of remaining abstinent, are

denied benefits such as housing and public assistance. Exceptions should be made for public

housing and educational assistance for addicts in recovery and their families, and assistance

should be continued for people getting out of prison.

• The mental health and substance abuse advocacy communities should maximize their efforts by

collaborating to obtain reforms in public and private treatment delivery systems, legislation,

regulations, and treatment practices.

• The Federal Government should rethink its television and newspaper advertising campaign, particularly those advertisements from the Partnership for a Drug-Free America that show people

throwing pottery. These advertisements inadvertently add to negative stereotypes. Instead, the

Government should promote messages that treatment works and that normal people can have

the disease of addiction.

Improving and Strengthening Treatment Systems

An overarching issue in strengthening treatment systems is the need for better integration and collaboration among service delivery systems. Agencies and organizations that provide services in the

areas of, for example, child welfare, juvenile justice, and domestic violence still tend to work independently. Better communication through the formation of clearly defined, integrated, and supportive relationships is needed among these fields.

PUBLIC HEARING SUMMARIES
Education of primary care physicians was also a prominent theme. Physicians need to be educated

about the disease of addiction, including the prescribing of habit-forming drugs, screening for 

substance abuse, and attitudes about substance abuse. An aggressive prevention intervention campaign is needed in which treatment providers work closely with physicians to educate and assist

with addiction-related issues.

Specific recommendations included the following:

• Provide inducements from the Federal Government to expand local and State money in matching funds. Place emphasis on the continuum of treatment, a full-service system, skilled assessments, and structured halfway houses.

• Place greater focus on nicotine as an addictive drug and a substance of abuse.

• Allow for more capital expenditures on vehicles for transportation and the staff to operate them

in rural areas.

• Mandate collaborative systems among those who affect adolescents’ lives — school systems, social

services, juvenile justice systems, and mental health and substance abuse treatment providers.

Formalize these systems to focus on a seamless identification, referral, treatment, and reintegration

of adolescents affected by mental illness, substance abuse, and other behavioral problems.

• Demand comprehensive training for those who deal with recovering adolescents, including

school educators and administrators, that will not only teach about addiction, relapse, and recovery but also address cultural competence and social stigmas.

• Encourage innovative projects that force all parties in the process to reduce the difficulties experienced by adolescents reentering their schools and communities after receiving treatment.

Develop teams made up of providers, school officials, social services, parents, and the faith 

community. Provide sufficient State incentives and funding to develop models of treatment for

vulnerable adolescents, evaluate the outcomes, and determine the cost benefits of the project.

Other recommendations concerned the criminal justice system:

• Focus sanctions and sentences for low-level, nonviolent substance abusers on treatment and

rehabilitation as well as deterrence and separation. Repeal mandatory sentencing laws. Judges

and legislatures should craft sanctions and sentences that focus on curbing negative behavior

rather than on processing offenders through the “revolving door” of treatment.

• Make access to intervention and treatment of addiction an integral part of the criminal justice

system so that treatment is available in a coordinated and continuous manner at every step of

the criminal justice process.

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• Eliminate barriers among the various entities of the criminal justice system so that they can

cooperate to reduce substance abuse.

• Include communities in planning and implementation of strategies for reducing substance abuse

on a system-wide basis — leave local drug efforts to local governments, while the Federal

Government restricts itself to pursuit of high-level drug dealers. State governments should focus

on setting appropriate standards for treatment, corrections, and probation and parole.

• The criminal justice system should include the entire community in ensuring public safety —

not only those in traditional law enforcement roles, but also teachers, clergy, business people,

neighborhood activists, homeowners, and tenants — anyone with a stake in the safety of their

neighborhoods and the well-being of their neighbors.

• Police should work in partnership with their communities to develop long-range strategies for

reducing substance abuse and short-range alternatives to traditional responses to substance

abuse and drug-related crime.

Connecting Services and Research

Improved drug testing was a focal topic under the domain of connecting services and research.

There was a call to increase the number, reliability, and efficiency of drug screens. Several testifiers

also pointed to the need to better identify the issues other than substance abuse that clients bring to

treatment, including dual diagnosis, domestic violence, and child abuse. Clients’ disabilities, such as

physical handicaps, trauma, brain damage from drug use, and learning disabilities, need to be identified and studied to determine their prevalence and how they affect treatment outcome.

As in other domains, much emphasis was placed on the importance of integrating public and private treatment systems. Mechanisms are needed to secure input from consumers and community

agents at all levels and to ensure outcome-driven systems. Data produced should reflect the community being served, and treatment services should be promoted across systems, including juvenile

justice and nontraditional settings such as faith communities.

Other recommendations were as follows:

• Promote valid research-based initiatives at the State level as best practices.

• Fund demonstration grants that allow dollars for service delivery.

• Set aside specific and increased funding for knowledge development initiatives based 

on previous research.

PUBLIC HEARING SUMMARIES
• Increase funding for following participants over time to test the lasting effects of interventions.

• Create a national system for monitoring the provision of substance abuse treatment services 

to persons with disabilities.

• Fund more research on the common risk factors for mental disorders, substance abuse,

and suicide and other forms of intentional violence, including homicide, domestic violence,

and child abuse.

• Allocate funding for research on the effects of hormone changes during and after pregnancy and

their effect on relapse.

• Conduct more research on alternative therapies that utilize the mind-body connection and its

usefulness in the treatment of addiction.

Addressing Workforce Issues

Discussion of workforce issues fell generally into two categories: (1) training, credentialing, licensing, and salaries of treatment providers, and (2) vocational rehabilitation and employment services

provided to clients of treatment programs.

Several speakers addressed the issue of counselor salaries, many of which are perilously close to the

poverty level. Along with increased salary levels, it was recommended that programs receiving

block grant funds should be required to employ addictions counselors who are either licensed or

certified through a State-recognized credentialing process. To determine appropriate salary levels, a

national survey should be conducted of counselor salaries based on a definition of the scope of

practice for various levels of clinical responsibility. Further, data should then be collected on salary

levels for other, comparable positions.

Areas of the country that have shortages in addictions counselors should be identified and additional training grants should be made available to them through Single State Agencies. This effort 

possibly could be coupled with a salary survey.

Speakers commented that the field must do a better job of defining its practice. It is also critical to

define best practices and disseminate them to the field. Addictions training should be included as

part of the academic curriculum in many professional fields. Training should be academically

based. A system of education, professional development, and training is badly needed. Addiction

Technology Transfer Centers (ATTCs) should be required to maintain close communication and to

work cooperatively with State provider associations in their regions.

Within the discussion of credentialing and licensing, there was a strong message from several speakers

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not to exclude the invaluable insight and experiential knowledge of non-degreed treatment providers

who are in recovery. People in recovery are often exceptionally skilled in reaching difficult-to-serve

clients. Their contribution must be kept in mind as competency standards are developed.

Several speakers agreed that addictions treatment should be made a specialty of medicine and that

counselors should be licensed. It was argued that psychiatrists and psychologists should have to be

subcredentialed if they provide or supervise treatment. Also needed is cross-training of nurses,

physician assistants, family nurse practitioners, social workers, and criminal justice personnel.

A statewide academy for basic training in the dynamics of addiction ought to be embedded in the

curriculum for law enforcement officers. Family counselors and certified teachers also should

receive training about addiction.

On the topic of vocational and job training for clients of treatment programs, it was recommended

that substance abuse treatment and return-to-work and vocational rehabilitation systems work

together to identify and evaluate models for providing services to individuals with substance use disorders, including those with one or more coexisting disability that negatively affects their ability to

return to work. This link should be strongly encouraged by requiring vocational readiness screening

for all persons served by chemical dependency treatment programs that receive Federal funding.

Other specific recommendations in this area were as follows:

• SAMHSA and CSAT should work together cooperatively with other vocationally oriented Federal

programs, such as Temporary Assistance for Needy Families (TANF), the Department of Labor,

and the Rehabilitation Services Administration, to support and disseminate national models for

cooperative services.

• Require vocational or work-related goals on all chemical dependency treatment plans underwritten by block grant dollars.

• Fund and promote models of cooperation that demonstrate how vocational assessment,

benefits analysis, and other prevocational services are incorporated into the chemical 

dependency treatment setting.

• Provide parity for chemical dependency treatment, as a critical mental health service, with other

mental health services when provided by health maintenance organizations and other health

insurance providers.

• At least some of the people in recovery serving as counselors and policymakers should share 

the drug culture of the clients; older recovering addicts have experiences different from those 

of their younger clients.

PUBLIC HEARING SUMMARIES
III. Written Testimony Received in Conjunction 

with Public Hearings

In addition to the oral testimony heard at the public hearings convened from June 30, 1999 to

November 8, 1999, CSAT also accepted written testimony. Previous reports of each public hearing

have summarized the testimony that was presented orally, some of which was supplemented by presenters’ written testimony. This document summarizes the testimony that was submitted in written

form only. Representatives of provider organizations, providers, consumers and family members,

State agency representatives, and others — including two first ladies, Lura Lynn Ryan of Illinois and

Hope Taft of Ohio — either submitted their written testimony at one of the hearings or sent their

testimony directly to CSAT.

The following summarizes the contributors’ recommendations, concerns, and other comments.

Closing the Treatment Gap

The gap in treatment resources was best quantified in the First Lady of Illinois’ written testimony.

She wrote that data indicate that combined State and Federal resources only provide funding to 

adequately address eight percent of treatment need, while studies indicate that every dollar spent for

substance abuse treatment generates seven dollars in savings to society.

Testimony echoed the First Lady’s remarks regarding the underfunding of treatment programs and

branched into gaps in service delivery, including the need for:

• Modifications in methadone distribution and the use of methadone as a long-term 

treatment option.

• Reduction of treatment barriers for adults with physical, sensory, and cognitive disabilities.

• Special treatment services for older adults.

• The incorporation of family therapy and alternative treatment modalities in recovery.

• Treatment parity and other insurance reform.

• More programs for women and adolescents.

• More treatment in jails.

• Increased study on the role of substance abuse in child welfare cases.

• Education about the hepatitis C virus.

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Other contributors focused on the inequities of the current system for the treatment of opiate

addiction. She cited studies that have shown that persons in recovery maintaining an adequate dose

of methadone will stop using heroin and often stop using cocaine. Because of disorders of the

endorphin system, many recovering addicts require medication for life. The United States is one of

the few industrialized countries that does not treat opiate addiction as a medical disease. Drastic

changes must be made to the current clinic-based system.

Several writers concentrated their testimony on the gap between treatment needs of the disabled

community and appropriate services being delivered. Americans with disabilities are at a disproportionate risk to be affected by substance abuse and are one of the least treated populations. One

writer referred to a study from the State of Wisconsin that reported that only one in every 1,000

people with disabilities in need of substance abuse services actually received services. Other barriers

confronting this group include treatment professionals unfamiliar with treating physically disabled

individuals, disability treatment providers not being cross-trained to recognize signs of substance

abuse, treatment programs that do not accommodate disabilities, and a lack of signs to communicate key addiction concepts in American Sign Language (ASL).

Advocates called for initiatives to provide grants for treatment of disabled populations that would

focus on areas of treatment enhancement, materials development, and personnel training opportunities. Additionally, grant applications should require grantees to indicate the specific methods used

to ensure the accessibility of their programs by disabled people, and CSAT should enforce the

Americans with Disabilities Act (ADA) and the Rehabilitation Act of 1973.

Providers, advocates, and consumers also discussed the treatment gap in specialty services for substance-abusing senior citizens, because 5.8 percent of persons receiving treatment are 55 or older

and up to 20 percent may have a chemical dependency problem. Unfortunately, misuse and abuse

of drugs and alcohol in older adults often mimic other psychiatric disorders — particularly depression, anxiety, dementia, or mania — making accurate assessment of the problem difficult even for

professionals. The writers asserted that funding must be directed to senior-specific programs and 

to training agency staff and community workers to identify the warning signals of substance 

abuse in senior citizens.

A psychologist wrote about the impact of alcohol abuse on the family — it is estimated that more

than 11 million children under the age of 18 are living with an alcoholic. His own one-year study

demonstrated that involvement of family members in treatment increases the length of stay for

female clients and the likelihood of recovery. He cited reviews of other treatment studies and 

outcomes that also conclude family therapy is an effective and cost-effective modality in the 

treatment of alcoholism.

PUBLIC HEARING SUMMARIES
The inequity of insurance benefits for substance abuse also was discussed. Testimony addressed a

DHHS report that estimated that parity for substance abuse treatment would increase private insurance costs by only 0.2 percent.

As many as 85 percent of inmates in Department of Corrections (DOC) facilities have a substance

abuse history and need treatment. A representative of the Connecticut DOC wrote about treatment

programs in 18 correctional facilities in his State. Each facility conducts specific programs according to standards and program models to meet the needs of specialized populations, such as male,

female, youth, and long-term inmates. Studies to evaluate the success of the programs have shown a

statistically significant lower incidence of recidivism than a non-treated comparison group held at

the same facilities during the same period of time. In general, the programs’ benefits exceed costs

by a ratio of approximately five to one (5:1).

The Child Welfare League of America (CWLA) submitted testimony regarding the significant role 

of substance abuse in child welfare cases. Evidence from various national studies suggests that 40 to

80 percent of all child abuse and neglect cases involve parental abuse of alcohol and other drugs.

The link between familial substance abuse and entrance into the child welfare system is proving to

be one of the largest and costliest public health problems in our society today. Both additional

training for child welfare workers and more substance abuse treatment that involves the children 

of alcoholics and substance abusers are needed.

Contributors also called for additional treatment resources for women and adolescents; the 

incorporation of alternative treatments, such as holotropic breathwork; and attention to and public

education regarding the growing HCV epidemic.

Reducing Stigma and Changing Attitudes

Providers, advocates, and consumers all agreed that a better understanding of drug and alcohol

abuse by the general public would result in significant changes in attitude and would positively impact

policy. One contributor wrote, “A drug war rather than an epidemic is being fought: 66 percent of all

funding goes into interdiction; only 33 percent goes to prevention and treatment.” She believes it

would be difficult to find any other social policy so misguided or another illness so neglected.

Testimony indicated that awareness campaigns and workshops on alcoholism and substance abuse

are needed, and should focus on the stigma, attitudes, myths, and facts about substance use, abuse,

and addiction. The public needs to understand that addiction is a disease that requires and

responds to medical treatment and that 95 percent of substance abusers are taxpayers, members of

intact families, employed, and otherwise law-abiding, productive members of society.

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Awareness campaigns and workshops need to be culturally and linguistically competent. In addition to the general public, the awareness campaigns also should extend to schools and businesses;

students; law enforcement and correctional personnel; doctors and pharmacists; and human 

services professionals, family therapists, social workers, and counselors. Providing accurate, updated

information is the first step to changing attitudes, judgments, and behaviors.

Friends, family members, and persons in recovery, including celebrities, should be encouraged to

join or create advocacy groups to share recovery experiences and help educate, inform, and shift

public attitudes.

In addition to educating the public, the contributors felt that the following would help reduce the

stigma of substance abuse and change attitudes about those who abuse substances:

• Allow those going through methadone maintenance treatment to get their methadone in a 

professional, respectful, dignified medical setting. Allow private doctors to prescribe methadone.

• Set up systems whereby persons with substance abuse problems can be diagnosed and receive

treatment as part of the welfare-to-work process.

• Provide free transportation to treatment.

• Create and distribute educational videos regarding substance abuse.

• Make more scholarships available for needed treatment positions, and require service for a set

number of years following graduation.

• Address the public stigma against having treatment facilities in neighborhoods.

Improving and Strengthening Treatment Systems

More than 50 writers shared their research, ideas, and personal experiences regarding ways to

improve and strengthen treatment systems. A representative of a Florida foundation advocated for

the inclusion of treatment agencies, government, law enforcement, and education representatives in

an effective plan to address the problem of substance abuse and promote prevention activities. She

cited research that has shown the effectiveness of early and ongoing prevention education in school.

Effective prevention must include training of teachers to ensure the consistency of the message.

Those providing testimony stressed the need for multifaceted and long-term program options as

well as the necessity for psychological treatment interventions to be geared to, and work in conjunction with, medical and pharmacological treatment interventions. Treatment programs that take into 

PUBLIC HEARING SUMMARIES
consideration the developmental needs of the teenage consumer are a specific need. Other concepts

covered in this domain included:

• Developing policy with a commitment to basic research and outcomes data collection;

• Funding innovative projects that increase family involvement in treatment;

• Integrating addictions education into all arenas of health care;

• Passing legislation that permits hospitals to detain highly intoxicated and drugged people for at

least 72 hours of observation, to allow for more effective interventions;

• Making methadone treatment more readily available and ensuring adequate dosing;

• Providing more State and Federal programs for the indigent;

• Increasing the availability of integrated systems for those with co-occurring disorders; and

• Ensuring that treatment is provided by professionals and that programs applying for funds in a

competitive bid process report in detail their credentials for providing required services.

Connecting Services and Research

Contributors in the domain of connecting services and research provided similar comments about

the need for more attention and resources for the development and research of treatment methodologies. While funding sources seem to be demanding more research and followup of programs,

one writer noted, none want to fund evaluation efforts. Another challenge is to “operationalize”

research findings, to ensure that they are uniformly translated into best-practice models that then

reach community treatment programs in a way that fosters implementation at the service site.

Initiatives are needed that bring researchers, service providers, policymakers, and other stakeholders

together to improve substance abuse treatment systems. Research results should be summarized in

lay language, and clinicians need to continually update their knowledge. Newsletters, the Internet,

community forums, seminars, and clinical training can be used to help integrate science-based 

findings into everyday practice. One contributor suggested that CSAT expand upon its Treatment

Improvement Protocols (TIPs) and identify some of the most promising, replicable treatment 

models (e.g., dual diagnosis and cultural competency) and disseminate information about these

models to States and service providers.

One writer cautioned against finding “universal cures.” He stressed that treatment programs, like

their clients, are unique and that this diversity should be accepted. In this regard, he felt a research

tack should be adopted that uses surveying of significant numbers of subjects from diverse 

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backgrounds, both those who have recovered and those who have not. The significant factors these

people identify as critical in their recovery or recovery failures would provide important insight that

could help reframe the questions to be explored by further research.

Addressing Workforce Issues

The testimony addressing workforce issues revolved around two aspects: (1) The need to attract

and maintain well-trained, mature, experienced substance abuse counselors, and (2) the impact 

and issues of substance abuse on the workforce. All plans for improvement of the substance abuse

treatment system will be to no avail if there are not enough counselors to provide services. When

providers face inadequate staffing, the quality and effectiveness of services to clients decline.

A representative of a Washington-based organization stated that most providers in her State have 

staff shortages of one to three counselors, and it typically takes three to six months to locate and

hire additional staff.

Testimony suggested that to maintain highly skilled individuals in the current job market, counselors must be offered competitive salaries, but these are difficult to pay on “shoestring” budgets.

Several contributors agreed that CSAT needs to explore ways to recruit professionals, particularly

ethnic minorities, into the field of addictions treatment. It was suggested that this could be done by

providing scholarships to new counselors entering the field and by supporting ongoing education

(e.g., student loan forgiveness programs).

While some of the contributors called for ensuring proper licensure among addictions counselors,

others encouraged the inclusion of more nontraditional, experienced-based personnel. One

provider mentioned councils, such as the Alcohol and Drug Abuse Council (ADAC), as positive

messengers to reduce the stigma of alcohol and drug abuse through education and advocacy 

in the workplace.

PUBLIC HEARING SUMMARIES

Section III: Participant 

Acknowledgements

213

Changing the Conversation

PARTICIPANT A CKNOWLEDGEMENTS

THE NATIONAL TREATMENT PLAN INITIATIVE

THE NATIONAL TREATMENT PLAN INITIATIVE

21215

Table of Contents

I. CSAT NATIONAL ADVISORY COUNCIL. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 216

II. NTP LEADERSHIP . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217

III. PANEL PARTICIPANTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 218

IV. PANEL MEETING SPEAKERS AND CONTRIBUTORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228

V. PUBLIC HEARINGS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

VI. NTP CONTRACTORS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 243

Changing the Conversation

PARTICIPANT A CKNOWLEDGEMENTS
216

Changing the Conversation

More than 150 individuals participated in the

development of the National Plan to Improve

Substance Abuse Treatment. In addition, over

four hundred people testified at the public 

hearings or provided written comments. These

individuals are listed here. Participation in the

NTP was purely advisory in nature. Listing of a

participant and their organization on this roster

does not necessarily imply organizational

endorsement of this report.

I. CSAT National 

Advisory Council

Substance Abuse and Mental 

Health Services Administration 

Center for Substance Abuse Treatment

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

FASAM (Chair) 

Director

Center for Substance Abuse Treatment

Rockville, MD

MEMBERS

Andrea M. Amprey, M.S.W.

President

Baltimore Substance Abuse Systems, Inc.

Baltimore, MD

Andrea Barthwell, M.D.

President 

Encounter Medical Group

Oak Park, IL

Louis E. Baxter, Sr., M.D., FASAM

Medical Director

Physicians’ Health Program

Medical Society of New Jersey

Lawrenceville, NJ

Shirley Coletti

President

Operation PAR, Inc.

Pinelas Park, FL

Peter B. Edelman, L.L.B.

Professor of Law

Georgetown University Law Center

Washington, DC

John R. Hughes, M.D.

Department of Psychiatry

University of Vermont College of Medicine

Burlington, VT

Martin Y. Iguchi, Ph.D.

Co-Director

Drug Policy Research

RAND Corporation

Santa Monica, CA

Lisa Nan Mojer-Torres, J.D.

Civil Rights Attorney

Lawrenceville, NJ

William Cope Moyers*

President

Johnson Institute Foundation

Minneapolis, MN

Rod Robinson*

Executive Director

Gateway Recovery Center

Great Falls, MT

Mayra Rodriguez-Howard, M.S.W.

Bureau of Substance Abuse Services

Massachusetts Department of Public Health

Boston, MA

Hope Taft, D.H.L.

First Lady

State of Ohio

Columbus, OH

THE NATIONAL TREATMENT PLAN INITIATIVE

* Members through October, 1999
217

PARTICIPANT A CKNOWLEDGEMENTS

Pamela Jumper Thurman, Ph.D.

Research Associate

Department of Psychology

Colorado State University

Ft. Collins, CO

Hershell A. Warren, J.D., M.B.A.

Executive Director

Lloyd C. Elam Mental Health Center

Meharry Medical College

Nashville, TN

Constance Weisner, Dr. P.H.

Professor

Department of Psychiatry 

University of California, San Francisco

Oakland, CA

EX-OFFICIO MEMBERS

The Honorable Donna E. Shalala

Secretary

Department of Health and 

Human Services 

Washington, DC

Nelba Chavez, Ph.D.

Administrator

Substance Abuse and Mental Health 

Services Administration

Rockville, MD

Roger Hartman

Health Policy Analyst

Office of the Assistant Secretary 

of Defense (Health Affairs)

TRICARE Management Activity

Falls Church, VA

Richard T. Suchinsky, M.D.

Associate Director for Addictive Disorders 

and Psychiatric Rehabilitation

Department of Veterans Affairs

Washington, DC

II. National Treatment Plan

Initiative (NTP) Leadership

STEERING GROUP

Shirley Coletti, D.H.L.

President

Operation PAR, Inc.

Pinelas Park, FL

Lewis Gallant, Ph.D.

Director

Office of Substance Abuse Services

Department of Mental Health,

Mental Retardation & Substance 

Abuse Services

Richmond, VA

John Gregrich 

Chief

Treatment Research Branch

Office of Demand Reduction

Executive Office of the President 

Office of National Drug Control 

Policy 

Washington, DC

Melody Heaps

President

Treatment Alternatives for Safe

Communities 

Chicago, IL

Linda Kaplan, M.A., CAE

Project Director

Danya International, Inc.

Chevy Chase, MD

Paul N. Samuels, Esq.

Director and President

Legal Action Center

New York, NY
218

Changing the Conversation

CENTER FOR SUBSTANCE ABUSE

TREATMENT (ROCKVILLE, MD)

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

CAS, FASAM

Director

Camille T. Barry, Ph.D., R.N.

Deputy Director

Donna M. Cotter, M.B.A.

NTP Coordinator

CSAT Project Officer

Mady Chalk, Ph.D.

Director

Office of Managed Care

III. Panel Participants

PANEL I: CLOSING THE 

TREATMENT GAP 

PANEL MEMBERS

Henrick J. Harwood (Chair)

Vice President

The Lewin Group

Falls Church, VA

Steven P. Amos, D.Crim.

Deputy Director

Office of Justice Programs

Corrections Program Office

Washington, DC

Mary Lou Andersen

Consultant

Health Resources Services Administration

Bethesda, MD

James F. Callahan, D.P.A.

Executive Vice President and CEO

American Society of Addiction Medicine 

Chevy Chase, MD

John Coppola

Executive Director

Alcoholism and Substance Abuse

Providers of New York State

Albany, NY

Marc Galanter, M.D.

Department of Psychiatry

NYU Medical Center

Division of Alcohol and Drug Abuse

New York, NY

The Honorable Richard S. Gebelein

Associate Judge

Delaware Superior Court

Daniel L. Hermann Courthouse

Wilmington, DE

Suzanne Gelber, Ph.D.

President 

SGR Health, Ltd.

Berkeley, CA

Irma Gonzales

Consultant

Sieta del Nortè

Community Development Corporation 

Embudo, NM

Janice Ford Griffin

Deputy Director

Join Together

Boston, MA

Michael Harle, M.H.S.

President, Executive Director

Gaudenzia, Inc.

Norristown, PA

Jerome H. Jaffe, M.D.

Clinical Professor of Psychiatry

University of Maryland

Towson, MD

Nolan E. Jones, Ph.D.

Group Director

Human Resources Group

National Governors Association

Washington, DC

THE NATIONAL TREATMENT PLAN INITIATIVE
219

PARTICIPANT A CKNOWLEDGEMENTS

David C. Lewis, M.D.

Director

Center for Alcohol and Addiction Studies

Brown University

Providence, RI

Gloria J. Merk

Deputy Director

Program Operations Division

Alcohol and Drug Programs

State of California

Sacramento, CA

Constance Pechura, Ph.D.

Senior Program Officer

Robert Wood Johnson Foundation

Princeton, NJ

The Honorable Toddy Puller

Legislator

State of Virginia

Mt. Vernon, VA

Mayra Rodriguez-Howard, M.S.W.

Director

Bureau of Substance Abuse Services

Massachusetts Department of Public Health

Boston, MA

Ian M. Shaffer, M.D., M.M.M.

Executive Vice President

Quality and Outcome Strategies

ValueOptions 

Falls Church, VA

Ronald Simeone, Ph.D.

Simeone Associates, Inc.

Albany, NY

Richard Spence, Ph.D.

Director of Research 

Texas Commission on Alcohol 

and Drug Abuse

Austin, TX

Flo Stein

Chief

Substance Abuse Services

Division of Mental Health, Development 

Disabilities, and Substance 

Abuse Services

Department of Health and 

Human Services

Raleigh, NC

Ronald White, M.D.

Program Director

Project New Life

Jamaica Plain, MA

Ronald Williams

President and CEO

New York Therapeutic Communities, Inc.

Stay ‘N Out

New York, NY

Robert A. Wilson, Ph.D.

Director

Health Services Policy Research Group

School of Urban Affairs and Public Policy

University of Delaware

Newark, DE

CSAT STAFF (ROCKVILLE, MD)

Mady Chalk, Ph.D.

Director

Office of Managed Care

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and 

Community Assistance

Herman Diesenhaus, Ph.D.

Public Health Analyst

Office of Evaluation, Scientific 

Analysis and Synthesis

Joan Dilonardo, Ph.D.

Social Science Analyst

Office of Managed Care
220

Changing the Conversation

Thomas Edwards, Jr.

Branch Chief

Organization of Services Branch

Division of Practice and Systems

Development

STEERING GROUP

John Gregrich

Chief

Treatment Research Branch

Office of Demand Reduction

Executive Office of the President

Office of National Drug Control 

Policy 

Washington, DC

Melody Heaps

President

Treatment Alternatives for 

Safe Communities 

Chicago, IL

PANEL II: REDUCING STIGMA 

AND CHANGING ATTITUDES 

PANEL MEMBERS

Sue Thau (Co-Chair)

Public Policy Consultant 

Community Anti-Drug Coalitions 

of America 

Washington, DC

Andrea G. Barthwell, M.D. (Co-Chair)

President 

Encounter Medical Group, P.C.

Oak Park, IL

Johnny W. Allem

Director of Operations

Commission on Mental Health Services

Washington, DC

John L. Avery, LCSW, M.P.A.

Cambridge and Somerville Program for

Alcohol Rehabilitation

Boston, MA

Jeffrey Blodgett, M.P.A.

Coordinator

The Alliance Project

St. Paul, MN

George R. Bloom, M.A.

Past President

Johnson Institute Foundation

Minneapolis, MN

Alpha Estes Brown, Ph.D., J.D., D.Min.

Chair

‘Cause Children Count Coalition

Washington, DC

June Gertig, J.D.

Project Director

Recovery Community Support Program

Technical Assistance Project

Health Systems Research

Washington, DC

Amalia Gonzalez del Valle,

M.S.W., M.P.H., LCSW

Program Manager

Contra Costa Community 

Substance Abuse Service

Martinez, CA

Patricia D. Hawkins, Ph.D.

Associate Executive Director

Whitman Walker Clinic

Washington, DC

Benjamin A. Jones, M.S.W., C.S.W.

President and CEO

National Council on Alcoholism 

and Drug Dependence, Inc.

Greater Detroit Area

Detroit, MI

THE NATIONAL TREATMENT PLAN INITIATIVE
221

PARTICIPANT A CKNOWLEDGEMENTS

Judi Kosterman, Ed.D.

Director

National Center for the Advancement of

Prevention

Washington, DC

Chris Koyanagi 

Policy Director

Bazelon Center for Mental Health Law

Washington, DC

Henry C. Lozano

President and CEO

Californians For A Drug Free Youth, Inc.

Big Bear City, CA

Donald Masters, J.D.

Chairman

National Partnership for 

Recovery and Prevention

Denver, CO

Carol McDaid

Senior Vice President

R. Duffy Wall and Associates, Inc.

Washington, DC

Kevin E. McEneaney

Executive Vice President

Phoenix House Foundation

New York, NY

Lisa Nan Mojer-Torres, Esq.

Civil Rights Attorney

Lawrenceville, NJ

Dennis Moore, Ed.D.

Associate Professor 

Department of Community Health

Director

Substance Abuse Resources and Disability 

Issues Rehabilitation, Research, and 

Training Center on Drugs and Disability

Wayne State University

Kettering, OH

William Cope Moyers

President

Johnson Institute Foundation

Minneapolis, MN

Stacia Murphy

President

National Council on Alcoholism 

and Drug Dependence, Inc.

New York, NY

Gregory R. Niblett

Senior Vice President

Social Development Programs

Academy for Educational 

Development 

Washington, DC

Lynn M. Paltrow, J.D.

Director

National Advocates for Pregnant Women

New York, NY

Kim Peck

Interim Director

Illinois Alcoholism & Drug 

Dependence Association

Springfield, IL

Lynn D. Powers, M.S.M.

Vice President 

Dreamcatchers, L.L.C.

West Mystic, CT

José A. Rivera, J.D.

President and CEO

Rivera, Sierra & Company, Inc.

Brooklyn, NY

Charles R. Schuster, Ph.D.

Director

Substance Abuse Research Division

Department of Psychiatry 

and Behavioral Neuroscience

Wayne State University School of Medicine

Detroit, MI
222

Changing the Conversation

Harold Tarbell

President

National Association for Native American 

Children of Alcoholics 

Ontario, Canada

Carol Tracy

Executive Director

The Women’s Law Project

Philadelphia, PA

STEERING GROUP

Paul N. Samuels, Esq.

Director and President

Legal Action Center

New York, NY

CSAT STAFF (ROCKVILLE, MD)

Jutta Butler

Public Health Advisor

Division of Practice and 

Systems Development

Marjorie M. Cashion, M.S.W.

Executive Secretary

CSAT National Advisory Council

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community 

Assistance

George Gilbert

Director

Office of Policy Coordination 

and Planning

Catherine D. Nugent, M.S.

Public Health Advisor

Division of State and 

Community Assistance

Ivette A. Torres, M.Ed., M.S.

Director

Office of Communications 

and External Liaison

PANEL III: IMPROVING AND

STRENGTHENING 

TREATMENT SYSTEMS 

PANEL MEMBERS

Victor Capoccia, Ph.D. (Chair) 

Principal 

Dougherty Management Associates, Inc.

Lexington, MA

Douglas Anglin, Ph.D.

Co-Director

UCLA Drug Abuse Research Center

Los Angeles, CA

Gaurdia E. Banister, Ph.D.

Director of Nursing

Behavioral Health Services

Providence Hospital

Washington, DC

Karst J. Besteman, M.S.W.

Chief Executive Officer

CMAC, Inc.

Washington, DC

Thomas H. Bornemann, Ed.D.

Deputy Director

Center for Mental Health Services

Rockville, MD

Benjamin P. Bowser, Ph.D.

Professor

Department of Sociology and Social 

Services

California State University at Hayward

Hayward, CA

Angela G. Burgess, M.B.A.

Manager 

Washington Business Group on Health

Washington, DC

Neal Cash, M.S.

CEO Community Partnership 

of Southern Arizona 

Tucson, AZ

THE NATIONAL TREATMENT PLAN INITIATIVE
223

PARTICIPANT A CKNOWLEDGEMENTS

Stephenie Colston, M.A.

Vice President

Johnson, Bassin & Shaw, Inc.

Silver Spring, MD

L. Foster Cook 

Director

Substance Abuse Programs

University of Alabama at Birmingham

Birmingham, AL

Michael Couty, M.S.C.J.

Director

Division of Alcohol and Drug Abuse

Missouri Department Of Mental Health

Jefferson City, MO

Diana Yazzie Devine, M.B.A.

Executive Director

Native American Connections, Inc.

Phoenix, AZ

Nancy Ferreyra

Executive Director

Progressive Research and Training 

for Action

Oakland, CA

Geoffrey Laredo, M.P.A.

Acting Director

Office of Policy, Legislation and 

Public Liaison

National Institute on Alcohol Abuse

and Alcoholism

Bethesda, MD

Dennis McCarty, Ph.D.

Research Professor

Brandeis University

Waltham, MA

Carole J. Otero

Director

Albuquerque Metropolitan Central Intake

Albuquerque, NM

Anthony B. Radcliffe, M.D.

Chief of Service

Department of Addiction Medicine

Kaiser Permanente

Fontana, CA

Roy I. Ross, M.A.

Chairman and CEO

CiviGenics, Inc.

Marlborough, MA

D. Dwayne Simpson, Ph.D.

Director

Institute of Behavioral Research

Texas Christian University

Ft. Worth, TX

Zili Sloboda, Sc.D.

Senior Research Associate

Center for Health and Social Policy

Professor

Department of Sociology

University of Akron

Akron, OH

Frank Sullivan, Ph.D.

Senior Advisor for Mental Health 

and Substance Abuse

Health Care Financing Administration

Baltimore, MD

Beth Weinman

National Drug Abuse Program Coordinator

Federal Bureau of Prisons

Washington, DC

Joan Zweben, Ph.D.

Executive Director

14th Street Clinic

East Bay Community Recovery Project

Clinical Professor of Psychiatry

University of California, San Francisco

Berkeley, CA
224

Changing the Conversation

Janet Zwick

Director

Division of Substance Abuse 

and Health Promotion

Iowa Department of Public Health

Des Moines, IA

CSAT STAFF (ROCKVILLE, MD)

Sharon Amatetti

Public Health Analyst

Office of Policy Coordination and Planning

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community

Assistance

Jon Gold

Branch Chief

Synthesis Branch

Office of Evaluation, Scientific Analysis 

and Synthesis

Ray Hylton, Jr.

Public Health Advisor

Office of Pharmacologic and 

Alternative Therapies

Rick Sampson

Director

Division of State and 

Community Assistance

Jane Taylor, Ph.D.

Director

Division of Practice and 

Systems Development

Karl D. White, Ed.D.

Public Health Analyst

Office of Evaluation, Scientific Analysis 

and Synthesis

Rockville, MD

PANEL IV: CONNECTING SERVICES

AND RESEARCH 

PANEL MEMBERS

Constance Horgan, Sc.D. (Chair)

Professor and Director

Health Services Research

Schneider Institute for Health Policy

The Heller School

Brandeis University

Waltham, MA

Barry Brown, Ph.D.

Adjunct Professor

Department of Psychology

University of North Carolina at 

Wilmington

Carolina Beach, NC

Daniel Conti, Ph.D.

Employee Assistance Program Director

Bank One

Chicago, IL

Brian Cuffel, Ph.D.

Vice President of Research and Evaluation

United Behavioral Health

San Francisco, CA

John Daigle

Executive Director

Florida Alcohol and Drug Abuse

Association

Tallahassee, FL

Thomas D’Aunno, Ph.D.

Associate Professor

School of Social Service Administration

University of Chicago

Chicago, IL

Bennett Fletcher, Ph.D.

Branch Chief

Services Research Branch

Division of Clinical and Services Research

National Institute on Drug Abuse 

Bethesda, MD

THE NATIONAL TREATMENT PLAN INITIATIVE
225

PARTICIPANT A CKNOWLEDGEMENTS

Steven L. Gallon, Ph.D.

Project Director

Northwest Frontier

Addiction Technology Transfer Center

Salem, OR

David Gastfriend, M.D.

Massachusetts General Hospital

Associate Professor of Psychiatry

Harvard Medical School

Boston, MA

Merwyn Greenlick, Ph.D.

Professor and Chair

Public Health and Preventive Medicine

Oregon Health Sciences University

Portland, OR

Michael Hilton, Ph.D.

Health Scientist Administrator

Division of Clinical and 

Prevention Research

National Institute on Alcohol Abuse

and Alcoholism 

Bethesda, MD

Michael W. Kirby, Jr., Ph.D.

Chief Executive Officer

Arapahoe House, Inc.

Thornton, CO

Jeffrey Kushner

Drug Court Administrator

Missouri Municipal Courts

St. Louis, MO

Therissa A. Libby

Chair

NAADAC Research Committee

Graduate Program in Neuroscience

University of Minnesota

Minneapolis, MN

Howard A. Liddle, Ed.D.

Professor and Director

Center for Treatment Research 

on Adolescent Drug Abuse

Center for Family Studies

Miami, FL

Cirilo Madrid

Executive Director

Aliviane No-Ad, Inc.

El Paso, TX

Jean-Marie Mayas, Ph.D.

President

The MayaTech Corporation

Silver Spring, MD

Thomas McLellan, Ph.D.

Scientific Director

The Treatment Research Institute

Philadelphia, PA

Robert Rosenheck, M.D.

Director

Northeast Program Evaluation Center 

VA Connecticut Health Care System

West Haven, CT

Arthur J. Schut

Executive Director

Mid-Eastern Council on Chemical Abuse

Iowa City, IA

Kenneth D. Stark

Director

Division of Alcohol and Substance Abuse

Washington Department of Social 

and Health Services

Olympia, WA

James Swartz, Ph.D.

Director

Research and Information Services

Treatment Alternatives for Safe 

Communities, Inc.

Chicago, IL

Constance Weisner, Dr.P.H.

Professor, Department of Psychiatry 

University of California, San Francisco

Berkeley, CA
226

Changing the Conversation

CSAT STAFF (ROCKVILLE, MD)

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community

Assistance

Frances Cotter

Social Science Analyst

Office of Managed Care

Edwin M. Craft, Dr.P.H., M.Ed., LCPC

Program Analyst

Office of Evaluation, Scientific 

Analysis and Synthesis

Jon Gold

Branch Chief

Synthesis Branch

Office of Evaluation, Scientific 

Analysis and Synthesis

Sheila Harmison, D.S.W.

Public Health Analyst

Division of State and Community 

Assistance

James M. Herrell, Ph.D., M.P.H.

Public Health Analyst

Division of Practice and Systems 

Development 

Roger Straw, Ph.D.

Deputy Director

Office of Evaluation, Scientific 

Analysis and Synthesis

PANEL V: ADDRESSING 

WORKFORCE ISSUES 

PANEL MEMBERS

Paula Horvatich, Ph.D. (Chair)

Director

Mid-Atlantic Addiction Technology

Transfer Center 

Virginia Commonwealth University

Richmond,VA

Ana Anders, LCSW

Senior Advisor on Special Populations

National Institute on Drug Abuse 

Bethesda, MD

Robert Bailey, M.Ed.

Director

Northern Cheyenne Recovery Center

Lame Deer, MT

Deb Beck, M.S.W.

President

Drug and Alcohol Service Providers 

Organization of Pennsylvania

Harrisburg, PA

Vivian Brown, Ph.D.

President and CEO

PROTOTYPES, Centers for Innovation 

In Health

Mental Health and Social Services

Culver City, CA

Bill B. Burnett

Director of Treatment

South Carolina Department of Alcohol

and Other Drug Abuse Services

Columbia, SC

Mary Cesare-Murphy, Ph.D.

Executive Director

Behavioral Health Accreditation Services

Joint Commission on Accreditation of

Healthcare Organizations 

Oakbrook Terrace, IL

THE NATIONAL TREATMENT PLAN INITIATIVE
227

PARTICIPANT A CKNOWLEDGEMENTS

Bishop Chears

Illinois State Coordinator

One Church One Addict

Governors State University

College of Health Professions

University Park, IL

Barbara Cimaglio

Director

Office of Alcohol and Drug Abuse

Programs

State of Oregon Department of

Human Resources

Salem, OR

David A. Deitch, Ph.D.

Clinical Professor of Psychiatry

Director 

Addiction Technology Transfer 

Center

University of California, San Diego

La Jolla, CA

Thomas Durham, M.A., LADC

Director

Military Services Unit

ETP, Inc.

East Hartford, CT

Patricia Fazzone, D.N.Sc., M.P.H.

Assistant Professor

University of Kansas School of Nursing

Kansas City, KS

Angela Gonzalez-Willis, Ph.D.

Senior Program Management Officer

Center for Quality Improvement

Bureau of Health Professions

Health Resources Services 

Administration 

Rockville, MD

Arturo Niño Gutierrez, M.P.A.

Texas Addiction Technology Transfer

Center Coordinator

Texas Commission on Alcohol & 

Drug Abuse

Austin, TX

Karen Kelly, Ph.D., MAC

President and CEO

Circle of Recovery, Inc.

Decatur, GA

Judith Lewis, Ph.D.

Interim Chair

Division of Health Administration 

and Human Services

Governors State University

College of Health Professions

University Park, IL

Bruce Lorenz, CADC, NCACII

Director

Threshold, Inc.

Georgetown, DE

Kathleen Malliarakis

Branch Chief

Specific Drugs Office

Executive Office of the President

Office of National Drug Control 

Policy

Washington, DC

Neal McGarry

Executive Director

Certification Board for Addiction

Professionals of Florida

Tallahassee, FL

David Mee-Lee, M.D.

DML Consulting

Davis, CA

Elvin Bernard Parson, M.D.

Medical Director

Metropolitan Hospital Center

Methadone Treatment Program

New York, NY

Gerry Schmidt, M.A., LPC, MAC

COO

Valley HealthCare System

Morgantown, WV
228

Changing the Conversation

David Smith, M.D.

President & Founder

Haight Ashbury Free Clinics

San Francisco, CA

Susan A. Storti, R.N., M.A.

Director

Addiction Technology Transfer Center

of New England

Brown University

Center for Alcohol and Addiction Studies

Providence, RI

Lala Ashenberg Straussner, D.S.W.,

CEAP, CAS

Professor

New York University

Ehrenkranz School of Social Work

New York, NY

Michael Taleff, Ph.D., CAC, MAC

Assistant Professor and

International President of INCASE

The Pennsylvania State University

University Park, PA

CSAT STAFF (ROCKVILLE, MD)

CAPT Carol Coley, M.S.

Public Health Advisor

Division of State and Community 

Assistance

CDR David Griffith, R.N.

Branch Chief

Performance Partnership Grant 

Program Branch

Division of State and Community 

Assistance

CDR Susanne Rohrer, R.N., M.B.A.

Public Health Analyst

Office of Evaluation, Scientific 

Analysis and Synthesis

STEERING GROUP

Linda Kaplan, M.A., CAE

Project Director

Danya International, Inc.

Chevy Chase, MD

IV. Panel Meeting Speakers

and Contributors 

John Allen, Ph.D. (Panel I)

National Institute on Alcohol Abuse and 

Alcoholism

Bethesda, MD

Karen Allen (Panel V)

President 

National Nurses Society on Addictions 

St. Joseph, MI

Carolyn Aoyama (Panel V)

Deputy Branch Chief for Clinical

Management and Professional 

Development 

Division of Community Bureau 

of Health Care 

Health Resources Services Administration

Rockville, MD

Susan Blacksher (Panel V)

Executive Director

California Association of Addiction

Recovery Resources 

Sacramento, CA

Ron Dreskin, M.B.A. (Panel III)

President

Integrated Healthcare, LLC

Greenwich, CT

Peter B. Edelman, LL.B. (Panel I)

Professor of Law

Georgetown University Law Center

Washington, DC

THE NATIONAL TREATMENT PLAN INITIATIVE
229

PARTICIPANT A CKNOWLEDGEMENTS

John French, M.A. (Panel I)

Research Consultant

Gaithersburg, MD 

Constance Horgan, Sc.D. (Panel III)

Professor and Director

Health Services Research

Schneider Institute for Health Policy 

The Heller School

Brandeis University

Waltham, MA

Aaron Johnson (Panel III)

Project Coordinator

Center for Research on Behavioral

Health & Human Services Delivery

Institute for Behavioral Research

University of Georgia

Athens, GA

Janice F. Kaufman, R.N. M.P.H.,

C.A.S. (Panel V)

Vice President

American Academy of Health Care 

Providers in the Addictive Disorders 

Cambridge, MA

Thomas A. Kirk, Jr., Ph.D. (Panel IV)

Deputy Commissioner

State of Connecticut 

Department of Mental Health 

and Addiction Services

Hartford, CT

Gene M. Lutz, Ph.D. (Panel IV)

Director

Center for Social and Behavioral Research

University of Northern Iowa 

Cedar Falls, IA

Ian M. Shaffer, M.D., M.M.M. (Panel V)

Executive Vice President, Quality and

Outcome Strategies

ValueOptions

Falls Church, VA

Dwayne Simpson, Ph.D. (Panel III)

Director

Institute for Behavioral Research

Texas Christian University

Ft. Worth, TX

Sandy Smith (Panel V)

Vice President

The Lewin Group

Falls Church, VA

Mary Lynn Stainton (Panel V)

Chief Operating Officer

Operation PAR

Pinelas Park, FL

Flo Stein (Panels IV & V)

Chief

Substance Abuse Services

Division of Mental Health, Development 

Disabilities, and Substance Abuse Services

Department of Health and Human Services

Raleigh, NC

Roger Straw, Ph.D. (Panel IV)

Deputy Director

Office of Evaluation, Scientific Analysis 

and Synthesis

Center for Substance Abuse Treatment 

Rockville, MD

Jane Ungemack, Dr.P.H (Panel IV)

Assistant Professor

Health Services Research Division

Department of Community Medicine 

and Health Care

University of Connecticut Health Center

Farmington, CT

Constance Weisner, Dr.P.H. (Panel I)

Professor

Department of Psychiatry 

University of California, San Francisco

Berkeley, CA
230

Changing the Conversation

Terry Zobeck, Ph.D. (Panel I)

Chief

Programs and Research Branch

Office of Programs, Budget,

Research and Evaluation

Office of National Drug Control Policy

Washington, DC

Janet Zwick (Panel IV)

Director

Division of Substance Abuse 

and Mental Promotion

Iowa Department of Public Health

Des Moines, IA 

V. Public Hearings

JUNE 30, 1999

ARLINGTON HYATT 

ARLINGTON, VIRGINIA

MODERATOR

Johnny Allem

PANELISTS

Camille T. Barry, Ph.D., R.N.

Andrea G. Barthwell, M.D.

H. Westley Clark, M.D., J.D.,

M.P.H., CAS, FASAM

Susan Thau

TESTIFIERS

Closing the Treatment Gap

Karla Carr

Don Coyhis

Amalia Gonzalez del Valle, M.S.W.,

M.P.H., LCSW

Joan Grier

Michael Harle, M.H.S.

Curtiss Jackson 

Walter Kloetzli

Dick Kunkel

Lois Olson

Robert Savage

Tina Eleanor Sokol

Reducing Stigma and 

Changing Attitudes

Tom Hill

Flo Hilliard

Curtiss Jackson

Walter Kloetzl

Improving and Strengthening

Treatment Systems

Bruce

Curtiss Jackson

Lois Olson

Sharon Vogel

Connecting Services 

and Research

Amalia Gonzalez del Valle, M.S.W,

M.P.H., LCSW

Flo Hilliard 

Addressing Workforce Issues

Sonya Baker

Deb Beck

Maryanne Frangules

THE NATIONAL TREATMENT PLAN INITIATIVE
231

PARTICIPANT A CKNOWLEDGEMENTS

Amalia Gonzalez del Valle, M.S.W.,

M.P.H., LCSW

Michael Harle, MHS

Dick Kunkel

Robert Savage

Other Issues

Deb Beck

Alex Brumbaugh

Joni Lacy

Sharon Vogel

JULY 8, 1999

STATE CAPITOL

HARTFORD, CONNECTICUT

MODERATOR

Dennis McCarty, Ph.D. PANELISTS

Camille T. Barry, Ph.D., R.N.

Andrea Barthwell, M.D.

H. Westley Clark, M.D., J.D.,

M.P.H., CAS, FASAM

John Coppola

Thomas Edwards, Jr.

Constance Horgan, Sc.D.

Linda Kaplan

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

Lisa Nan Mojer-Torres, J.D.

José A. Rivera, J.D.

Albert J. Solnit, M.D.

Ronald White, M.D.

TESTIFIERS

Closing the Treatment Gap

Tom

David Biklen

Richard Bilangi

Sheryl Breetz

Andrew Cherry

Alison Cunningham

Denise Devlin, LADC

Brunie Emmanuel

Mark Kraus, M.D., FASAM

Douglas MacLean

Tanyss Rhea Martula

Maria Muldenado

Richard Orstrom

Peter Panzarella, M.A., M.S., MAC, LADC

Joseph Petrello

Nancy Sarah

Robert Savage

Joseph Sullivan

Lewis Ware on behalf of

Errol Lennard, D.P.A.

Lorrie Zehe

Reducing Stigma and 

Changing Attitudes

William Anaskovich

Larry Arann, Ph.D.

David Biklen

Richard Bilangi

Robert Brex

Donna Bristol
232

Changing the Conversation

Laura Carey

Addie Corradi

Jeanne de Florio

Brunie Emmanuel

Dee Georgette

Joe Harding

Ronald Hunsicker, D.Min., FACATA

Virginia Katz

Christopher Leary

Douglas MacLean

Ernie Newton

Judy O’Leary

Richard Orstrom

Dorian G. Parker

Joyce C. Poole

Mitchell Sahn

Sarah Trobaugh

Improving and Strengthening

Treatment Systems

David Biklen

Richard Bilangi 

Jeraldine Bryant, M.A., LADC

Donna Campbell

Andrew Cherry

Scott Cochrane

Neil Corkory

Charles Creech

William Dyson

Brunie Emmanuel

Delores Franks

Neil Gaer

Dee Georgette

Larry Hames

Toni Harp

Ronald Hunsicker, D.Min., FACATA

Jean Jones 

Joy Kiss

Jack Malone

Paul McLaughlin

Kathy McQuarrie

Joseph Odell

Dorian G. Parker

Shirley Pavone, M.A., LADC

Joseph Sheehan, M.S., LADC

Sam Silverman

Loretta Vasso

Jeffrey Walter

Connecting Services 

and Research

Thomas Babor, Ph.D., M.P.H.

Constance Bastek-Karasow, L.S.W.

Richard Bilangi

Andrew Cherry

Betsy Cronin

Deborah Delp

Dolores Gascon

Beverly Haverly

Leslie Hayes

Thomas Kosten, M.D.

Richard Orstrom

Richard Schottenfeld, M.D.

THE NATIONAL TREATMENT PLAN INITIATIVE
233

PARTICIPANT A CKNOWLEDGEMENTS

Addressing Workforce Issues

Richard Bilangi

Philip Brewer

Linda Degutis

Maryanne Frangules

Allen McQuarrie

Michael Meyer

Diane Potkin

Elizabeth Westfield

Jay Yutes

Other Issues

Constance Bastek-Karasow, L.S.W.

SEPTEMBER 16, 1999

LOYOLA UNIVERSITY

CHICAGO, ILLINOIS

MODERATOR

Melody Heaps PANELISTS

Camille T. Barry, Ph.D., R.N.

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

CAS, FASAM

Michael Couty

Nick Gantes

George Gilbert

Benjamin A. Jones, M.S.W., C.S.W.

Judith Lewis, Ph.D.

Chilo Madrid

Lura Lynn Ryan

Susan Weed

TESTIFIERS

Closing the Treatment Gap

Kim

Dorothy Chemler, R.N., CAC

Lois B. Collins, M.D., M.S.

Preston A. Daniels

Anthony Dillard, NCRS 

Scott Elliott

Bettie Foley, M.S., CMAC

Patricia Frampton

Nina Henry

Joe Jenkins

Peg Rider

Nathan Rush

Mark Shinderman, M.D.

Cozzetta Uwejeyan

Reducing Stigma and 

Changing Attitudes

Suzanne Bassey

James Boyce

Juanita Brezell, L.P.N.

Mary Chatman

Lois B. Collins, M.D., M.S.

Vickie Crawford

Scott Elliott

Sterling Gildersleeve

Eric Guerrero

Jack King

Shaun Lane

Rose Ann Long, CARN

Donald E. Malec
234

Changing the Conversation

Peter Moynikin

Charlotte Owens

Eugene Russell

Dawn Scrutchins, R.N.

Mark Shinderman, M.D.

William M. Stone

Improving and Strengthening

Treatment Systems

Karen Batia

Anthony A. Cole

James Coleman

Lois B. Collins, M.D., M.S.

Eric Guerrero

Margaret Houlihan

Shaun Lane

Marilyn Leahy, CARN

Ethel Molla

Peg Rider

Felicia Roberson

Mark Shinderman, M.D.

Edward Stellin

John Stellinger

Steve Swink, M.A., CMADC

Sherry Thomas-Cloud

Al Turner, B.A., CADC

Connecting Services 

and Research 

Lois B. Collins, M.D., M.S.

James Fleming

Mark Godley, Ph.D.

Nathan Linsk, Ph.D.

Carla Olson, LMSW, CAS

A. Doris Reynolds

James Schwartz

Mark Shinderman, M.D.

James Williams

Tony Woodard, Sr.

Addressing Workforce Issues

Michael Bennett

Terry Bering

Robert Cager

Tom Collier

Lois B. Collins, M.D., M.S.

Stan DeKepmer

Laura Durkalski

William R. Heffernan, M.S.

Mattie Hunter, M.A., CADC, LCSW

Mary B. Larsen, LCPC, CSADC

Valerie Magee, R.N.

Robert Norman, CADC

Bill O’Brien

Thomas Bernard Pettus

Raphael Rios

Robert Warner

THE NATIONAL TREATMENT PLAN INITIATIVE
235

PARTICIPANT A CKNOWLEDGEMENTS

OCTOBER 18, 1999

METROPOLITAN WASHINGTON 

COUNCIL OF GOVERNMENTS

WASHINGTON, DC

MODERATOR

Peter F. Luongo PANELISTS

Guardia E. Banister, Ph.D.

Camille T. Barry, Ph.D., R.N.

Alpha Estes Brown, Ph.D., J.D., D.Min.

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

FASAM 

Karen Dale

Thomas Davis

John Gregrich

Patricia D. Hawkins, Ph.D.

Elvin Bernard Parson, M.D.

Melanie Randall

Dedra Roach, M.D.

Michael C. Rogers, J.D.

Sue Thau

TESTIFIERS

Closing the Treatment Gap

Benjamin

James L. Becker, M.A., NCCDC

Tim Bradley

Barbara Brown

Christine Cooper

Jacqueline Corbata

Melanie Cramer

Brian Elzey

Mary Jane England, M.D.

Andrea Evans, LCSW-C

Jeffrey A. Hoffman, Ph.D.

Ingrid Jacobson

Alice Johnson

Reverend Johnson

Kris Kelley

Walter Kloetzli

Eric Latke

Abe Macher, M.D.

William Reid

Larry Siegel, MD

Lloyd Smith

Lynn Smith, M.A., CCDC

Kia Soar

William H. Williams, Jr.

Reducing Stigma and 

Changing Attitudes

Johnny W. Allem

John Ashton

James L. Becker, M.A., NCCDC

George Bloom

Sarah Casson

Anne Ellis

Charles Fletcher

Michael C. Helms

Robin Ihara on behalf of Sharita Prince

Fred Johnson

Linda R. Wolf Jones, D.S.W.

Pat Jones
236

Changing the Conversation

Walter Kloetzli

Kate McCoy

Randy Pumphrey, D.Min., LPC

Paul Poplawski, PhD, on 

behalf of Renata J. Henry

Carl Soderstrom

Chuck Thomas

Improving and Strengthening

Treatment Systems

Corinne Carey, Esq.

David Catania

Holly Catanya

Adrian Dominguez

Harry Hart

Ed Hendrickson

Dennis Hoyle on behalf of

Kathleen Kennedy-Townsend

Robin Ihara

Katherine S. Jacobi, LCSW

Paula Labaton

Rene Loman

Julie Lopez, M.S.W., LCSW

Pauline H. Menes

Russell Morrison

Alice Peyton-D’Orio

Dedra Roach on behalf of Ivan CA Walks

Kevin Schifman

Fritz Schmidt

Major John Toland

Rob White

Oliver Williams

Connecting Services 

and Research

Gloria Elliott

Katherine McAlpine, Ph.D., LCSW-C

William McCall

Paul Poplawski, Ph.D., on 

behalf of Renata J. Henry 

Tiffany Tatter

Floyd Wilson

Addressing Workforce Issues

Carol

Dona Dmitrovic

Richard Kunkel

Julie Lopez, MSW, LCSW

Denise Lynch

William McCall

Thelma Noble

Paul Poplawski, Ph.D., on behalf of Renata 

J. Henry 

Andrea Siss

Ralph Turner

Beverly Vehinger

Celeste Wiley

OCTOBER 26, 1999

THE PORTLAND BUILDING

PORTLAND, OREGON

MODERATOR

Victor Capoccia, Ph.D.

THE NATIONAL TREATMENT PLAN INITIATIVE
237

PARTICIPANT A CKNOWLEDGEMENTS

PANELISTS

Camille T. Barry, Ph.D., R.N.

Mady Chalk, Ph.D.

Barbara Cimaglio

Amalia Gonzalez del Valle

Lewis E. Gallant, Ph.D.

Steven L. Gallon, Ph.D.

Melody M. Heaps

Alan Melnick, M.D., M.P.H.

Rod K. Robinson

Kenneth D. Stark

Flo Stein 

TESTIFIERS

Closing the Treatment Gap

Kathy Abel

Robert Bailey

John Connors, CADC

Pam Curtis

Sarah DeHart, M.S.N., Ph.D.

Stephen Dickey

Lloyd A. Duncan

Eldon Edmundson, Jr., Ph.D.

David Eisen, LAc, M.S.W., OMD(am)

Fred Garcia

Richard Harris

Irene A. Holland, R.N.

Norma Jaeger

Cheryl Kennedy

Jacqueline Mercer, M.A., CADC II

Robert Miller

Jim Peterson, M.S.W.

Paul Parker

Terry Robinson

John Simmons

Sheila Staggs

Carol Stone

Joseph Stone, Ph.D., CAC III

Gary K. Weeks

Reducing Stigma and 

Changing Attitudes

Jeremy

Robert Bailey

Paul Barnett, Ph.D.

Tom Buhler

Linda Chase

Rodney Road Runner Clarke

Sarah DeHart, M.S.N., Ph.D.

Lloyd Duncan

Fred Garcia

Sharon Kelley

Mark W. Knudsen

Kayla Mary Leopold, LCSW

Valerie Moore

Susan O’Donnell

Al Rodriguez

Neil Scott

Randy Sorvisto

Joseph Stone, Ph.D., CAC III

Ron Williams
238

Changing the Conversation

Improving and Strengthening

Treatment Systems

Dennis

Billy C. Anfield

Robert Bailey

Stanley Benally

Vernay Berner

Jean Bucciarelli on behalf

of James Peterson

Alyce Dingler

George Etsitty

Fred Garcia

Norma Jaeger

Farah Lees

Anita Berardi Maher

Judy McMullen

Connie Moreno-Perraza

Laureen Oskochil, M.P.H.

William Padgett

Mary Proper

Beverly Stein

Joseph Stone, Ph.D., CAC III

Cleve Thompson

Dale Walker

Connecting Services 

and Research

Robert Bailey

Sarah DeHart, M.S.N., Ph.D.

C. Haven Fearn

Ed Fox

Fred Garcia

Norma Jaeger

Sarah Lees

Thomas Moore, Ph.D.

Joseph Stone, Ph.D., CAC III

Phillip Windell

Addressing Workforce Issues

Virginia Almeida

Robert Bailey

Cindy Berg

Ellen B. Eaton, CADC II

Fred Garcia

Anthony Hauck, CADC II

Farah Lees

Linda Lewis

Anita Berardi Maher, Ph.D.

Toni Moore

Joseph Stone, PhD, CAC III

Mike Sweeney

Ann Uhler

NOVEMBER 8, 1999

COUNTY CENTER

TAMPA, FLORIDA

MODERATOR

Shirley D. Coletti, DHL 

PANELISTS

Camille T. Barry, Ph.D., R.N.

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

FASAM

Kenneth A. DeCerchio

Donald Evans

Bill Janes

THE NATIONAL TREATMENT PLAN INITIATIVE
239

PARTICIPANT A CKNOWLEDGEMENTS

James R. McDonough

Neal McGarry

Stacia Murphy

Carole Otero

Thomas Scott

Ronald Williams

TESTIFIERS

Closing the Treatment Gap

Dorothy Baker

Mike Bridenback

John Daigle

Patricia M. Daly

Richard Dembo, Ph.D.

James Dominguez

Carole Colleran Egan

Mark Englehardt

Donald Evans

Robert Glenn, Ph.D.

Nicole Harris

Juliane Holt

Albert Jackson

Daniel Kane, M.A., Ed.S., LMHC

Libby Lubin, LMHC, MBCC, CRC

Dennis Moore, Ed.D.

Richard Nimer on behalf of Michael Moore

Pat Scoones

Nancy Shevitski

Timothy Siegler

Wes Smoyer

Lynda Spreitzer, CAP, ICADC

Reducing Stigma 

and Changing Attitudes

Ronald S. Brown, CAC

Bryan Camereno on behalf

of Harry Lee Cole

Nancy Conine

Carol Colleran Egan

Kimberly Grey

Michael Jaeger

Jodi James

Steve Kersker

Debbie Peeden

Sherry Reno

Barbara Shayeb-Helou

Wes Smoyer, CAAP

Lynda Spreitzer

Charles A. Starks, Ed.D., LMHC

Randee Steinacker

Robert Watson

Improving and Strengthening

Treatment Systems

Richard Brown, M.S.W.

Jose Castillo

Joseph Dorsey, M.D., FASAM

Beth Ficquette

Dena Geraghty, R.N.

Daniel Kane, M.A., Ed.S., LMHC

Susan Latvala

Gerald Long

Nero Moore, III

Anthony Mulvihill

Barbara Palomino de Valasco
240

Changing the Conversation

Sally Parks

David M. Parrish

Karen Salmon

John Sheehan

Jeremy Taylor

Penelope Tobias

Connecting Services 

and Research

Al Davis

Jack Espinoza

Nancy L. Hamilton, M.P.A., CAP, CCJAP

Dennis Moore, Ed.D.

Janice W. Petersen, Ph.D.

Pat Scoones

Addressing Workforce Issues

Ronald S. Brown, CAC

John Daigle

Bill High

Dennis Moore, Ed.D.

Anthony Mulvihill

Vickie B. Tanaka

Lauren Tompkins

Janice Velez

David Lee Whiters, LMSW, CAC I

WRITTEN-ONLY TESTIMONY

Closing the Treatment Gap

Anna

Brandi

Brian

Emma

Heidi

Jason

Katie

Lindsay

Tiffany

Rich Aanderud

Cynthia Bergh, B.A., NCACI, CCDC II

Kent Berton

William Boylin

Jeremy Brown, CASAC

Alex Brumbaugh

Child Welfare League of America

Ronald C. Clark, LPC

John de Miranda

District of Columbia Community

Prevention Partnership

James Donagher 

Debra Guthmann, Ed.D.

Sharron Kelley

Chris Kelly

Harry Kressler

Amy Krymkoski

Diane Kurtz

Larry Langdon

Spence Meighan, M.D., FRCP, FACP

Scott Newsom, Ph.D.

Robert E. Olson

Brett S. Rayford

Tammy L. Rhein

Lura Lynn Ryan

Max Schneider, M.D., FASAM

THE NATIONAL TREATMENT PLAN INITIATIVE
241

PARTICIPANT A CKNOWLEDGEMENTS

Karen Schrock

Jeffrey Shelton, Ph.D., LPC

Tim Sheridan

Donald N. Snyder, Jr.

Hope Taft

Kylea Taylor, M.S.

Ray Wilson, M.S., CADC

Stephan Young, LISW

Reducing Stigma and 

Changing Attitudes

Tom

Bruce B.

John Baldasare

Cynthia Bergh, B.A., NCACI, CCDC II

Marty Boldin, LISW, CCDCIIE, ICADAC 

Alex Brumbaugh

Debbie C.

Thomas J. Delaney, Jr.

Michael B. Del Camp

Stuart H.

Indiana Response, multiple collaborators

Ivan K.

Sharron Kelley

Chris Kelly

Amy Krymkoski

Daniel J. La Prova

Barry M. Lester, Ph.D.

Peter M.

Gina Matthews, CASAC

Terri Martinez

Ruth Maxwell

Jill N.

Mary N.

Michael N.

Colleen O.

Susan O.

Patricia R.

Ronny R.

Michael W. Robinson

Renee Robinson, M.P.A.

Nancy Rothstein

Lura Lynn Ryan

John S.

Robert S.

Max Schneider, M.D., FASAM

Jeffrey Shelton, Ph.D., LPC

Diego Uriburu

Karen W.

Roy W.

Unnamed

Unnamed

Improving and Strengthening

Treatment Systems

Kent Berton

Regina Birrenkott

John Boyd and Janis Gold

Gary E. Braden, EdD

Alex Brumbaugh

David G. Buby, D.O.

Michael D. Clark, M.S.W., C.S.W.

Tom Crull

Pam Curtis
242

Changing the Conversation

Cheryl Dubois 

Indiana Response, multiple collaborators

Steven K.

Amy Krymkoski

Marion Lavrinec

Robert M. Lipgar, Ph.D., ABGP, FAGPA

Luis Lozano

Alan Mabry, Ph.D.

Helen McNut

Ethel Mull

Edwin Rivera

Linda Ryan

Lura Lynn Ryan

Max Schneider, M.D., FASAM

Jeffrey Shelton, Ph.D., LPC

Kathy Himsl Spear

Henry Tews

Stephanie Vitali

Beverly I. Walker

Ron Williams

Unnamed

Connecting Services 

and Research

Kent Berton

Alex Brumbaugh

Ann H. Davis, M.Ed., CCAS, MAC, CCS

Indiana Response, multiple collaborators

Amy Krymkoski

Lura Lynn Ryan

Max Schneider, M.D., FASAM

Jeffrey Shelton, Ph.D., LPC

Ken Stark

Faye S. Taxman, Ph.D.

Karen Wheeler

Addressing Workforce Issues

Cynthia Bergh, B.A., NCACI, CCDC II

Kent Berton

Alex Brumbaugh

Sarah S. DeHart, MSN, Ph.D.

Thomas J. Delaney, Jr., M.S.W., M.P.A.

Indiana Response, multiple collaborators

Michael J. Kirby, CSW, CASAC

Amy Krymkoski

Jeffrey Shelton, Ph.D., LPC

Jerry Weber, LADAC

CSAT PUBLIC HEARING STAFF

Doug Basher

Betty Bast

Rosalind Bauer

John Campbell

Marjorie Cashion, M.S.W.

Peggy Cockrill

Captain Carol Coley

Donna M. Cotter, M.B.A.

Jackie Derdeyn

Cynthia Graham, M.S.

James Herrell, Ph.D., M.P.H.

Kathy Howell

Love Foster-Horton

Commander Ann Mahony 

Claudia Richards

THE NATIONAL TREATMENT PLAN INITIATIVE
243

PARTICIPANT A CKNOWLEDGEMENTS

Marcus Gabriel Rodriguez

Gayle Saunders

Julie Stevens

Ivette Torres, M.Ed., M.S.

Fabrine Walker

Michele Westbrook

Leah Young

VI. NTP Contractors

CSAT AND PANEL STAFF SUPPORT

The Lewin Group

3130 Fairview Park Drive

Falls Church, VA 22042

Leslie Scallet, J.D.

Senior Vice President

Project Director

Dianne Faup, J.D.

Senior Manager

Project Manager

(Panels I & III Domain Leader)

Additional Panel Staff Support was 

provided by the following individuals 

at The Lewin Group:

Lesa Barnes

Melanie Barraclough (Panel V 

Domain Leader)

Lezli Baskerville, J.D. (Panel II 

Domain Leader)

May Chao (Panel IV Domain Leader)

Marisa Diana, Ph.D.

Errol Fields (Panel I Team Assistant)

Terri Hall

Christina Hughes (Panels II & 

V Team Assistant)

Jonathan Lo (Panel III Team Assistant)

Lora-Ellen McKinney, Ph.D., M.P.A.

Sandy Smith 

Andrew Tucker (Panels III & IV 

Team Assistant)

SUPPORT CONTRACTORS

McFarland and Associates

8601 Georgia Avenue, Suite 601

Silver Spring, MD 20910

Audrey Benjamin

Regina Guyther

Paulette Wiggins

ROW Sciences, Inc. 

1700 Research Boulevard, Suite 400

Rockville, MD 20850

Heather Banks (Writer/Editor)

Cheryle David (Logistics)

Elizabeth Hayes (Writer/Editor)

Esther Roberts (Logistics) 

Andrea Savoye (Writer/Editor)

Deborah Schulman (Consultant Writer)

Sandra Thompson (Logistics)

Cosmos Corporation (Subcontractor 

to ROW Sciences)

3 Bethesda Metro Center, Suite 950

Bethesda, MD 20814

Carolyn Davis (Writer/Editor)

Kara Johnson (Writer/Editor)
244

Meeting Presentation Group

(Subcontractor to ROW Sciences)

4201 Mitchellville Road, Suite 10

Bowie, MD 20716

Paul Allen III

Lisa Fornatuna

Manny Harris, Jr.

Tim Wilson

Tascon, Inc. 

1803 Research Boulevard, Suite 305

Rockville, MD 20850

Patricia Evans (Project Manager)

Sandra Hart (Word Processor/DTP)

Evelyn Johnson (Administrative Assistant)

Deborah Jones (Director)

Un Lee (Senior Meeting Planner)

Patrice Pettinato (Editor/Proofreader)

Mary Savannah (Production Manager)

Maria Smith (Meeting Planner)

Van Tong (Word Processor/DTP)

Chris Weber (Project Manager)

Lori Whitten (Writer/Editor)

Triumph Technologies, Inc. 

109 Oronoco Street

Alexandria, VA 22314

Diann Fahey (Logistics)

Tyric Sims (Project Director)

CSAT PROJECT OFFICERS

Richard Bast

Donna M. Cotter, M.B.A 

James Herrell, Ph.D., M.P.H.

Rachel Mather

Marvena Simmonds
DHHS Publication No. (SMA) 00-3480

NCADI Publication No. – BKD 383

Substance Abuse and Mental Health Services Administration

Printed 2000