SUBSTANCE ABUSE AND MENTAL HEALTH
CENTER FOR SUBSTANCE ABUSE TREATMENT
NATIONAL ADVISORY COUNCIL
May 20, 2005
Sugarloaf Mountain and Seneca Rooms
Substance Abuse and Mental Health Services Administration
1 Choke Cherry Road
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Center for Substance Abuse Treatment
1 Choke Cherry Road, Room 5-1015
Rockville, Maryland 20857
Cynthia A. Graham, M.S.
Public Health Analyst
Center for Substance Abuse Treatment
1 Choke Cherry Road, Room 5-1036
Rockville, Maryland 20857
Anita B. Bertrand, M.S.W.
Northern Ohio Recovery Association
P.O. Box 360833
Strongsville, Ohio 44149
Kenneth A. DeCerchio, M.S.W.
Florida Department of Children and Families
Substance Abuse Program
1317 Winewood Boulevard
Tallahassee, Florida 32311
David P. Donaldson, M.A.
We Care America
44180 Riverside Parkway, Suite 201
Lansdowne, Virginia 20176
Bettye Ward Fletcher, Ph.D.
Jackson State University
1120 Andrew Chapel Road
Brandon, Mississippi 39047
Valera Jackson, M.S.
Village South/West Care Foundation, Inc.
3180 Biscayne Boulevard
Miami, Florida 33137
Chilo L. Madrid, Ph.D.
Aliviane NO-AD, Inc.
7722 North Loop Road
El Paso, Texas 79915
Francis A. McCorry, Ph.D.
Clinical Services Unit
Division of Health and Planning Services
New York State Office of Alcoholism
and Substance Abuse Services
501 7th Street
New York, New York 10018
Eric A. Voth, M.D., F.A.C.P.
Assistant Medical Director
Topeka, Kansas 66606
Forest County Potawatomi Tribal Court
P.O. Box 340
Crandon, Wisconsin 54520
Ex Officio Members
Richard T. Suchinsky, M.D.
Associate Director for Addictive Disorders
and Psychiatric Rehabilitation
Department of Veterans Affairs
810 Vermont Avenue, N.W.
Washington, D.C. 20420
C O N T E N T S
H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM
Director, CSAT 5
Recovery Month Update
Ivette Torres, M.S., M.Ed., Director, Consumer
Affairs Office, SAMHSA/CSAT’s Office of the
International Perspective on the Harm Reduction Movement
Eric Voth, M.D.
NAC Member 18
Valera Jackson, M.S.
NAC Member 47
Sheila Harmison, D.S.W., L.C.S.W., Special
Assistant to the Director, SAMHSA/CSAT’s
Office of the Director 58
Community and Faith-Based Update
NAC Member 71
Jocelyn Whitfield, Senior Public Health Advisor,
CSAT; Co-chair, SAMHSA Community and Faith-Based
Initiative Work Group 79
David P. Donaldson 84
Council Roundtable 97
1 P R O C E E D I N G S (10: 03 a.m.)
2 DR. CLARK: Welcome to the final open session
3 of this meeting. Our first presentation will be a Recovery
4 Month Update. Ivette Torres is the director of CSAT’s
5 Office of Consumer Affairs and will begin this section of
6 the meeting. Ivette manages the team responsible for
7 generating and disseminating substance abuse treatment
8 information for SAMHSA’s mission-related consumers. She
9 developed national communications strategies and campaigns,
10 including the observance of National Alcohol and Drug
11 Recovery Month celebrated each September. She is
12 president-elect of HHS’s Hispanic Employee Organization.
13 Her term begins in November. As mentioned earlier, she is
14 also a member of the CSAT Hispanic Work Group.
15 MS. TORRES: Good morning. I’m going to try to
16 be very quick, because my esteemed colleague from our team
17 reminds me that smaller audience, quicker presentation. So
18 let’s see how quickly I can get through this.
19 Many of you know that Recovery Month
20 essentially highlights the societal benefits. We aim to
21 reduce stigma, and we want to empower people in recovery.
22 Anita Bertrand here is one of our best examples of doing
23 that in a local community, because she just told me
24 yesterday that she is running three Recovery Month
25 activities in September, which is wonderful.
1 We also support ONDCP in their demand reduction
2 efforts, and I’ll be more clear and let you know how we do
3 that in a minute. We generate momentum for holding state
4 and local community-based events to enhance the knowledge,
5 improve understanding, and promote support for addiction
6 treatment nationwide. We publicize messages that reduce
7 stigma, encourage the need to get into treatment—very
9 I want to emphasize every single year that I
10 come before you, just to remind you that this is not just a
11 straight-out public education campaign where people get
12 messages and we expect some type of behavior change. What
13 we are experiencing is an average of 24,000 calls a month
14 to our hotline, which is significant. So if we take any of
15 the other CSAT programs that are serving directly people,
16 and a program may serve 60 to 70 people, this particular
17 effort basically helps two things. It helps to get people
18 information so they can address their addiction issues. It
19 also helps to really try and increase the number of people
20 who go into treatment. And some of those people in fact
21 are going into some of our publicly funded programs, if
22 you’ve seen the latest report from DR. Chalk’s shop in
23 terms of the number of people who are going into publicly
24 funded programs because of the reduction of the privately
25 funded resources.
1 What do we do? Seventy-five thousand kits,
2 which you have in this handy little bag that I’ve given
3 you. I have a copy. We just got them yesterday afternoon.
4 I haven’t even opened one. Yes, I did. I opened it and
5 it looks beautiful. The posters, which are quite nice this
6 year. Every year we try to do them a little bit different.
7 These are very rectangular and hopefully you will find
8 room for them in your offices and homes. No, I’m kidding.
9 Ten thousand flyers, 20,000 giveaways. The new jewelry
10 that you have in the bag is also one of these Lance
11 Armstrong knock-offs, which is for Recovery Month.
13 MS. TORRES: So I want you to remember to wear
14 them everyday.
15 We’ve won yet another award for our Web page,
16 and I can’t even remember the name of it. It’s in the
17 monthly report that I submit to Rich. But it’s amazing!
18 People keep giving us awards for the campaign. This one is
19 significant because it’s not just for the Web. It’s
20 actually an award that is for the entire campaign, in other
21 words, not only for the webpage and the e-government aspect
22 of the campaign, but also for the print materials and the
23 activities that are conducted.
24 As you can see, we’re nearing a million hits
25 every month on the Web. We have a series of webcasts
1 called “The Road to Recovery,” which I’m going to show you
2 a promo in a minute. We’re in 149—I just counted. I have
3 to correct that, because it’s 149 cable markets. It’s
4 probably 160 by now, because we’ve got the Alliance for
5 Community Media working with us to increase it, and they
6 started their work about two months ago. So we’re probably
7 past this. But on the list that I saw yesterday, it was
8 149. So I’m going to tell you it’s 149.
9 Beyond what we get, which is potentially what
10 you’re seeing here in the 149 cable markets, I looked at
11 the number of potential subscribers. We’re potentially
12 reaching about a million people a month with the webcast.
13 Beyond that we get about 12,000 or 13,000—12,900, almost
14 13,000—people who are coming onto the Web to look at the
16 And in addition to that, we are selling, for
17 cost recuperation, the CDs and the tapes of the webcasts,
18 and they’re being used by local communities to train. We
19 haven’t kept track of how many people see it through that
20 avenue, but certainly I think that’s a very significant
21 aspect of the campaign, because people are actually using
22 these tools to train people in treatment centers as well as
23 in academic settings.
24 Here’s the promo for “The Road to Recovery.”
25 (Video clip played.)
1 MS. TORRES: And that was Maryann Fragulis, who
2 used to be an RCSP director, but she has graduated.
3 As you can see, it’s a very well done
4 production. I think that’s one of the reasons that it’s
5 really helping us to get into those local public
6 educational and government channels through cable.
7 What else can I tell you? The hits for the Web
8 are booming. We went from 2003 to 2004; we increased
9 unique visitors by about 232 percent, and we see the
10 increases each year to be exponential growth with such
11 large numbers. We have very high expectations for this
13 Here’s the award-winning website. I encourage
14 you to go in, because it’s really very full of information.
15 Your whole Recovery Month kit is there. We’ve got a
16 virtual Recovery Month kit on the website. We have people
17 having dialogues and chats who are in recovery and posting
18 their stories. We have a listserv that you can sign up to,
19 and we can let you know exactly when these “Road to
20 Recovery” shows are coming on or when we have the Ask the
21 Experts sessions that we host with one of the panels. And
22 the reason you saw my picture up there, by the way, is not
23 that I’m putting myself first; it’s that I host the show.
24 We use one of the people who participates in the panel to
25 actually respond to questions from the folks who come on to
1 the Web.
2 I encourage you again and again and again.
3 We’ve got slots for panels coming up. I can certainly have
4 Cynthia and George send you what the topics are if you’re
5 interested in participating in one of these shows and being
6 a panel member. We welcome you, and just let us know about
7 your availability. The one that we have to worry about is
8 Mr. Curie and Dr. Clark’s schedule, and that really is what
9 sets the production agenda, if they’re interested in doing
10 a show. So we’re not very flexible in terms of dates when
11 it comes to Mr. Curie and Dr. Clark. But everyone else, if
12 it’s flexible, we’ll work around your schedule.
13 Community events. These are the proposed sites
14 for this year. We tried to go this year where we haven’t
15 been before in communities that really target rural areas
16 as well as urban areas, where we haven’t been to before.
17 As you can see, it’s a whole host of new areas that we’re
18 going into.
19 Our Major League Baseball is going very, very
20 strong. These are the proposed major league teams that we
21 will be working with this year. We may even go beyond
22 these because some folks are already starting to work with
23 these and have gotten local community support already.
24 When we go into these cities, if that’s happened, we’re not
25 going to go in there. We’re going to use our resources to
1 go to other teams that have not yet hosted these types of
3 MR. DeCERCHIO: (Inaudible.)
4 MS. TORRES: The Yankees weren’t up there?
5 MR. DeCERCHIO: We’re going to have to work on
7 MS. TORRES: Oh, yes. If you can help us,
10 MS. TORRES: They need all the recovery they
11 can get?
14 MS. TORRES: All right. We’ve got 44 events
15 already listed, folks, and we haven’t even distributed the
16 kits this year. So what does that tell us? It tells us
17 that people out there from last year are coming onto the
18 Web, and even without the materials, they’re already
19 planning events and we’re absolutely thrilled. Last year,
20 417 events, which was 44 percent growth from the previous
21 years. I’ve said to people that I will not be happy until
22 this year we have about a thousand events.
23 I just talked to Dr. Suchinsky to see if we can
24 get the Veterans Volunteer Network to work with us, and
25 right there, we’ll have thousands of events, because the
1 veterans do have an incredible network of volunteers
3 A hundred and eleven proclamations. We went
4 down a little bit because there was a young man at the
5 Governors Association who no longer was there this year to
6 help us, but governors do get the letters. As a matter of
7 fact, the president of the Governors Association
8 essentially signs the letter and sends it to the other
9 governors. So we’ve been very fortunate that this year
10 we’re connected and can be doing that. We also send kits
11 to legislators, mayors, city and county managers, and so
12 on, so we really spread the wealth quite a bit.
13 “Treat Me” and “Artist” are the two treatments
14 for the public service announcements this year, and I’m
15 going to show them to you in a minute. “Treat Me” is
16 really about people in recovery, and “Artist” is about the
17 trajectory of an individual from being addicted to reaching
18 his recovery. We try every year to give a different focus
19 in terms of the people we portray in our public service
21 I have to tell you that with the limitations in
22 our budget for ’06, we’re either going to get rid of the
23 webcasts—unless I can get some support from RWJ or NIDA—or
24 the PSAs. That’s where we have to make choices, and the
25 planning partners have so been told, and we will see what
1 happens. But certainly NIDA was in one of our last
2 webcasts that we did on medication-assisted therapies, and
3 they very much enjoyed participating. So I told Dr. Vocci
4 to go back and tell Tim Condon that we needed some cash if
5 they wanted to continue to participate in these.
6 Okay. We get tons of money coverage, and this
7 isn’t the half of it, because we are in the matching
8 program, as I always tell you, with ONDCP. So our PSAs are
9 really in prime time everywhere, nationwide. So this is
10 only what we generate from our effort.
11 Here is our first, which is our “Artist.”
12 (Video clip played.)
13 MS. TORRES: And now, for Chilo’s benefit, we
14 will go to the Spanish version.
15 DR. MADRID: I’ll do the translation.
17 (Video clip played.)
18 MS. TORRES: And “Treat Me.”
19 (Video clip played.)
20 MS. TORRES: And essentially, that’s the
21 campaign for this year. We hope that you join us in the
22 observance of Recovery Month by working on events in your
23 local community, if you’re able to do so, and encouraging
24 others in your community and your state to get involved
25 also and to plan statewide events, which I think are really
1 critical. I think those are the ones that really bring the
2 message to the governors, to the legislators, about the
3 miracle of recovery.
4 This would not be possible without, first of
5 all, a host of planning partners that are just wonderful.
6 Many of the organizations that you’re very familiar with
7 are involved and come about three times a year, as well as
8 Dr. Clark’s support certainly, and the staff. Carol
9 DeForce is here and Stephen is waiting for 125 boxes of
10 kits that are coming in, so he can’t be here, or he would
11 be here. And of course the AWS phenomenon. Michelle
12 Westbrook is on her AWS today, and she wasn’t able to be
13 here. But certainly the team works very, very hard each
14 year with the contractors to make all of this possible.
15 Next year, just another word about the public
16 service announcements, there is a campaign that is being
17 put forward. NCADD with Mannesis Communications started
18 the effort about three years ago, and CSAT has supported
19 the campaign. So perhaps what can happen if those public
20 service announcements actually bear fruit and are
21 compatible with the Recovery Month message, we want to work
22 in synergy with that campaign, and hopefully then we can
23 salvage the webcast by using those PSAs. But it’s yet to
24 be determined.
25 Thank you very much for your time.
1 MR. DeCERCHIO: When will the PSAs be released?
2 You always give us access to them. When will they come out
3 for release so we can use them?
4 MS. TORRES: The public service announcements,
5 the only thing that we have to do is code them for the
6 hearing impaired. And as soon as that happens, and it
7 should be within the next two or three weeks, we will make
8 CDs available and have the folks send them to you.
9 MR. DeCERCHIO: Do you have the rural area in
10 Florida identified, or are you still trying to work on
11 that? I noticed you had Florida as one of the states.
12 We’ve done events there in the past.
13 MS. TORRES: In Florida there are two efforts
14 going on. I think NCADD is trying to do something in Tampa
15 through Sherise.
16 MR. DeCERCHIO: Yes. I’m surprised the Yankees
17 aren’t on board yet.
18 MS. TORRES: Also this year we have three new
19 initiatives. I really didn’t get into it.
20 MR. DeCERCHIO: We can go offline. Just give
21 me the cities.
22 MS. TORRES: Absolutely. We’ll also have a
23 motorcycle run. We’re trying to get the Sober Riders
24 together in Florida. That will be Massachusetts, Florida,
25 and California. We’re going to put together Sober Rides.
1 So that will take place in Florida as well.
2 But I’ll talk to you during the break.
3 Yes, Dr. Suchinsky?
4 DR. SUCHINSKY: Do you have any idea of the
5 content of the telephone inquiries? Are these inquiries for
6 treatment? Inquiries for information? Do you have any sense
7 of what people are asking about?
8 MS. TORRES: Well, we can tell how many are
9 asking for materials and being referred. That’s the
10 extent. We have to be very careful because of privacy laws
11 and the anonymity of the people who are calling in. So
12 it’s hard to ask for more information. But to the best of
13 my knowledge, we can tell how many people are coming in for
14 referrals and information or just for information.
15 DR. MADRID: Congratulations, Ivette, for the
16 creativity. Those Spanish PSAs really hit on target, very,
17 very relevant, very creative. The “Treat Me” theme is
18 very, very nice. It had the same impact in English as well
19 as in Spanish, which is unique. So congratulations for all
20 the work that you, your staff, and Dr. Clark have put into
21 this campaign. I think that it’s probably one of most
22 successful campaigns nowadays in reference to health care,
23 period. So I think those six awards are very, very well
25 MS. TORRES: Thank you, Chilo.
1 DR. CLARK: Any other comments?
2 (No response.)
3 DR. CLARK: Thank you, Ivette.
5 DR. CLARK: While we prepare for our next
6 speaker, I thought I’d read a little vignette out of this
7 week’s Potomac Gazette. Eric would be interested in this.
8 There was an article, “Community Deals with Student Drug
10 “School officials said there is no drug problem
11 at Cabin John Middle School after three students were
12 charged with drug possession earlier this month.
13 “Three boys, aged 11, 12, and 13, all of
14 Potomac, were found with marijuana on school
15 property. Each was charged with possession of a
16 controlled dangerous drug. The 11-year-old was
17 charged with possession with intent to distribute.
18 “‘I don’t see a problem in the schools,’ says
19 Cabin John principal Paulette Smith. ‘I look at it
20 as an unfortunate incident.’”
21 Eleven, 12, and 13. But there’s no drug
22 problem. The kid is arrested for intent to distribute. To
23 whom? I thought Eric would like that.
24 Obviously there’s a problem in the school, and
25 the school had to struggle with how to deal with it. But
1 one of the major elements in terms of the problem is that
2 the school has got its blinders on. One of the issues is
3 one of denial. How you deal with the kids is certainly
4 another matter, but if those in authority don’t recognize
5 that there is a problem, then there is a problem.
6 DR. VOTH: That’s a great segue towards maybe a
7 future presentation on student drug testing, if we really
8 want to stir up the controversy.
9 DR. CLARK: Speaking of controversy . . .
11 DR. CLARK. . . . presenting on the
12 international perspective on harm reduction is Dr. Eric
13 Voth. Dr. Voth is a specialist in internal medicine and
14 addiction at Stormont-Vail HealthCare in Topeka, Kansas.
15 He’s chairman of the Institute on Global Drug Policy,
16 recognized as an international authority on drug use, and
17 lectures nationally on drug policy-related issues, pain
18 management, and appropriate prescribing practices.
19 He serves as an advisor on alcohol and drug-
20 abuse issues to the Kansas State Board of Healing Arts. He
21 is also a consultant on a number of international drug
22 prevention organizations and is a clinical associate
23 professor of internal medicine at the University of Kansas
24 School of Medicine.
25 Dr. Voth?
1 DR. VOTH: It’s great to be here among friends.
2 One of the major things that I do in the course
3 of my personal and professional time is chase around the
4 world trying to stay one step ahead of the legalization
5 effort. It’s a little bit like those of us in prevention
6 and treatment trying to bail the water out of the boat
7 while somebody else is running around drilling holes in the
8 bottom of the boat.
9 One of the areas that has surfaced is a
10 fundamental change in what we all recognize as harm
11 reduction policy. Some of us are now calling it pseudo- or
12 so-called harm reduction. I want to go through some of
13 that historically so we can get a good handle on this.
14 Let’s keep in mind that traditional drug
15 policy, which most of us grew up with and I believe
16 probably most of us agree with, is a fundamental
17 abstinence-based type of a phenomenon—in other words, harm
18 elimination for treatment, primary prevention, or harm
19 prevention, fundamental emphasis on no drug use as our
20 ultimate goal, even though we recognize that’s difficult to
21 achieve, and an element of legal enforcement underlying a
22 lot of this policy.
23 Why is it so important? If you go back to the
24 risk-focused prevention model and think about the community
25 risk factors, one of the fundamental areas that underlie
1 drug policy and risks is community laws and norMs. And if
2 community laws and norms change, there is a paradigm shift,
3 and then there’s more acceptance of drug use that takes
5 Currently we’re really seeing three areas show
6 up in the drug policy arena. I’d say most of us in the
7 room fall into this group, which is largely an abstinence-
8 based type of policy orientation. There is a group
9 absolutely pushing for the broad, all-out legalization of
10 drugs, and there is a group that’s more or less originated
11 some of the original features of the harm reduction
12 movement, and, as you’ll see through what I’m talking
13 about, there’s been an invasion of some of the legalization
14 movement into the harm reduction movement and then
15 subsequently into the overall drug policy arena.
16 In general the way that harm reduction is
17 shaking down, I think that harm reduction policy is
18 probably most effective only in those behaviors that are
19 generally legal and socially acceptable. So think, for
20 instance, about wearing seatbelts in a car. We know that
21 some element of car accidents are simply unavoidable, and
22 we want to do things to mitigate those.
23 Helmets, for those of us who drive motorcycles
24 or ride bicycles. We know that sooner or later there’s a
25 chance we may fall. It’s an acceptable, otherwise
1 generally healthy, behavior. But how can we protect
2 ourselves and our children?
3 But here’s the sinister side of what we’re
4 calling the pseudo- or so-called harm reduction movement.
5 Back in the late 1980s, there was a group—this is quoting
6 Peter McDermott, who is the editor of the International
7 Journal on Harm Reduction, who said, “I was part of the
8 Liverpool cabal who hijacked the term harm reduction and
9 used it to aggressively advocate for change.”
10 Down here he’s saying, “Harm reduction implied
11 a break with the old, unworkable dogmas, the philosophy
12 that placed a premium on seeking to achieve abstinence.”
13 That old dogma sits alive and well in this
14 room, and I think is workable, that we want to try to seek
15 to achieve abstinence, and there’s nothing about it being
16 an inappropriate goal.
17 Another bit of sinister side of harm reduction.
18 This is quoting Pat O’Hare, who was at that time director
19 of the International Harm Reduction Society, who said, “If
20 kids can’t have fun with drugs when they are kids, when can
22 Another hole being drilled in the bottom of
23 that boat. You can see we’re working on prevention,
24 working on treatment, while some people in the arena are
25 actually espousing this type of policy.
1 Ethan Nadelman, who has served as one of the
2 primary drivers behind the drug legalization movement,
3 saying, “Recognize that many, perhaps most, drug problems
4 in the Americas are the result not of drug use per se, but
5 of our prohibitionist policies.”
6 So the new what I’m calling so-called harm
7 reduction, or pseudo-harm reduction, really gives up on the
8 user and seeks more only to encapsulate the user. It is
9 predicated only on trying to reduce societal harm, and it
10 considers drug use inevitable and uses this nihilism to try
11 to get folks in society, and actually involved in other
12 drug policy arenas, to say, “Yeah, well, it’s inevitable.
13 I guess we just have to accept that.”
14 Andrea Barthwell and I had a long, wonderful
15 discussion on this, and she opened my eyes to an arena I
16 hadn’t thought about before. The harm reduction movement,
17 as it’s panning out, really only focuses on this segment of
18 the drug-using world, the addict and those who are in
19 pretty bad shape, as far as the nonaddicted drug user
20 population, but really does nothing for primary prevention
21 and does very little, if anything, for the nonaddicted drug
22 users. So we end up with this enormous reservoir up here
23 feeding the addict population almost inexorably, and we’re
24 just standing by in that movement, saying, “Well, if they
25 start using their I.V. drugs, we’ll do various things for
2 So what you’ll be hearing from me, and clearly
3 from the President and Mr. Curie, etc., is that we need to
4 look at this entire phenomenon, the whole population, to
5 really have effective drug policy.
6 So here’s what we’re seeing as the variance
7 between what we’ll call traditional drug policy and maybe
8 even where harm-reduction policy originally intended to be,
9 and where it’s really ending up today. One is a
10 “responsible use” message, and, I kid you not, there are
11 literally movements around the country that are trying to
12 convince parents to teach kids to use pot responsibly, to
13 drink responsibly. Underage kids. Imagine those 12- and
14 13-year-olds drinking, using pot, responsibly.
15 “Medicalization.” We can talk about that if we
16 have some time. Needle exchange, some forms of methadone.
17 And by the way, I just give you my hats off to all the
18 work that Wes has done in terms of trying to get a handle
19 on methadone treatment and standardizing and moving it
20 forward in appropriate realMs. I think it’s wonderful work.
21 I never had a chance to say that to him, so I do it in a
22 public realm.
23 Heroin handouts are beginning to pop up around
24 the world. There are actually some cities that have been
25 handing out “safe crack kits,” intended, one, to move
1 addicts away from I.V. drug use, but also to teach them
2 how to use crack safely. There’s a great paradox in that,
3 I hope you’re seeing, but the instructions in the safe
4 crack kits say, “If you have cracked or bloody lips, don’t
5 share your crack pipe.” There’s a condom thrown in with it,
6 too, and some really incredibly ridiculous points, rather
7 than, “Wait a minute, let’s maybe try to get them away from
8 that behavior.”
9 Then other forms of treatment, trying to
10 moderate use and tossing out the notion that abstinence is
11 a reasonable thing.
12 I want to run through some of the areas where
13 harm reduction policy has been tried and give you some
14 examples. We don’t have near enough time to really dig
15 into these, and if I have some, I’d like to dig into some
16 of the examples where harm reduction has really caught on
17 around the world.
18 First off, alcohol policy. You talk about
19 trying to bail water out of the boat while people are
20 drilling holes in the bottom of it. We’ve done wonderful
21 things recently—and for years—to try to reduce underage
22 drinking, to try to reduce the problems associated with
23 alcohol. But good heavens, consider alcohol. By no
24 question it is our biggest addictive problem outside of
25 tobacco, and youth are using twice as much alcohol on a
1 regular basis as marijuana.
2 Consider advertising alone. This is what we’ve
3 got. We’ve got a legal drug, where harm reduction things
4 are taking place. Enormous advertising budgets being
5 dumped right on kids. Enormous spending on advertising.
6 It’s gone up 148 percent in the last couple of years.
7 Thirty million dollars alone advertising in the top 15 teen
9 We’re bailing out the boat. Guess who’s
10 drilling holes in the bottom?
11 Tobacco policy. Well, we all know about
12 tobacco, and this is singing to the choir. But let’s keep
13 in mind that if we are going to have this legal drug, and
14 people say, “Let’s legalize drugs and tax it and gain all
15 that back,” we would need to be pricing tobacco at about
16 $40 a pack to regain societal costs that are going down the
17 drain. There are now those who are beginning to try to
18 push a responsible smoking agenda, believe it or not.
19 To give you an idea of this responsible usage,
20 there’s a brand new book that’s just hitting the market
21 called, “It’s Just a Plant.” It is absolutely targeted at
22 the pre-teen market. One of the people who wrote a
23 foreword in it, Marsha Rosenbaum, has been very deeply
24 involved in the responsible-use message. It is published
25 by the Magic Propaganda Mill. It says in the back, “Thanks
1 to Ethan,” of course, likely Ethan Nadelman, George Soros,
2 etc. And it was funded by folks who George Soros funds,
3 like the Marijuana Policy Project.
4 Its message is very clear. In fact, in one
5 place in that book, the little pre-teen girl who went down
6 the hall and smelled funny smoke coming out of Mommy and
7 Daddy’s bedroom says, “Marijuana’s not so bad. I want to
8 grow some myself.” This is the kind of message that some of
9 these folks are pushing.
10 The medical marijuana movement is my alter ego.
11 I spend hundreds of hours involved in this, and I have
12 nowhere near enough time to talk about it today. If you’re
13 ever interested, we can do that. But again, this is
14 another one of these diversionary tactics, trying to push a
15 perceived or alleged medical application or excuse for
16 marijuana, smoked marijuana, and the ballot initiatives
17 have been heavily driven again by organizations who are
18 squarely behind the legalization movement.
19 Now, needle exchange programs started off with
20 good intent. I would have to say, though, that as they’ve
21 unfolded, a lot of negative has begun to show up. I want
22 to make you aware of at least the negative side. Most
23 people have a sense that maybe there’s some sort of
24 positive behind needle exchanges. Quite honestly, I quit
25 referring to them as needle exchanges, because for all
1 intents and purposes, they’re really needle handouts.
2 First let’s consider the average needle
3 requirements of either heroin or cocaine addicts. Then if
4 you multiply that by the millions of them floating around
5 out there, you’ll begin to realize that there is no way we
6 can possibly, conceivably provide enough clean needles to
7 handle all of the needs of addicts. And then one gets into
8 the question of what do we do with those needles once
9 they’re out there.
10 It’s a little bit dated now, but an excellent
11 look by CDC about exchange rates. Only 62 percent of the
12 needles in the needle exchanges in North America that were
13 looked at were returned. That’s 7 million needles in one
14 year on the street. Seven million in one year on the
15 street. That’s needle handout, folks, that’s not needle
17 And it’s not specific to North America. This
18 just came out of Glasgow this last December. The return
19 rate was 54 percent, so about 400,000 in that small city,
20 400,000 needles on the street.
21 In some areas of the world, there are so many
22 people being stuck by needles around these needle exchanges
23 that people have even quit reporting it to local health
24 authorities, because they figure it’s just going to happen.
25 When you look at the research, and I know we’ve
1 all heard these statements: “There’s no question needle
2 exchange helps.” We’ve had some national folks in previous
3 administrations that say, “No question we have to support
4 needle exchange.” But here’s some reality. First of all,
5 most of the looks at needle exchange have been very small
6 sample sizes. Few if any have had control groups. There’s
7 largely been a self-selection of participants, high drop-
8 out rates, and self-reporting of behaviors.
9 There’s a brand new report that’s coming out of
10 Sweden, some folks that I work with over there that have
11 looked very rigorously. It’s not published yet, so it’s
12 still embargoed. But they went back and looked at 143 of
13 the studies looking at needle exchange. And if you look at
14 the diversity of how the studies were done, you can sift
15 out of them that, in fact, the randomized controlled
16 studies really showed no difference in benefit. There were
17 13 that looked at HIV primarily that showed no difference.
18 Three showed better HIV rates; two showed worse. The five
19 that focused on hepatitis showed mixed results.
20 As far as risk behavior, 31 found risk behavior
21 worse, 15 better, 21 really no particular change. That’s a
22 pretty mixed bag of those studies. Standardization is a
23 question there.
24 I want to look at a couple of studies. We
25 don’t have near enough time to go through all of them. But
1 a couple are just interesting. In one of the Chicago
2 studies, and this is getting a little dated now, but it was
3 interesting that 39 percent of the needle exchange
4 participants in that study shared needles versus 38 percent
5 of nonparticipants. And 68 percent displayed injecting
6 high-risk behaviors.
7 Montreal, which really was quite a good study,
8 and it’s interesting because subsequently, when I
9 communicated with those researchers, they really tried to
10 backpedal on their own findings, because, unfortunately, it
11 really showed that those involved in their needle exchange
12 had a significantly higher risk for HIV/AIDS conversion and
13 seroprevalence than the nonneedle population. Their
14 conclusion was that the risks were substantial and
15 consistent in all three scenarios that they looked it. It
16 was really not a bad study.
17 Hagan over in Seattle looked at hepatitis B and
18 C. Similar kind of a finding, particularly among the
19 sporadic needle exchange users, that their risks for
20 hepatitis B conversion were 2.5 times and hepatitis C 2.6
21 times higher than the nonneedle exchange participants. The
22 Seattle conclusions were fairly similar. The highest
23 incidence was among the current users of the needle
24 exchange, and the goal of elimination and reduction of risk
25 behaviors had not been achieved.
1 Puerto Rico. I’m trying to give a more
2 international flavor with some of these. No significant
3 change in injection habits. Only 9 percent entered
4 treatment, and remember, many of the proponents of needle
5 exchange have been saying that this is the way we attract
6 folks and try to get them into treatment ultimately. Only
7 9 percent enter treatment, and this is remarkable, the
8 number of needles that were not returned. Twenty-six
9 percent of the needles returned were seropositive for HIV,
10 although I think that’s a terrible way to really measure
12 India. If you look at what happened from 1996
13 to 2002 during particularly their use of the needle
14 exchange, compare from line to line here. This is HIV,
15 hepatitis, hepatitis C—instances were respectively 1
16 percent going to 2; 8 percent going to 18 percent;
17 hepatitis C, 17 going to 66 percent prevalence.
18 Scandinavia is really a phenomenal area,
19 because you’ve got one of the most “liberal” parts of the
20 world working on drug policy, but at the same time, you’re
21 going from some of the most liberal drug policy to some of
22 the most conservative drug policy in the world when you
23 move from Denmark to Norway to Sweden. And this is really
24 one of the best side-by-side comparisons of societal drug
25 policy that’s been looked at.
1 If you look, for instance, at Denmark, and
2 Denmark’s process has been pretty much an open needle
3 exchange, there’s really been no mandated compliance or
4 reporting, and counseling and testing is very lax and a
5 voluntary phenomenon. Through 1991 to 1996, their HIV
6 incidence has been pretty steady, about 1.49 per thousand.
7 If you look at Norway and Sweden, though, it’s
8 interesting that with limited handouts, and here in Sweden
9 with no handouts whatsoever, but with aggressive reporting,
10 aggressive counseling, aggressive intervention, there has
11 been a steady reduction in HIV down to the point where here
12 in Sweden, we’re down to 0.58 and Norway 0.58. So, a third
13 the HIV rate as Denmark, which pretty much hands out
14 needles and steps back and says, “Do what you think is
15 right for you all.”
16 So what are the problems with needle exchanges
17 fundamentally? Most are essentially handouts. There are a
18 few that have pretty good return rates. There is not a
19 clear reduction in HIV and hepatitis B and C. They do
20 really nothing to change the underlying destructive
21 behavior of I.V. drug use. There is clearly a sense of
22 immunity in the drug-using community around needle
23 exchanges, and that then provides an atmosphere supportive
24 of use. There was concern that there might be a recruiting
25 process going on, but that really hasn’t borne out in some
1 of the research that’s been done looking at this.
2 I think that it’s a real problem that when you
3 start looking at needle exchange, there’s really no
4 advantage over aggressive outreach programs and abstinence-
5 based programs. And it seems to me to be a waste of limited
6 financial resources. No one has grappled with the product
7 liability risks. In other words, if you get stuck by a
8 needle walking on the beach, or if you’re an addict and
9 something happens to your rig that you’re getting from my
10 needle exchange, or I’m a parent and an adolescent of mine
11 gets tangled up in a needle exchange, and I think that
12 somehow they become injured, who’s going to bear that
13 product liability risk? We’re in a liability-laden society.
14 Certainly a significant risk for needle sticks,
15 and let’s keep in mind that most of the deaths of those
16 addicts is from disease or homicide, not from the disease
17 specific that they’re hoping to stop.
18 I want to talk about the heroin maintenance
19 program, because this phenomenon is beginning to catch on
20 around the world, and it’s worrisome. The Swiss in 1997
21 came up with something that typically the Swiss would do,
22 which is, how can we possibly keep those folks from causing
23 harm to the rest of us? The Swiss are kind of provincial
24 people, and all of my good Swiss friends would agree to
25 that. They thought, “Well, let’s come up with a plan to
1 look at three legs or arms of the study, methadone,
2 morphine, and heroin, giving this to patients.”
3 What ended up happening is, they didn’t keep
4 their study groups pure, and most of the patients ended up
5 migrating to using heroin. So they ended up with no
6 comparison groups.
7 All of the outcomes were self-reported. They
8 initially wanted to use end-stage addicts so they could
9 really see if there was a benefit. But they ended up using
10 folks in pretty good health, which kind of biased that
11 severity index. There was no data that was ever captured
12 on those who left the program.
13 No independent drug testing. They said, “Are
14 you using other drugs?”
15 “Oh, yes. I’m not using other drugs. I’m
16 staying sober.”
17 There was no random drug testing. It was
18 always agreed upon, the schedule, by the tester and the
19 patient. It was not witnessed. There was no independent
20 evaluation of HIV, no requirement for HIV testing. The
21 conversion rates were not measured. The criminal behavior
22 was self-reported. There was no look at police files
23 whatsoever or any contact with the police departments.
24 So, imagine, the addict came into these and
25 they’d say, “Are you using other drugs?”
1 “Oh, no, no, no.”
2 “Are you involved in crime?”
3 “Oh, no, no, no.”
4 Well, of course! And they get their free
5 heroin, and away they go.
6 There was no systematic evaluation of
7 employment records.
8 Now, the original intent, again, was to try to
9 bring people in, get them stabilized, maintain them for a
10 while, move them towards abstinence and employability.
11 In the last year, they reassessed this, and
12 only 5 percent of that population became abstinent. One of
13 the negative things that happen is that abstinence-based
14 programs started finding reduction in their numbers,
15 because people were saying, “Wait a minute! I don’t have to
16 quit. I just go over here and shift to the heroin
17 maintenance program so I can keep using.”
18 Only 4 percent of the original group have
19 actually stayed off heroin. Thirty of their abstinence-
20 based treatment centers have closed, and the actual annual
21 cost to maintain the addicts on this program has been
22 24,000 Swiss francs a year. That’s pretty darn good funds
23 for any kind of treatment, much less something like this.
24 So what’s really happening there now is, even
25 though they have said this has been a very, very successful
1 program, the international look is very skeptical.
2 Actually the World Health Organization said, “Wait a
3 minute. The way you structured this was so terrible, we
4 really can’t draw any kind of conclusions.”
5 Now, we’ve seen areas of harm reduction in the
6 United States. I want to just brush across some of those.
7 Baltimore has had a phenomenal drug and a
8 phenomenal drug and violence program. They have actually
9 been making some progress in the last few years. Dr.
10 Beilenson and I testified to a congressional hearing a
11 couple of months ago, and they are making efforts.
12 Actually, though, he admitted in that hearing that some of
13 what they’re doing is not just harm reduction any more.
14 It’s mandated treatment.
15 He could not say that they had actually put
16 treatment groups beside each other, one getting the needle
17 exchange plus all the social support versus a research
18 group that had all the social support and no needle
19 exchange. So whether needle exchange plays a positive role
20 for them, don’t know.
21 They still have a phenomenal crime problem,
22 worse than all of these other similar-size cities, twice as
23 high in overdose deaths as these other major cities. So
24 they’re paddling upstream. We’ve all seen what a problem
25 they’ve had. It will be interesting to see how this pans
1 out over time.
2 Vancouver is another area that’s a real hotbed
3 of harm reduction policy. One of the more recent studies
4 has looked at the HIV incidence among their addict
5 population. It’s phenomenal.
6 It’s interesting here, too, when we talk about
7 what’s our net hope for some programs, a 27 percent needle-
8 share rate certainly shouldn’t be one. The overdose death
9 rate was the leading cause of death in Canada among 30-49
10 year olds being overdose deaths. And among the needle
11 exchange program participants who were on methadone, 50
12 percent are sharing needles.
13 Wait a minute, now. We’re maintaining them on
14 methadone. We ought to be working away from I.V. drug
15 use, right?
16 The police in Canada are literally pulling
17 their hair out. I work with many of them up there, and
18 they’re saying that Canada, if you look at the big picture
19 of what’s happened with this softer drug policy, Canada is
20 now becoming a source country and Vancouver is right at the
21 heart of it.
22 Some other little spin-offs of lenient drug
23 policy there. Marijuana has escalated to a billion dollar
24 annual import. There are virtually no marijuana fines.
25 Border smuggling is huge. Three million needles were
1 handed out in 2000. They are now initiating a heroin
2 handout program to add insult to injury. And there have
3 already been 109 overdose deaths in the government-
4 sponsored shooting galleries, where people can come and
5 have “safe shooting.” A hundred and nine overdose deaths
7 The overall Canadian results spill over into
8 other areas. The overall use of marijuana is beginning to
9 go up. Eighteen percent of users are smoking daily. And
10 look at that population we worry about so much, the
11 adolescent use.
12 I hate to rocket through these, but I told them
13 I’d stay on time today.
14 England has seen a significant increase in
15 marijuana since their decriminalization plans. Now their
16 head law enforcement officers have said they are very
17 concerned, and they think it was probably a mistake to have
18 decriminalized marijuana.
19 Holland, one of the hotbeds of harm reduction
20 and actually marijuana tolerance. Their adolescent
21 marijuana use skyrocketed in the early years. Their
22 organized crime groups have skyrocketed. They’ve now
23 become a leading exporter of ecstasy. Their own people
24 feel that their laws are too lax.
25 And again the spin-off, not just marijuana use,
1 but look at cocaine, ecstasy, meth use among young people.
2 So when drug policy is softened, there is that spillover
3 into other arenas.
4 And, of course, as you’d expect, HIV rates are
5 going up, an increase in just that period of time alone.
6 So where do we go from here? One of the things
7 that I try to support on an international basis is a broad
8 approach, looking at prevention, treatment, and
9 interdiction. Harm prevention, harm elimination through
10 treatment, and recognizing the importance of interdiction.
11 And I think now it’s safe to say that enough of the harm
12 reduction movement has been invaded that there is a
13 significant segment of it that has jeopardized and maybe
14 even being an almost harm production movement.
15 I’m open for some questions. That was a
16 mouthful. But I stayed on time, didn’t I?
17 DR. CLARK: You stayed on time. Council
19 MS. JACKSON: Thank you. That was a very
20 informative presentation.
21 I think that the information that you gave really
22 points out some of the pitfalls of harm reduction. I know
23 that just from my local point of view, working in an
24 agency, some of the federal agencies do talk harm reduction
25 and when you write grants to get money for services, you’ve
1 got to talk about harm reduction, not necessarily
2 legalization. I don’t think I’ve ever applied for anything
3 that promoted that.
4 However, where is the U.S. and the helping
5 agencies—CDC, HRSA, ACF—what is their general policy now on
6 harm reduction?
7 DR. VOTH: Well, I’ll speak briefly about that.
8 I tell you that it’s all over the board. There are,
9 within government, some very clear hotbeds of harm
10 reduction. One of the most recent, as it came up, is out
11 of the State Department. The USAID was pushing needle
12 handouts across parts of the country on one hand, while
13 ONDCP and the government was saying, “No needle handouts.”
14 All of a sudden they realized that we’re
15 working against each other. I’ve certainly dealt with
16 folks at CDC that have pushed and supported needle
17 exchange. I’d like to believe that as a national policy—
18 and I think if you go to the White House, they’ll
19 absolutely say they do not support harm reduction or
20 related policy. But I think there are clearly hotbeds of
21 it throughout government.
22 I think from our standpoint, we ought to be
23 clear that we do not support harm reduction as a part of or
24 the focus of any treatment-based funds.
25 DR. CLARK: Richard?
1 DR. SUCHINSKY: I’d like to pull together some
2 aspects of presentations at this meeting to really focus in
3 on what the harm reduction movement is all about. First of
4 all, we spent an awful lot of time yesterday talking about
5 outcomes measurement and how we had to convince people that
6 our treatment was able to produce improvement.
7 Now there’s a huge literature that has for
8 years shown that treatment can produce improvement. Our
9 technology is certainly not perfect, and we don’t even
10 approach 100 percent. But we produce significantly good
11 results. But there are people who perseveratively ask us
12 to justify our existence and say, “Well, prove that what
13 you’re doing is worthwhile.”
14 In my experience, many of these are the same
15 people who are now promoting legalization and harm
16 reduction activities, and I think that the bottom line here
17 is that the crucial issue is the stigmatization and bias
18 that is involved in the attitudes towards people who use
19 substances and people who treat people who use substances.
20 So I think there is a connection among all three of these
21 aspects of the presentations that we’ve had here at this
23 I think that probably the place that we have to
24 start is at stigmatization issue. I think we can devote
25 ourselves endlessly to justifying our existence, but that
1 is not going to convince a certain segment of the
2 population that we have any validity, because the major
3 issue is how much they dislike people who use drugs.
4 DR. VOTH: And I would just echo that there’s a
5 real cynicism among a segment of that harm reduction group.
6 If you go to Canada—and I’ve been up there. I’m all over
7 the world studying these folks. And I’m going to tell you
8 that there’s no harm reduction taking place among those
9 addicts that go to the shooting galleries and shoot up and
10 go out on the street and sleep under the bridges and
11 things. There’s a cynicism and a sense of ostracism. Just
12 encapsulate those people and sort of keep them away from
13 hurting society. It is something I think society needs to
14 be aware of and health professionals need to be aware of,
15 that that is a sinister part of this whole thing. Rather
16 than embracing the addict and saying, “We can help you.
17 Let’s make your lives better. Let’s help you at least try
18 to get to abstinence," it’s like, “Well, here’s your
19 heroin. Just stay away from me and my folks.” Harm
20 reduction does not help people.
21 DR. CLARK: Frank?
22 DR. McCORRY: Well, Eric, I take issue with
23 some of your conclusions, or what I think would be mixing a
24 couple of different elements into a single presentation.
25 Harm reduction, I think, is larger than syringe
1 exchange programs. And in fact, I had looked at the syringe
2 exchange program data recently, and I look forward to
3 seeing that Sweden article. Perhaps you could pass it
4 around when it comes out, that meta-analysis of 114,
5 whatever it was, 119 syringe exchange programs.
6 But the earlier data I didn’t think was so bad,
7 and certainly in a high HIV state like New York, syringe
8 exchange from the data showed reduced levels of HIV among
9 syringe exchange users. I’d be really interested in that,
10 because syringe exchange is a separate issue to me. While
11 it might be an example of harm reduction, I don’t think
12 it’s the totality of harm reduction.
13 I think yesterday’s SBIRT presentation—SBIRT,
14 in fact, employs a harm reduction approach. We’re looking
15 to reduce the use of alcohol among problem drinkers. We’re
16 not sure about diagnosis, because it wasn’t put in. But in
17 effect we’re not looking for abstinence from drinkers.
18 We’re looking for better use, less use, less problematic
20 Harm reduction is a standard clinical technique
21 that many individual therapists use. You try to keep
22 someone in treatment to retain them, so you do not throw
23 out them out when they use, because you know that relapse
24 is part of the disorder. So by keeping them in treatment,
25 it’s a harm reduction kind of approach, rather than saying,
1 “Well, you can’t meet abstinence, therefore you can’t be in
3 Of course, I’m not at all addressing issues of
4 legalization and how some of the harm reduction movement
5 might be co-opted, or the camel under the nose. I think
6 that’s another whole set of issues of drug policy,
7 countries’ drug policy.
8 But I’d be cautious about defining harm
9 reduction solely or predominantly as a syringe exchange
10 program. That would be my first point.
11 And my second point would be, I’m not sure that
12 the data on syringe exchange programs is as poor as you
13 present, so I’d be interested in further discussion about
14 that. It certainly is an absolute question, if the
15 evidence does not support some reduction in nondrug-use
16 related behaviors. If they’ve been able to show that
17 there’s no increase in drug use, they have not been able to
18 show its decrease necessarily in drug use based on syringe
19 exchange. I’d be interested in knowing more about that.
20 DR. VOTH: A brief comment on that.
21 I think part of the difficulty is the focus on
22 what’s our endpoint. Our endpoint really isn’t to reduce
23 drug use or necessarily to reduce the individual’s drug
25 It’s like smallpox. Our intent was to
1 eliminate smallpox. We would love to eliminate addiction,
2 wouldn’t we? I mean, that’s our ultimate goal. We
3 recognize it’s a relapsing disease. People will relapse.
4 People we work with are likely to continue using, but our
5 goal ultimate goal is an abstinence-based phenomenon.
6 Now we may use techniques that reduce the harm
7 to that individual, but to say that our ultimate focus is
8 harm reduction, I think, is dangerous. And in fact, they
9 talk about that being the public health model. But the
10 public health model really is identify the disease, prevent
11 the disease, treat the disease—not just sort of accept the
12 disease. You may have to accept elements of it.
13 As far as the early research on needle
14 exchange, I think there was some terrible research that was
15 heralded as being wonderful, supportive stuff, that was
16 poorly put together. The Bruneau and Hagan studies were
17 some of the best research that I’ve seen. I don’t want to
18 argue just that.
19 I think that one might even say that an element
20 of needle exchange in the process of trying to get some
21 control over addicts’ situations may be reasonable, but not
22 as an endpoint. Do you see what I’m saying? So I’m not
23 saying an element of accepting harm reduction to try to
24 work with the addict is not appropriate. I’m just saying
25 that an endpoint of harm reduction focus is where we should
1 not be.
2 DR. CLARK: Frank?
3 DR. McCORRY: I think that there’s a clinical
4 tension between—exactly as you described it, Eric—how much
5 you can tolerate in terms of an individual patient’s
6 behavior without having to act on it. While you’re pushing
7 towards abstinence, how much you’re able to stay engaged
8 with an individual, where you don’t land up by trying to
9 keep engagement, in fact defaulting off what the goal of
10 the treatment is, what the therapeutic goal is.
11 I like the way you described abstinence-based
12 phenomenon, because it’s really not abstinence we’re
13 looking for—and I think SAMHSA has been wonderful in this.
14 We’re really looking for recovery, which an abstinence-
15 based phenomenon, which takes in much broader aspects of
16 life than simply nonuse.
17 To look at harm reduction as a technique in the
18 path towards recovery, I think, is the appropriate clinical
19 model. As you default into the unwillingness to confront,
20 the unwillingness to challenge, the acceptance of a
21 lifestyle that is really detrimental to the community as
22 well as individual, I agree with you. That’s where it’s no
23 longer harm reduction, but it’s something less. The
24 expectations are just not sufficient in terms of what
25 you’re looking at therapeutically.
1 But I think it’s equally dangerous to equate
2 harm reduction with syringe exchange and to lump them into
3 a view that in fact excludes or preempts the use of these
4 kinds of techniques, because they’re going on all the time,
5 every day, in our prograMs. Counselors are engaged with
6 folks, keeping them in treatment, because they have their
7 eye on the right goal, the goal of abstinence and recovery,
8 and to do that they sometimes must live with the tension of
9 having to accept use while they look towards a brighter day
10 for that client.
11 DR. CLARK: Any other discussion on this
13 (No response.)
14 All right. We shall move to the next issue,
15 except for Val’s not here.
16 I really should point out that federal dollars
17 cannot be used to support needle exchange programs. I just
18 want to put that on the record. Federal policy does not
19 support harm reduction as a construct at this juncture in
20 time. I’d like for Council to be aware of that.
21 We promised you an e-therapy update. Sheila’s
22 handing out some materials. I’m going to temporize, I
23 guess, until Val returns, since she’s going to present with
25 Dr. Harmison is my special assistant. She has
1 spearheaded CSAT’s efforts in the area of e-therapy. She’s
2 joined today by your colleague Val Jackson. Val is the
3 former CEO of The Village located in Miami. She has more
4 than twenty-five years of experience in community, state,
5 and national services for people with substance abuse
6 problems. The Village has facilities in Miami, Florida, and
7 the U.S. Virgin Islands.
8 During this past year Val has changed her
9 position to vice president of WestCare Foundation, the
10 umbrella organization that includes The Village South
11 Miami, The Village in the Virgin Islands, partners in
13 Sheila and Val?
14 MS. JACKSON: We’re handicapped. Somebody help
15 us get into the slide show?
16 PARTICIPANT: Sure.
17 MS. JACKSON: I want to thank you, Dr. Clark
18 and Dr. Harmison, for allowing us to talk about e-therapy
19 again. As you know, we did talk about this last time a
20 little bit. I left on the second day, and Sheila gave a
21 presentation, which I thought was excellent.
22 Since then I’ve had the opportunity to present
23 at a conference and to do some more study about this. So
24 today, we have a little bit of repetition just to refresh
25 everybody where we were with the e-therapy, and then we
1 wanted to request a couple of items from the Council.
2 That’s sort of where we’re heading with this little thing.
3 So let me see if I can figure out where we page
4 down at. If I get that, we’ve got it. Okay. I’m going to
5 flip through these pretty fast.
6 My husband was in the hospital recently in Las
7 Vegas, and one of the things that happened was that the
8 nurse came in and said, “You know, probably his CAT scan
9 was read in India, transferred back over to Las Vegas,
10 Nevada, and then actually brought back by the doctor in his
12 I just sort of looked at him and went, “Well,
13 I’ll bet that does happen.” But I hadn’t really thought
14 about it before.
15 The days of technology, and what happens in
16 technology and in medicine, have really come a long way
17 from those old days when you had to wait for the
18 radiologist to come in and read a scan or something like
19 that, and then come back to your local doctor and get the
20 information back.
21 I think we have to recognize that we are moving
22 along. Just as in medicine, we have to begin to look at
23 how the Internet and, in fact, all electronic kinds of
24 therapies, may affect us. The Internet has brought about a
25 way to interact with a person or group without leaving your
1 home or your office.
2 I was thinking of another story. How many of
3 us know someone, or have a son or a daughter or a niece or
4 a nephew or a friend, who’s finding love on the Internet?
5 It’s something that they’re very comfortable with,
6 something that many people are very comfortable with, and
7 it’s being used every day in many ways: Internet
8 prescriptions, Internet records, telehealth, education,
9 psychiatry, counseling.
10 Last time, I remember, Dr. Harmison showed you
11 a couple of the webpages that had individuals who were
12 advertising themselves. Some of that is positive, and I
13 think that we need to think of it as positive. And, of
14 course, some of it also may be very, very dangerous, and we
15 need to really look at the qualifications, at the impact
16 and outcome, and how this is done—which, of course, is
17 where we’re leading with this presentation.
18 These are just some of the other ways that
19 online communication formats are coming across.
20 I read in the last month a lot more about doing
21 therapy by e-mail, for instance. Some of the advantages of
22 that, in terms of being able to do a diary as a patient or
23 as a continuing care individual or even in the engagement
24 stage, you begin to do a diary, because you’re actually
25 writing out this as you go, when you use the Internet.
1 There’s ways to do it by voice, but this is
2 talking about plain old type-out Internet e-mails version
3 of therapy. Besides that, if you have a counselor or
4 therapist just coming back to you, you have information
5 that you can read and reread, and you can digest.
6 So from a position where I was some time ago—
7 not that long ago, maybe only months ago—of really
8 questioning where we could possibly go with substance abuse
9 prevention, treatment, and aftercare, I’ve begun to have
10 some doors opening, and I want to share those with you to
11 think about the possibilities.
12 We’ve all participated in webcasts. I think
13 that the message boards, the listservs, those kinds of
14 things are common things. These are more recent articles
15 that have come out about behavioral health counseling and
16 the Internet and how it’s worked. There are more studies
17 being done. I don’t think we’re at the end of having
18 studies done. I think we’re at the beginning of that. But
19 here are a couple of references for you that we’ve handed
20 out that allow you to begin to look at those.
21 When we think about what we might be able to
22 do, the first thing that we really have to admit in this
23 society and in substance abuse and mental health is that
24 there simply is no way that we’re going to be able to
25 provide residential or outpatient face-to-face treatment to
1 all the people in need in all of those places in need in
2 these United States and territories. In many areas,
3 getting to people is virtually impossible. Having the
4 funds to be able to build and maintain sites and treatment
5 programs is really, really not something that is very, very
6 feasible. I think because of that, it’s really important
7 for us to take a look at not only some of the populations,
8 but also some of the areas that we have to look at.
9 This mentions Native American communities,
10 juveniles, rural clients. I think some of the first things
11 you think about are perhaps the rural clients.
12 How is it in rural America? I was talking to
13 the judge earlier today about Native American communities,
14 and he made a very good point, one which I lived when I
15 used to live in South Dakota. I used to be the assistant
16 state director for South Dakota. One of the grants that
17 came in to us, an application, was for a woman to buy her a
18 car—not a new one; she just wanted a used car—and she
19 wanted enough gas so that she could go down to the Rosebud
20 Indian Reservation and travel from house to house and sit
21 at the kitchen table of those individuals who had very
22 difficult problems, and through that she would gain their
23 trust, and she was able to actually do door-to-door
24 treatment, so to speak. It would be what we’d technically
25 refer to now as in-home, onsite. But in those days, you’d
1 go sit at the kitchen table and you’d talk and you’d get
2 the trust, and it works that way.
3 I think there’s still something very, very
4 important about that kind of face-to-face trust, but also I
5 think that we have to look at that there are many, many
6 areas where simply that’s not possible.
7 There are populations—gay, lesbian, bisexual,
8 and transgender individuals—who, for whatever reason, are
9 much more comfortable on the Internet than they are in a
10 face-to-face therapy group. Co-occurring clients, women,
11 juveniles. Juveniles, the kids that we have in treatment
12 today, I can tell you, and we’re actually going to do this
13 at The Village, it is very easy for us to take a $200
14 computer, teach them how to interact with an aftercare
15 group before they leave treatment, give them that $200
16 computer, which is pretty worthless on the street, so it
17 isn’t a danger for sales, and then allow them to do their
18 follow-up and aftercare through the Internet. They’re
19 comfortable with it. It’s okay for them. They have travel
20 problems if we ask them to come back into our program. So
21 there are some real opportunities, if we would begin to
22 look at this in an out-of-the-box sort of way.
23 Some patients really like the idea of
24 computers. They’re very comfortable with it.
25 I won’t go through all these.
1 One of the studies at point number 4, attrition
2 is lower in online treatment. Dr. Alemi, who is recognized
3 at the bottom of your slide, has done some studies. He is
4 from the College of Nursing and Health Sciences at George
5 Mason University. I met him at a recent event, and I was
6 talking to him about a study that he completed.
7 His study showed that those people who were in
8 a continuing care or aftercare program—they had received
9 treatment, outpatient treatment I believe it was, and once
10 they left that treatment then they joined in an aftercare
11 program. Their attrition was much lower coming out of
12 treatment if they participated in the Internet study than
13 it was if they were just expected to come back into groups
14 and do that.
15 So from my own logical thinking, what it seems
16 to me is that what happens at The Village, where we are in
17 Miami—we’re in a very urban area; we’re not in a rural
18 area—adults or women with children particularly have
19 transportation problems in our urban area. They have care
20 problems. They leave treatment with every intention of
21 coming back to the aftercare groups, but you know what?
22 It’s really, really hard for them to do that. What we need
23 to do is find a way to make it easier for them to do that,
24 and this Internet, whether it be telephone, Internet talk
25 or Internet type—and again, you have to look at the skill
1 level of the individual—may be something that is worth us
2 looking into and doing some pilots and work in the future.
3 I think that, as the judge and I were talking
4 this morning, there are some real questions. Who the heck
5 are you counseling with when you get on Internet therapy?
6 How do we ever license or certify that those people are
7 qualified? Those are huge, huge questions that I think need
8 to be asked?
9 How do we deal with it if it’s from California
10 to Florida, or from London to Nevada? Those kinds of things
11 are really, really big questions.
12 How do we measure any kind of effectiveness or
13 outcomes? It’s like a lot of things on the Internet. It is
14 really, really difficult to put any controls on it and put
15 it in a box where you can measure it, know that it’s doing
16 good and not some harm. So first do no harm. We need to
17 find out that it’s first do no harm and take it from that
19 Right now there are no minimum standards of
20 care. Anybody who wants to can get online, say that they
21 can treat you. “I can make you feel better.” I hear
22 commercials on the radio station I listen to every day that
23 says, “Call me. I can take care of your drinking problem.
24 It’s no problem. If you can’t stand it, go to AA, come to
1 I have no clue who that woman is. She might be
2 the greatest thing since sliced bread, but I have no way of
3 knowing, or even asking to find out, what kind of standards
4 she would meet.
5 Confidentiality and privacy issues, lack of
6 technology and expertise. The reimbursement for services
7 is another issue. One of the things that I would like to
8 suggest on that is that it’s quite possible that in
9 reimbursement— Ken just walked out on a telephone call. I
10 wish he were here, because I want him to hear this
11 question, because he’s in my state. But I have often asked
12 myself in Florida, we go by cost centers, and of course
13 counseling is a cost center, individual counseling or group
14 counseling, however you might like to do it. There’s
15 nothing really in the rule or the regulation that says an
16 hour of Internet counseling wouldn’t be as valid as an hour
17 of any other kind of counseling. So it would be very
18 interesting to see how we might be able to fit some of
19 these services in the services that we’re already
20 providing, either through the block grant or the state
21 maintenance or even through grants that we have through
22 SAMHSA and other organizations at this point in time. And
23 it depends on how we want to define that. But I think
24 those are questions that we need to have answered—and to
25 ask, first—and then to get answered before we can actually
1 go forth and be able to take this nationwide.
2 Cultural issues obviously, I mentioned that a
3 little bit with the Native American issue, the rural issue.
4 I think those are all relative.
5 The cost of e-services can be much lower than
6 the services that we try to perform face to face. We don’t
7 know exactly what the cost is. We don’t know where the
8 savings would be, compared to the benefits. So we need to
9 look at that.
10 And of course, we mentioned before, the ethical
11 and legal guidelines.
12 I think I’m close to getting to you, Sheila.
13 One of the things that I discovered, though,
14 that I wanted to mention, before I turn this over to Sheila
15 is that, people say, “How can you possibly do e-therapy
16 when you can’t see the eyes and you can’t see the body
17 movements and you can’t see the body language?”
18 It turns out that there have been some studies,
19 though, that because we have changed, we have grown
20 comfortable with our technology. There’s an expression
21 that basically becomes telepresence, a person can be
22 working in therapy with someone through the Internet and
23 they sense that that person is there with them, and they
24 actually establish a bond. That’s been shown to be a
25 benefit in this kind of therapy. And I think that the
1 text-based bond can lead to telepresence and illusion of
2 being in someone else’s presence without sharing any
3 immediate physical space.
4 All of us have that sense sometimes, if we’re
5 on the phone with someone, and we get so comfortable that
6 it’s as though we’re sitting on the couch actually having
7 that conversation with someone. We need to think about
8 that. How does that apply to therapy?
9 I think that I’m going ask Dr. Harmison to go
10 ahead and continue on from me with the activities that the
11 Council has done, and then what we’d like to do is to talk
12 to you a little bit about a couple of requests that we
13 would like to ask the Council to support for e-therapy and
14 how we want to continue on with that.
15 Since Ken’s walking in now, then I’ll repeat my
16 question about costs. We were talking about paying for e-
17 therapy, and I said in Florida—you don’t have to answer
18 this question; I just want to pose it right now—we go by
19 cost centers, and the cost centers have individual
20 counseling, group counseling, and there is really nothing
21 in there that says whether it is necessarily sitting in a
22 room face to face or through the Internet. Would that be
23 recognized as that, and how can we possibly look at fitting
24 a valid—if we choose that it’s valid and find that it’s
25 valid—Internet therapy into our existing cost centers,
1 versus trying to find a whole new pot of money to do that?
2 So consider that I have repeated that for you, and now I’m
3 going to ask Dr. Harmison to continue with the activities.
4 DR. HARMISON: Thanks.
5 Good morning. It’s really nice to see all of
6 you here today, and I want to tell you, when I saw the
7 weather outside before I came, I was thinking, “Gosh,
8 wouldn’t it be nice if we had televideoconferencing, and I
9 could just do that instead of coming in today.” But I made
10 it. I made it.
11 Let me just go back one piece here, because
12 this is important. Last month we did a presentation, which
13 Val was a part of, and I just want to thank you so much.
14 Her presentation was excellent in giving an introduction
15 and overview of what we are trying to accomplish with e-
16 therapy in C-SAT, what we’re looking at and what we’ve done
17 so far—which is really a lot, considering the other OPDIVs.
18 We did have a presentation, and Dr. Clark spoke
19 to you about this briefly. It was called “Not Just for
20 Downloads: An Innovative Approach to Treatment in Minority
21 Communities.” It was at the Lonnie Mitchell conference in
23 The thing that was unique about this particular
24 conference was that it was directed towards minority
25 students, and those who really want to get into the field
1 of addictions. So all the presentations were around
2 looking at how we could assist these students understand
3 the issue of e-therapy with the minorities community more,
4 and then give them ways in which to get into the field and
5 work their way up.
6 Patrice Clark was our NAFEO intern at that
7 time. She was the moderator. Val was there. Stephanie
8 Moles from Women’s Heart spoke. She’s from California.
9 Dr. Alemi from George Mason University and Angela Harg, who
10 is working with Dr. Alemi on many of the various studies
11 that he does. And Dr. Alemi has been in this field almost
12 ten years, I’d say, just looking at some of the research—
13 maybe longer—and had a lot of wonderful suggestions for us.
14 Again, we can share those slides with you at any time and
15 give you an idea of where we’re going when it comes to that
16 particular topic area.
17 On February 3rd, I presented at a Joint
18 Workgroup on Telehealth at the Appalachian Regional
19 Commission in Washington, D.C. This is a group of federal
20 agencies that get together on a regular basis and discuss
21 what is happening when it comes to e-health, telehealth,
22 telepsychiatry, e-records, what have you, within the
23 federal government. That was quite interesting.
24 They were very interested in what we had
25 presented in December, with the conference. And, by the
1 way, we did send around all of those slides to you. There
2 were about 30 PowerPoint presentations. If you didn’t have
3 time to read all 30, you can go back to the table and look
4 at the newsletter that’s been developed also, which is the
5 second point. It really does say, in a nutshell, what that
6 particular conference had to present and gives you some
7 ideas of where we might want to go.
8 The important thing to remember about that
9 conference and what we’re looking at within SAMHSA is that
10 that was considering all three areas of concern in SAMHSA,
11 substance abuse prevention, substance abuse treatment, as
12 well as mental health services. And it also dealt with
13 medical services in primary care. There are a lot of
14 wonderful studies that were presented, and we did do quite
15 a bit of literature review on that to get to that point.
16 Since that conference has occurred, I’ve had
17 some suggestions from the field I wanted to present to you
18 and tweak your innovation with. Dr. Alemi did state that
19 reimbursement was one thing he would consider that needs to
20 be addressed at this time. He felt that it was urgent that
21 we get those pieces looked at and worked out before we go
22 on, because that’s what it all revolves around, actually.
23 If this is a type of treatment that’s going to
24 be less costly, how are we going to fund it? What is it
25 that we’re going to do with it when it comes to the various
1 kinds of criteria that we need to make sure are there?
2 He thinks that we could reimburse e-therapy in
3 a way that is budget neutral (doesn’t increase the total
4 cost of care to a population), or is performance based (and
5 it will pay less to firms that have worse outcomes), and is
6 medium neutral (that it does not mandate in-person, visual,
7 voice, or text connection).
8 If you’ve looked at any of these pieces, you
9 can see that there are many different modalities for e-
10 therapy. We even had one presentation—I was fascinated by
11 it—where somebody could access their therapist and their
12 behavioral modification program on their Palm Pilot, and
13 that was for food disorders and eating disorders.
14 Another suggestion that I received, and this is
15 from Carolyn Young, who is the executive associate of the
16 Hogg Foundation for Mental Health in Texas. She called me
17 and stated that the Texas Juvenile Probation Commission is
18 developing a proposal now to fund a pilot project to
19 provide mental health and substance abuse treatment through
20 telemedicine, and this is for the juvenile population in
22 They’re finding a serious need for serving
23 these children in that they have language difficulties;
24 they can’t find the counselors that know Spanish; and they
25 have cultural issues that only folks who are in those
1 particular indigenous communities can really understand.
2 So they want to reach the rural populations, but they also
3 want to treat their urban children that are having
4 problems, too, and they’re looking at consultation,
5 medication management, and treatment services. I thought
6 it was fascinating.
7 One other thing that she suggested to me, and
8 it’s just a little piece of food for thought, was that she
9 was looking at recovery services also in regards to faith-
10 based communities being involved, and that somehow they
11 wanted to work with those particular entities.
12 The federal response has been—I’ve sent around
13 to you, too, various newsletters that have come out, May
14 11th. It just shows that the HHS Secretary, Mr. Leavitt,
15 is concerned and leading the charge on this. His statement
16 on that is that public and private collaboration is
17 necessary to achieve the President’s vision for widespread
18 health IT adoption.
19 Mr. Leavitt also issued a new report entitled
20 “Health Information Technology Leadership Panel: Final
21 Report,” citing that investment in information technology
22 is essential, and that we really do have to begin to
23 develop it more. He states that the information technology
24 is pivotal for our health care system, and that we’re at a
25 critical juncture and need to work together with the
1 private sector. Specifically they’re looking at fewer
2 medical errors, lower costs, less hassle, and better care.
3 And I want to underline better care, because that’s where
4 we fit in.
5 The panel identified two basic themes:
6 Investment in health IT is urgent, as we have increasing
7 demands—we’ve been discussing all this. But we do have
8 business interests in it also, in a broader U.S. economy,
9 and that the potential benefits and costs of health IT must
10 be clearly perceived by its stakeholders.
11 On April 26th there was another press release,
12 which I sent around. This is the “Indian Health Service Is
13 Sharing Electronic Health Record System with NASA.” This is
14 an MOU, memorandum of understanding, between the IHS and
15 NASA that was signed to transfer technology from the
16 Resources and Patient Management System, which is a suite
17 of applications, including electronic health records, to
19 Why am I bringing this up? Because this is
20 another example of how the federal government can partner
21 together to incorporate more of what is being done in the
22 federal government to improve not only us but also our
23 partners in the field.
24 The Indian Health Service is a pioneer in the
25 use of computer technology when it comes to health data, as
1 well as doing clinical services. This particular system,
2 though, the RPMS, is an integrated solution for management
3 of clinical and administrative information in health care
4 facilities of various sizes and orientations.
5 I do have to say that our Division of Services
6 Improvement, Mady Chalk’s division, is now looking at e-
7 records, and Sara Wattenberg is heading up that initiative.
8 And I have to say that we’re really taking a look at how
9 we can make certain that our field is represented in the e-
10 record movement that’s occurring very, very quickly with
11 medical records.
12 So we’re at a point now that we are suggesting
13 that we might want to consider a subcommittee through the
14 National Advisory Council for CSAT. These are just
15 beginning suggestions to start thinking about. That’s what
16 this whole presentation has been about, just to get you to
17 think again about the usefulness, if it’s something you
18 want to consider. We can support a comprehensive
19 literature review. We could prioritize the issues with
20 that particular review, hold a kitchen cabinet meeting of
21 advisors and experts in the field. If you like, we could
22 support a preliminary needs assessment on the lack of
23 access or capacity for substance abuse treatment. There
24 have been many of those. But when it comes to locking into
25 the e-therapy issue, not so much. And we could also
1 support the development of a TIP on e-therapy. Just some
3 With that, I’d like to hand it back to Val.
4 Dr. Clark would be the one who would handle this.
5 DR. CLARK: I would turn it over to Council
6 members, and Val can start that.
7 MS. JACKSON: Well, I think, as it’s shown in
8 the last side, after talking about this and learning more,
9 what I found is that I think that we have crossed an issue
10 that is really very important, something that does warrant
11 the National Advisory Council’s attention. And by turning
12 it into a subcommittee of the Council, that would be the
13 request, noting that it also allows Council members who
14 might want to participate in the expert panels and in the
15 meetings could be in that. That’s my understanding.
16 So help me out, Dr. Clark, if I’m saying this
18 And the other issue is, of course, that report-
19 backs to the National Advisory Council ups the priority of
20 it and gets us moving along and supported much better if we
21 go this route.
23 DR. MADRID: Presently, we are working with the
24 Juvenile Probation Department in the development of an e-
25 therapy program in Spanish, and a lot of the issues that
1 you talked about are a lot of the issues that we are being
2 confronted with.
3 The one issue that you did not touch on that I
4 wanted to throw this on the table, and that is, will this
5 particular component of the agency that I represent be able
6 to pay for itself? So one thing that we’re looking at in a
7 very intense way is how to “Google-ize” our website. In
8 other words, how are we going to advertise online so that
9 we will be able not just to capture the market, the
10 probationees that need a lot of this assistance in rural,
11 remote, and frontier, but others that might be interested.
12 We’re looking also at targeting mothers,
13 because our study is showing that there’s a lot of hits
14 going into the Internet by mothers that are very desperate
15 concerning their kids. So I definitely would agree that
16 further study is needed, and I definitely would want to be
17 part of this study group, and perhaps share what we have
18 done so far, as we’ve worked with Juvenile Probation in our
19 area there in Texas, which is about two thirds rural,
20 remote, and frontier.
21 DR. CLARK: All right. So it sounds like at
22 least one of the Council members is interested in this
23 activity. And it sounds like we’ve got a large
24 jurisdiction that is actually moving forward to address
25 this as an element of the spectrum of approaches that they
2 The VA has actually used telemedicine as an
3 adjunct to both psychiatry and general health care as a way
4 of reaching rural or remote areas. So that dynamic is out
6 So I think the question on the floor is whether
7 this particular Council would like to have a subcommittee
8 on e-therapy to move forward through time.
9 MS. JACKSON: Yes, that’s the question. I
10 don’t know if I’m asking someone else to make a motion or
11 if I’m just asking—
12 DR. CLARK: You can make a motion. Nothing
13 keeps you from making that motion.
14 MS. JACKSON: Thank you very much. Then I
15 would make a motion that we have a subcommittee of the
16 National Advisory Council that addresses treatment and
17 recovery in substance abuse through the electronic
18 modalities and to explore that.
19 DR. MADRID: And I’ll second that.
20 MS. JACKSON: Thank you.
21 DR. CLARK: It’s been moved and seconded that
22 there should be created, within the Center for Substance
23 Abuse Treatment National Advisory Council, a subcommittee
24 on e-therapy/telemedicine, etc. All those in favor?
25 (Chorus of ayes.)
1 DR. CLARK: Anybody opposed?
2 (No response.)
3 DR. CLARK: So moved. Well, that was easy
4 enough, don’t you think?
5 And it’s good to hear that Texas is doing this,
6 since we’ve been exploring this. And also it’s important
7 that we need to recognize this is occurring in the arena of
8 juvenile justice. So that’s something else that you
9 raised, Val, but it’s the thing that we need to continue to
10 flesh out and address. Co-occurring disorders is another
13 JUDGE WHITE-FISH: Yes, Dr. Clark. I had some
14 questions about e-therapy at the previous meeting. I would
15 like to volunteer, if possible, to also serve on that work
17 Val, you used my exact words. She remembered
18 very well from last meeting my concerns. And I suppose, in
19 order to take it further than that, if I serve on a work
20 committee or that committee, maybe those concerns will be
21 taken care of.
22 I told her I’ll be her worst opponent in there,
23 but she says, “No.” And that’s the reason we had talked
24 previously, because I do have some concerns looking at the
25 cultural aspects, as well as looking at quality of
1 treatment. I believe that as SAMHSA looks at quality of
2 treatment, that’s where my biggest concerns are.
3 MR. DeCERCHIO: I think one of the challenges
4 on the mental health side in Florida, we’re about to
5 experiment with doing emergency screenings for involuntary
6 commitments in a rural area. But one of the challenges
7 from my perspective as a state, I think we need to work
8 through this and embrace it. I think it has a tremendous
9 amount of promise.
10 This whole regulatory piece, perhaps one of the
11 taskings might be to look at some basic standards that we
12 could employ, because we license programs and how you get
13 into licensure—if we open the door, circumventing the
14 licensure process, anyone in Florida could say, “Well,
15 we’re doing e-therapy. We don’t need to be licensed,” or,
16 “If I’m in another state, you’re not licensing us. You
17 have no authority.” To me that’s the biggest question, as a
18 state officer, that we have to work out.
19 Reimbursement we work out. We can do telephone
20 counseling. We can figure out reimbursement. But the
21 regulatory piece and how to assure some public confidence
22 and how to respect the legitimacy of licensure for the more
23 traditional things that we do, how to reconcile all that.
24 Dr. CLARK: Actually, the experience of
25 eGetGoing is that in some jurisdictions they were not
1 licensed and therefore could not pursue their therapeutic
2 schedule and therefore had to figure out how to anchor the
3 treatment in jurisdictions. Jurisdictions can do whatever
4 they jolly well please, because they’re the ones who decide
5 who can or cannot do what within their jurisdictions. So
6 it’s less of a threat, if you will. It is always, and
7 remains, an issue. The question, though, for
8 jurisdictions, if I reimburse, then I can require that you,
9 as a Medicaid, need to provide certain documents. You need
10 to be on registry, etc., etc. You just get that
12 But, we won’t dwell on this. What we’re going
13 to do is focus on letting the subcommittee deal with it and
14 figure out what we’re going to do over time, because this,
15 I think, will assist us in dealing with some of these rural
16 and remote issues, unique population issues, etc.
17 With that, if that’s okay, we can move forward.
18 Chilo will work with the committee. Three names: Chilo,
19 Val, and Eugene White-Fish.
20 MR. DeCERCHIO: You can add me to that.
21 DR. CLARK: And Ken DeCerchio. We’ll make sure
22 that your names are on there and we’ll move forward.
23 Did we work out our technology problems?
24 MR. DONALDSON: Well, we’ve got the first-
25 generation version, but we’ll do our best.
1 DR. CLARK: All right. Very good.
2 During the January meeting, we had a
3 presentation from Dave Donaldson, chair of the faith-based
4 subcommittee, accompanied by CSAT staff Clif Mitchell and
5 Jocelyn Whitfield.
6 Some of you expressed an interest in working
7 with the subcommittee with the hope to be able to carve out
8 time during the course of this meeting for the subcommittee
9 to meet. However, with the schedule we were working with,
10 we weren’t able to set aside time for the subcommittee to
12 We suggested to Dave that he and members
13 interested in working on the subcommittee meet Wednesday or
14 Thursday. It’s my understanding that they did meet last
15 night and have a report to present to Council today.
16 Dave’s expertise includes a strong faith-based
17 focus, disaster response, substance abuse and mental
18 health, volunteer mobilization, promotion and
19 organizational development. He’s the founder and CEO of We
20 Care America, an organization that helps the community of
21 faith build a greater capacity to serve the needy through
22 advocacy training, resource development, and volunteerism.
25 MR. DONALDSON: Thank you, Dr. Clark.
1 Jocelyn’s going to be joining me in a moment to talk about
2 some of the collaborations that have emanated out of the
3 trainings that we have conducted across the country.
4 But I’m happy to announce, as you just
5 mentioned, that we do have a faith-based subcommittee.
6 Bettye is on that and Anita. So I’ve asked them to chime
7 in as they want to.
8 Let me just say as a preface that I really feel
9 that we are at a tipping point as it relates to the faith
10 community, its involvement in social services, and also the
11 faith community as it relates to partnering with
13 There are two converging movements that are
14 happening in our country. First of all, in the faith
15 community, churches are moving from being a fortress to
16 becoming what I like to call a Wal-Mart, a one-stop shop,
17 where people can go to for their physical, spiritual, and
18 emotional needs.
19 I was asked to speak at our church, and the
20 pastor went up to the podium. I thought he was going to
21 introduce me, but instead he resigned from the church.
23 MR. DONALDSON: And then he asked me to come up
24 and speak. And to make matters worse, my sermon title was,
25 “Never Quit!”
2 MR. DONALDSON: And afterwards we had lunch,
3 and I asked him, “Why are you leaving this church and this
5 He said, “There’s just too many problems here.”
6 It’s exciting for me to see that the pastors of
7 old that saw these so-called problems now see them as
8 opportunities for the church to be the church that cares.
9 So that’s happening in our nation.
10 The second movement that is converging is that
11 the faith community for decades saw government as
12 adversarial, and there’s a shift that’s gradually
14 Ronald Reagan said in the 1980s, “If you get in
15 the same bed with government, you probably will not get a
16 good night’s sleep.” But at least the faith community is
17 now keeping one eye open, and they’re looking for full
18 partnerships with government to build healthy communities.
19 I think that’s happening through two primary
20 ways, first, the government affirming the value of faith-
21 based organizations, especially as it relates to treatment
22 and recovery. I think, Ken, maybe you mentioned this
23 yesterday. These churches, these shopping malls of
24 compassion, have the greatest opportunity for providing
25 that continuum of care—I think one of the greatest
1 opportunities, also, to minimize and perhaps even eliminate
2 the stigma attached to treatment. In many cases, it’s not
3 an agency/client relationship. It’s a deeper trust in
4 relationship. Also, just with the recovery management
5 services that are already inherent in many of these
7 You add to that, as somebody who is a person of
8 faith, the one that nobody voted in and nobody’s going to
9 vote out, God in His power, and you combine that with this
10 continuum of care, and that’s where it leads: to
11 transformation of lives, families, and communities. And
12 we’re seeing that across our nation.
13 So this mission that you’re looking at here, in
14 this emerging partnership with faith-based and government—
15 and I mentioned this the last time that I gave an update—
16 the mission is not to publicly fund proselytizing. That’s
17 not what it’s about. What it is about is to increase the
18 capacity of faith-based organizations and community-based
19 to more effectively provide clients with a higher quality
20 of treatment and recovery services.
21 So we’re seeing a leveling of the playing field
22 so that both faith-based and community-based groups can
23 compete on a level playing field for the funds and to
24 become that recommended service provider. But also we are
25 building their capacity. The net result is that the needy,
1 those who have needs in our country, are going to have
2 access to the best services. And that’s what all of us
4 SAMHSA and, more specifically, CSAT had been in
5 the vanguard of moving that forward. That has now
6 permeated into other agencies of Health and Human Services
7 and other agencies beyond that, like Education and Labor.
8 But a lot has been accomplished, and a lot of it started
9 right here. I think we need to give ourselves a hand
11 The five Rs that we have employed as a
12 strategy: first, building relationships, helping the faith
13 community find common ground with the government agencies
14 like CSAT. I’ve shared this before. I feel like ATR is
15 the greatest and most natural connection for the faith
16 community working with government.
17 But it’s not easy. We’ve had these workshops
18 around the nation, and for many people in the faith
19 community, working with government is like dancing with a
20 porcupine. They don’t know exactly where to grab on to.
21 So we’re helping them to understand how to do that.
22 Representation, building these coalitions.
23 Jocelyn’s going to share about that in a moment. It’s just
24 incredible what’s happening with these coalitions. I see
25 it as a Rubik’s cube of capacity, where we’re able to
1 galvanize these groups and then together they can apply for
2 these resources, where, in themselves, they probably
3 couldn’t compete.
4 Third is results, not just faith based, but
5 outcome based. This is hard for some groups who think that
6 the only qualification is to be moved by the spirit. We’re
7 helping them to not to eliminate that, but to build upon
8 that and become more sophisticated. It’s neat to see that
9 many of them are getting licensed, getting their
10 certification. It’s happening.
11 Resources. Showing them ways to leverage their
12 private resources with public funds. Part of that is
13 making sure that they’re writing the best possible
14 proposals. We’ve done a lot of training on how to write
15 grants, even showing them, walking them through the process
16 of writing a proposal.
17 Before that we would get a lot of handwritten
18 sermons. Now we’re getting some proposals. Just last year
19 we did a sampling of the organizations that were part of
20 these workshops. There was more than $18 million that they
21 had garnered for the first time. That’s just a small
22 sampling of those that attended these training.
23 Replication. We talked about this yesterday,
24 but multiplying these effective models. We’ve got to
25 document these models. But, as Dr. Clark mentioned
1 yesterday, we’ve got to show them how to adopt it.
2 Ken, Florida has incredible models as it
3 relates to the faith-based community working with
4 government. I’d just love to package those and see those
6 I know there’s a challenge with getting these
7 best practices adopted, but in the faith community, we’re
8 pretty good at pirating things. Like they say, first you
9 quote the person. Then you say, “I heard the other day.”
10 Then the third step is, “I’ve been thinking.”
12 MR. DONALDSON: So we’re pretty good at that.
13 The obstacles. I’ve already gone over some of
14 these. I’ll go through it fast. The skepticism of
15 government sources. Am I going to sell my soul? Am I going
16 to compromise my mission and values by partnering with
17 government? Understanding faith-based and government
18 language barriers.
19 I remember one of the trainings we did in
20 Atlanta. I asked, “How many here even know what an RFP
21 is?” And only half the group raised their hands. I
22 mentioned SSA, and one lady raised her hand. She says,
23 “What does this have to do with Social Security?”
25 MR. DONALDSON: So it’s just like taking a
1 machete to the jungle. This is carving new territory.
2 And it is important. And, Dr. Clark, you put
3 this in your presentation the last time we met, how
4 important it is to have these operational definitions.
5 Because otherwise it’ll exacerbate it even more.
6 Limited capacity. We had a good discussion
7 about that this morning, Anita, and Bettye, and I. I think
8 that’s one of the greatest challenges. And it’s a tug of
9 war, because on one hand we’ve got to be stewards of the
10 public’s trust and resources. But on the other hand, you
11 see these well-meaning organizations that have big visions,
12 but they have little provision. So we’ve had to drill
13 down, instead of doing the larger venues, even though we
14 are going to do some of those with Dr. Clark, more of a
15 vision casting with ATR educational forums, but we’ve gone
16 to these smaller mentoring groups to qualify which
17 organizations truly have the potential to garner these
18 resources, and then to mentor them to actually succeed.
19 With that, the strategy that we’ve employed,
20 addressing the trainees through organizational assessment
21 conducted for each of these organizations in the state.
22 Two, we’ve conducted the training, as I’ve mentioned, in
23 these small mentoring groups, as opposed to the larger
25 What we’re trying to convey is that we’re
1 building collaborations, where they’re not just coming to
2 hear us, but the days following, they’re now cultivating
3 relationships with others in their own city.
4 With that said, Jocelyn’s going to come and
5 share with us about what’s happening with these coalitions.
6 MS. WHITFIELD: Could you give us a minute? It
7 appears that our CD did not copy, so we’re going to insert.
8 There it is, right there.
9 I want to show you exactly what we’re doing. I
10 know that at the last committee meeting, what we did was
11 talk about the coalitions that we had developed in the
12 communities. We told you about the technical assistance
13 that we have provided to these coalitions.
14 As of today we have 15 coalitions that were
15 formed as a result of the TA that has been provided by
16 SAMHSA and CSAT. So what I want to do in a few minutes is
17 to showcase what we’ve been doing so that you’ll get a
18 little idea of exactly—
19 What we’re trying to do is bridge the gap to
20 those whom we serve. We’ve done that by forming coalitions
21 in about 15 states.
22 This is the Institute for Therapeutic Wellness.
23 As you can see, we have almost every type of community
24 service represented there, but mainly their treatment,
25 prevention, recovery, and mental health providers.
1 In each state that we have a coalition, Dr.
2 Clark will be visiting those states in order to educate
3 them about ATR. This is the one in Louisiana. We will be
4 going to Louisiana. I think that’s June 16th. And Dr.
5 Clark will be meeting with most of these providers that we
6 have been training over the past two years.
7 You need to know one thing about these
8 providers. Most of them have their 501(c)(3). They’re
9 nonprofit organizations. They’ve had three years of
10 operational experience. Many of them have been funded by
11 other entities. And they have the staff capacity to carry
12 out the services in their community. Some of them are
13 treatment providers, and they are certified and licensed by
14 the state, while we have others who are meeting the
15 recovery standards of the state. So that is Louisiana, one
16 of the states where we have a coalition.
17 We have the Nebraska Continuum of Services.
18 You can see all of the service providers we have that are
19 part of that coalition. You’ll see that most of them are
20 recovery and treatment providers. Some of them are
21 community and some of them are faith based.
22 North Carolina and South Carolina. We have a
23 network of providers there. Last year the Center for
24 Mental Health Services gave us $350,000.
25 What have I done? I must have done something.
1 Am I doing something wrong? Oh, sorry.
2 Thank you, Dr. Clark. What could we do without
3 Dr. Clark? He’s my favorite.
4 MR. DONALDSON: I thought I was.
6 MS. WHITFIELD: No, Dr. Clark is my favorite.
7 Okay. Thank you, Dr. Clark. You’re just so precious.
9 We have the Institute for Therapeutic Wellness.
10 That’s a network of providers I just showed you. You can
11 look at all the different providers that we’ve put together
12 in this network. This is over a two-year period, so if you
13 go to the state, don’t let the state tell you that there
14 aren’t providers who are certified, that are credentialed,
15 that are licensed, that have been delivering community
16 services for over ten years.
17 One of the criteria was that basically they
18 would have to have three years of operating experience,
19 that they would have had to have been funded by some
20 entity, that some of them would have to be licensed
21 providers. And you can see very well that we have a real
22 mix there.
23 This is Nebraska, Continuum of Services.
24 You’ll see that it will be community service providers as a
25 part of that group. Most of these are treatment and
1 recovery providers in Nebraska, and they are all faith-
2 based and community-based organizations.
3 What we’ve done over the last three years,
4 we’ve provided TA in certification, showing them how to
5 become licensed providers. We’ve provided TA in
6 infrastructure development, TA in fiscal management, TA in
7 grant writing and proposal writing, TA in project
8 management. So you see that everything that we’ve done in
9 the last three years, it has paid off.
10 This is North Carolina. We received $350,000
11 from the Center for Mental Health Services. We plugged in
12 the Mental Health Associations in North Carolina and in
13 South Carolina, as you will see. These are our providers
14 in South Carolina. You can see there are homeless
15 shelters, treatment programs, co-occurring disorder
16 providers, and a mix.
17 We contracted with the New Jersey Office of
18 Faith-Based. What they did was pull together a team, a
19 network of providers called ATLAS. You can have a good
20 look at what they’re bringing to the table.
21 I think that’s the last one.
22 The other coalitions and provider networks
23 formed are in Hartford, Connecticut. We will be in
24 Hartford, Connecticut, on May 25th, next week. Dr. Clark
25 will be hosting or one of our panel speakers, and he’ll be
1 talking about ATR and other opportunities for faith and
2 community groups to partner with SAMHSA.
3 Dr. Clark will be in Washington State, I think
4 it’s June 7th, and will be working with a community action
5 coalition there that we’ve helped support over the years.
6 Alabama; Pennsylvania; Brooklyn, New York;
7 Bronx, New York; Baltimore, Maryland. We’re working with
8 the Mayor’s Office of Faith-Based, and we have a coalition
9 out of the city of Baltimore, Maryland. Then we have
10 Arkansas and Pine Bluff, and you can see what we’re doing.
11 Coalition and provider networks that are in
12 process are in Virginia, Indiana, Ohio, and Wisconsin. So
13 that tells you a little bit about how much we’ve been doing
14 as a faith office—what we’ve been doing over the last year
15 and a half—to show you that, basically, your money’s at
16 work. We’re doing some responsible things with it.
17 People’s services are being improved as a result of it.
18 They’re building capacity as a result of it. And they will
19 be some of the ATR providers in the future.
20 I’m going to turn it back over to Dave. I hope
21 this has interested you.
22 MR. DONALDSON: Terrific. Let’s give her a
23 hand. That was tremendous.
25 MR. DONALDSON: Tremendous. Great pleasure to
1 work with Clif and Jocelyn.
2 Very quickly, the outcomes that we’re looking
3 for: helping to develop a strategic plan for each
4 participating organization.
5 It’s like that pilot. The watch tower says,
6 “Do you know where you’re going?
7 He said, “No, but I’m making record time.”
8 That’s many of the groups that we’re helping to
9 really develop a path of travel.
10 Equipping and mobilizing volunteers. There’s
11 gold in them there pews.
12 Identifying candidates with the highest
13 potential, as we share the 501(c)(3) preparation and board
15 Sustainable funding. One thing the President
16 has said, the last thing he wants to see is a new welfare
17 state called nonprofits. So we’re making sure that there
18 is a leveraging of the private with public resources.
19 Helping to identify specific grant
20 opportunities, even helping them write the proposals,
21 managing the grants. This is mentoring.
22 Documenting the models, as we’ve already
23 shared, and then evaluating these outcomes.
24 I just wanted to highlight another model, Full
25 Circle Health. I’ll be with them this weekend and on
1 Monday. This is one of these Wal-Marts that we were
2 referring to, but it’s now become our lead agency there in
3 the coalition in New York. They’re integrating faith and
4 science into practice. The provide now for 1,500 active
5 patients. You can see the staff, some of the different
6 fields there. We wrote a proposal for them through the Red
7 Cross and got $467,000, and now we’re writing some
8 proposals for here for CSAT.
9 Let me just conclude by saying this. This is a
10 tipping point. What has been ordinary has become
11 extraordinary. But if this is not adequately funded, it’s
12 going to become a teeter-totter. I would just appeal to
13 this group and to the leadership of CSAT to make sure that
14 we continue to move this ball down the field. There’s too
15 much at stake. There’s too much momentum, and there’s too
16 much promise to stop right now. The greatest days are
18 I’m happy to field any questions that you may
19 have, or comments.
20 MS. BERTRAND: Thank you both for your
21 presentation. I guess my comment is just for the
22 Administration and just something for us all to think about
23 as we move forward. I want to commend you on the work that
24 you’re doing in Florida with Access to Recovery and being a
25 pioneer for the rest of the world.
1 I’m thinking about the language in terms of
2 moving forward and making it really clear to individuals
3 that are applying for funds that we want to be inclusive of
4 faith-based organizations and community-based
5 organizations. I don’t know how to say it, so I’ll just
6 say it, but just to ensure in language, if we do have an
7 opportunity, or the states have an opportunity, to apply
8 for Access to Recovery or even grants with the recovery
9 community, that there is language that makes it really
10 clear that this is a priority and that the Administration
11 is willing to work with the grassroots organizations that
12 struggle with information technology and things that
13 underfunded organizations have that they struggle with.
14 I’m thinking that my charge on the committee
15 will be just to think of ways to ensure that those
16 organizations and their services, because they are so
17 valuable, are outlined very clearly. Another thing I’m
18 thinking of, in terms of when we as Council look at
19 applications, and I know that we just concur, and I don’t
20 think there’s anyone here who works in those departments,
21 but that perhaps earmarks for faith-based organizations. I
22 know we’re trying to level the playing field, and can’t say
23 we’re going to fund X number of faith-based projects out of
24 a group of applications, but those are the kinds of things
25 that may help, because being an administrator and working
1 with other administrators, I know that sometimes new things
2 aren’t necessarily welcomed because it’s different, and we
3 just don’t want to see a wonderful opportunity like this
4 for the grassroots organizations.
5 I know in Ohio, in the area where I’m at, I
6 have people who cannot wait for my recovery project to get
7 off the ground. I haven’t moved fast enough for some of
8 them. We have services going on every night, and we just
9 started in December.
10 I would want to urge the Council to think of
11 some ways to ensure the integrity of this program and work
12 with those that are underprivileged, who may not
13 necessarily have the opportunity and the means to be able
14 to write these grants. Just because you can nail the grant
15 to the table, it might not necessarily mean that you can
16 provide the services.
17 DR. CLARK: The beauty of ATR is that, one, the
18 President has made it clear and the Secretary has made it
19 clear that the principal objective is to expand the reach
20 into community-based and faith-based organizations. In
21 fact, under the new Secretary’s 500-day plan, one of the
22 items in that plan is expanding services to community-based
23 and faith-based organizations.
24 The beauty of ATR with regard to those
25 objectives is that you don’t have to be a grant writer.
1 You simply have to be able to provide competent services
2 and account for the money that you receive as a voucher
3 that you process. That’s the key issue here with ATR.
4 It’s not being a grant writer, but being able to
5 demonstrate that you didn’t take the money and run. I
6 think that then puts the organizations at a less
7 complicated level, in the sense that they’re not competing
8 for a grant.
9 I’m fond of saying, he who has the client has
10 the voucher, and he who has the voucher has the money. So
11 if the faith-based community has a relationship with those
12 individuals who are adversely affected by alcohol and
13 drugs, in essence they become key factors in the delivery
14 of services. If you just want the vouchers without having
15 a relationship with clients or the community of people have
16 clients, then, of course, you have to adhere to the
17 traditional standards, because you’re providing primary
18 treatment, as opposed to recovery-support treatment.
20 MS. JACKSON: Thank you very much.
21 I’m sorry, David, I missed part of your
22 presentation on an important issue.
23 MR. DONALDSON: I was counting on you to be
24 here to laugh at my jokes.
1 MS. JACKSON: Oh, you know what? I laughed
2 down the hall. Didn’t you hear me?
3 I think that it does need to be noted that ATR
4 is a very important movement. And I think that one of the
5 things, though, as we saw in the presentation yesterday,
6 it’s certainly limited. I’ll say it personally, because it
7 affects me, but it doesn’t only affect me, it affects
8 however many counties there are in California, except for
9 two, and numerous other places across the United States,
10 and that is that the Access to Recovery movement, just
11 because it’s said to be in California or Florida or some of
12 the other states, does not mean that it is covering those
13 states, nor is it providing services to all of those areas.
14 Whether it’s through discretionary grants—which I think
15 discretionary grants are still a lynchpin of being able to
16 look at new and different approaches to services—things
17 that maybe would never happen if we just gave all the money
18 to the states, it’s extremely important to do that. You
19 mentioned writing grants. If the states are the only ones
20 that can write grants, some of us are really, really left
22 So I hope that as we look at whether it’s ATR
23 or any of the initiatives that we’re looking at now, we
24 look at the ability to spread that across to those areas
25 that are severely in need but not being covered.
1 DR. CLARK: Again, one of the other beauties of
2 ATR is consumer choice. So, as I mentioned earlier, he who
3 has the client has the voucher. He who has the voucher has
4 the money.
5 You’re right in terms of jurisdictional
6 limitations at this juncture in time, but those programs
7 within the jurisdictional reach of ATR that are able to
8 demonstrate that they’re accountable, that clients do well,
9 that recovery is supported over time, will probably do
10 better than those programs that don’t.
11 Innovative programs should not suffer under
12 ATR. It offers them an opportunity to apply the models
13 that they use.
14 We talked about incentive therapy. Ostensibly
15 an ATR program that’s offered incentive therapy would do
16 better, at least according to the preliminary research,
17 than one that did not, and they would have the data to
18 support that.
20 DR. MADRID: I wanted to thank Mr. Donaldson
21 for representing this Council in excellent fashion and
22 certainly the faith community of this country. So thank
23 you very, very much. And certainly Jocelyn and Mr.
24 Mitchell. Mr. Mitchell’s not here, and the rest of the
25 staff has been doing an excellent job. And also take the
1 opportunity of inviting you all again to our international
2 conference, faith-based, partially funded by CSAT, where
3 we’re going to be addressing a lot of the ATR issues.
4 We’ve invited our ATR director from Texas. The governor of
5 Texas, as well as the governor of Chihuahua, will be there.
6 We’re expecting about 50 faith-based organizations that
7 are wanting to work with us as far as ATR, so all of you
8 all are invited. We’ll even put you up in my house, if you
9 go there.
11 DR. MADRID: It’s an open invitation.
12 MR. CLARK: Bettye?
13 DR. FLETCHER: I, too, would like to add my
14 thanks to Dave as well as to Clif and Jocelyn for the work
15 that you are doing in this area.
16 One of my observations is that I don’t know if
17 it was listed as an outcome, but one of the outcomes of
18 this whole area is building the indigenous capacity within
19 the community. I have created a term called “projectized,”
20 and some of our communities have been projectized to death,
21 to the extent that you come in with some dollars and you
22 have a project, and when the project is over, the
23 capability, the capacity, and the project are gone, and the
24 community is left with nothing.
25 In this instance, building this indigenous
1 capacity in the community is probably the penultimate of
2 sustainability, because you’re creating the capacity within
3 the community, and I see that as one of really the values
4 of this particular effort.
5 I also think that as we go down this road, it’s
6 important to recognize the reciprocal process, the
7 reciprocal learning that can take place. Because there’s a
8 tremendous amount of social ministry or social
9 entrepreneurship that is happening in these communities.
10 But what they need is the best practice to go along with
11 it. And they’ve been doing it for many, many, many years
12 in many of the communities that we are exposed to. But
13 here’s an opportunity to reinforce what they’re already
14 doing and provide them with the resources to really carry
15 out that work that is driven strictly by their passion in
16 many instances.
17 So I think we have an opportunity here that
18 really we can do more than maybe what appears on the
19 surface in terms of advancing the social entrepreneurship
20 that exists in our communities.
21 My last comment would be—and Jocelyn, I know
22 that you all have done some work with some of the
23 institutions of higher learning—but again the bridging with
24 institutions of higher learning and the communities’ faith
25 community represents again an opportunity that has not been
1 maximized at this point.
2 How do we get our institutions to leave the
3 ivory towers, where I spent 30 years, and come into the
4 communities and do some serious work with communities in
5 terms of building the capacity for them to sustain their
6 efforts in community building?
7 MS. WHITFIELD: Can I just say one thing? I
8 think what we’ve done over the last three or four years has
9 really been tremendous. And I know that we have a lot of
10 work to do in the future. But one of the things that Clif
11 and I have really focused on in the last couple of years is
12 building these communities and building the capacities in
13 these communities among the grassroots faith and community
15 We know that after our federal dollar leaves
16 that area that they need some capacity to sustain their
17 services over time. So that’s what we’re doing. And as
18 many states as we are allowed to do, we’re going into those
19 states and we’re trying really to build capacities in those
21 I can tell you one thing. We’re trying to do a
22 little in Mississippi. You know that we’ve been working in
23 Mississippi for the last two years, trying to establish a
24 place were people can come to the table and learn about
25 grantsmanship, learn how to build infrastructure. That’s
1 exactly what we’ve been doing the last three or four years.
2 MR. CLARK: Ken?
3 MR. DeCERCHIO: One of the other things we’ve
4 learned is that the connectivity of relationships between
5 the faith-based community and traditional delivery systems
6 and state agencies, the motivation for bringing that
7 together can’t be funding. We had the good fortune of
8 having two years of discussion about how our systems need
9 to connect for the purpose of enhancing folks’ access to
10 recovery services. It was never a conversation around
12 And Access to Recovery came on the table, and
13 by that time, the conversation was real easy. But if the
14 conversation starts out about dollars, it’s very easy to
15 get (inaudible). And the feedback with our faith partners
16 at the state level has been, “You know, it was a lot easier
17 because when we got together, no one was talking about
18 there’s money on the table. Now we have to figure this
20 It was, we’ve been out here for years providing
21 addiction services and support services. How can we
22 connect and benefit from clinical treatment, how can we
23 connect and how can you provide more access to training and
24 the kinds of support that the faith community needs?
25 We return people from treatment back into the
1 community without adequate support except for AA and NA,
2 how can we do that? Faith community, how can we support
3 ministers who have people with addiction, and what do they
4 do? How do we support that?
5 So it was those kinds of dialogues and
6 discussions that made it a lot easier. I lamented on an
7 ATR visit a couple of months ago that if ATR is the focus
8 for the initial discussions between the faith community and
9 our systems, that’s a tough discussion when you’re putting
10 money on the table, and then we’ve got to figure that out.
11 So the opportunities around the rest of the other 54
12 states and territories that aren’t getting ATR to have the
13 dialogues, to connect on some layer, that’s what needs to
14 be happening now, not waiting for the dollars. Because the
15 sustainability is going to be the partnerships. And I’m
16 convinced that it’s the partnerships and the commitments
17 and the soul of this that will continue long after our
18 little bit of seed money or your little bit of seed money
19 goes away, frankly.
20 DR. CLARK: Frank?
21 DR. McCORRY: Thanks, Westley.
22 Thank you, David and Jocelyn. I really enjoyed
23 your presentation, and I enjoyed hearing these updates on
24 the faith-based initiative. It really stimulates my
25 thinking on perhaps how to do more in my work back in New
2 I definitely want to get the names of the folks
3 from Full Circle and the coalition in the Bronx.
4 What struck me when I was thinking as you were
5 presenting was yesterday we heard about SBIRT. I had made
6 a comment about how primary care is this continuous health
7 relationship, and that treatment is like an episode within
8 the continuous health relationship. On the front end and
9 on the back end of that treatment experience, health care
10 fits. If you can empower the primary care physician to
11 have a place to both identify people in need as well as to
12 return people after their finished with our system.
13 Of course, what strikes me is how much the
14 faith-based initiative is exactly that, too, to identify
15 people in need, both the ability on the front end of
16 identifying people in need and this continuous relationship
17 that’s often not just individual but familial and community
18 based, so that the same paradigm that we talk about in
19 terms of health care really can fit in terms of faith-based
21 It struck me in your presentation how powerful
22 that could be. I enjoyed hearing about it. It helps me
23 think through some of those kinds of issues. So, thank
25 DR. CLARK: All right. Well, we appear to be
1 about to wrap things up.
2 We did promise you time for additional
3 roundtable discussion, so roundtable is open.
5 MS. JACKSON: Thank you very much. I really
6 enjoyed the presentations that we had in the last two days.
7 I think they were very relevant and also informative in
8 terms of my world.
9 There’s something that came up this morning in
10 a discussion that I had with Randy Muck, who runs your
11 adolescent services, I believe. We were talking about best
12 practices and evidence-based practices.
13 I am a tremendous fan of evidence-based
14 practice. No doubt about it. One of the issues that we
15 have run into as—first of all, we’re in the Clinical Trials
16 Network, and second of all, any grant almost or application
17 that we put in now is for evidence-based practices. One of
18 the things that we’re finding, and I won’t mention names,
19 some of them are my friends, but unfortunately the pricing
20 of the training and the requirements of the training for
21 evidence-based practices is extremely expensive.
22 DR. CLARK: Let me interrupt. You mean NREPP?
23 MS. JACKSON: Excuse me?
24 DR. CLARK: NREPP-driven evidence-based
1 MS. JACKSON: I can mention in-home, onsite–a
2 very wonderful in-home, onsite program that was all
3 developed by public funds, and I have no problem with
4 people needing to get funds to train those folks, but
5 somehow, if we’re ever going to get the evidence-based
6 practice to the streets, we have to make it affordable.
7 And $120,000 for most agencies isn’t affordable, or six
8 months of training to a therapist who probably then moves
9 on, because they’ve got more training. “I’m gone.”
10 I think it’s a very real problem that SAMSHA
11 faces, not so much NIDA, because they train evidence-based
12 practices, but SAMHSA has to carry those on and sustain
13 them. I wanted to bring that up as an issue. Perhaps we
14 need to hear more on it later. But it’s certainly a
15 problem for us, and we know that two of three studies that
16 we’re doing now will not be sustained in our agency—are
17 highly likely not to be sustained in our agency—simply
18 because of the cost.
19 DR. CLARK: I’d like to echo that we do have
20 some concerns about the issue of the privatizing of public
21 sector-driven knowledge, because what happens is that the
22 cost becomes prohibitive, and therefore the knowledge is
23 not transferred, which means, basically, the cost functions
24 as a barrier.
25 We don’t have any answers for that, but it is a
1 concern, because others have raised it.
2 NREPP-validated strategies have often become
3 associated with high price tags, and that, of course, means
4 it is not available. What we need to do is to keep
5 monitoring these things as we push for evidence-based
6 practices, so that we can address the downside of that
8 We believe that since we don’t do research,
9 some of our best practices have been understood as research
10 driven, and in fact they’re not. As you’ve noticed, our
11 best practices budget has declined. What we’ve used the
12 best practices budget for is to in fact translate the
13 research developed by the research enterprises into
14 digestible components so that the delivery system can
15 afford to acquire the new knowledge. If it sits in books
16 and sits on the desk, it doesn’t help, no matter what we
18 I’m fond of citing the laser eye surgery
19 community. The manufacturers of the devices and the trade
20 organizations got together and they’ve essentially
21 revitalized ophthalmology over a ten-year period.
22 The actual price of the laser eye surgery has
23 plummeted because of increased efficiency and greater
24 availability of services. It didn’t go up; it went down
1 I cite that as an example of how, in fact, you
2 can privatize without creating fiscal barriers. If you
3 create fiscal barriers, you’re right back where you started
4 from. So we just need to keep monitoring this.
6 DR. McCORRY: I’d just like to echo Val’s
7 comments. I think there are some issues around copyright
8 here as well. The whole research endeavor might be with
9 the public dollar, and somehow the training is taken
10 offline and is copyrighted as a private enterprise, and I’m
11 not sure, they might still be on the public dollar of some
12 sort, but there’s an assertion of a right to ownership that
13 I don’t know whether it exists. But I wonder about it.
14 As you said, Westley, the monitoring of it is
15 something we should continue to explore, like how these
16 things get so darn expensive, when it seems all along they
17 were being paid for by the taxpayers.
18 DR. CLARK: Well, we cannot bring in the
19 community-based and faith-based activities. In fact when
20 we do that, we’re erecting all these barriers and then
21 expect the community-based and faith-based organizations to
22 use “evidence-based practices”—but, oh, by the way, we’re
23 going to make sure you can’t afford them. We cannot create
24 that paradox. We’ll just have to keep monitoring and see
25 how we proceed with that.
1 All right, anybody else with any other topic
2 for the Council discussion?
3 MR. DeCERCHIO: I just want to thank you and
4 thank the staff for making this a productive day and a
5 half. We take a lot back with us. We learn a lot and it’s
6 very helpful. It’s value added, and we appreciate that.
7 And thank colleagues on the Council who took the time to
8 present. I know how busy all of you are and how much time
9 and extra work that requires to come before and present. I
10 want to tell you how much I appreciate that.
11 DR. CLARK. Very good. Thank you very much for
12 your comments.
13 I want to remind you that we have a September
14 14 and 15 meeting of Council, remind you that we also hope
15 to convene a teleconference on September 7 to review any
16 grants that are remaining. The September 14 and 15 meeting
17 will not be a grant review meeting. Nevertheless, if you
18 have agenda topics that you’d like to present, would you
19 please bring that to Cynthia’s notice so that what we’ll be
20 doing then is discussing topics of your interest and topics
21 that we believe that you might find interesting.
22 Any further discussion?
23 (No response.)
24 DR. CLARK: I will entertain a motion to
1 PARTICIPANT: So moved.
2 PARTICIPANT: Second.
3 DR. CLARK: All those in favor?
4 (Chorus of ayes.)
5 DR. CLARK: This meeting is adjourned. Thank
6 you. There is no further business, and moving on.
7 (Whereupon, at 12: 34 p.m., the meeting was