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                      May 20, 2005

          Sugarloaf Mountain and Seneca Rooms
Substance Abuse and Mental Health Services Administration
                  1 Choke Cherry Road
                   Rockville, Maryland



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

Executive Secretary

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.
Executive Director
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
Stormont-Vail HealthCare
901 Garfield
Topeka, Kansas 66606

Eugene White-Fish
Tribal Judge
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
      Director                                              5

      Discussion                                           15

International Perspective on the Harm Reduction Movement

      Eric Voth, M.D.
      NAC Member                                           18

      Discussion                                           38

E-Therapy Update

      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

      Discussion                                           65

Community and Faith-Based Update

      David Donaldson
      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
      Discussion                                           85

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

8    critical.

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.

12                 (Laughter.)

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

15   webcast.

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

12   year.

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

2    events.

3                   MR. DeCERCHIO:    (Inaudible.)

4                   MS. TORRES:    The Yankees weren’t up there?

5                   MR. DeCERCHIO:    We’re going to have to work on

6    them.

7                   MS. TORRES:    Oh, yes.     If you can help us,

8    indeed.

9                   (Inaudible.)

10                  MS. TORRES:    They need all the recovery they

11   can get?

12                  (Laughter.)

13                  (Inaudible.)

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

2    nationwide.

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

20   announcements.

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.

16                (Laughter.)

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

24   deserved.
25                  MS. TORRES:   Thank you, Chilo.

1                DR. CLARK:    Any other comments?

2                (No response.)

3                DR. CLARK:    Thank you, Ivette.

4                (Applause.)

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

9    Arrest”:

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 .       .   .

10                (Laughter.)

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

4    place.

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

21   they?”

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

1    them.”

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

8    shows.

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

16   exchange.

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

11   it.

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

6    there.

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
18   discussion?

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

22   meeting.

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

19   use.

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

2    treatment.”

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

24   use.
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

12   matter?

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

24   you.
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

12   recovery.

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

11   room.”

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
18   point.

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
25   me.”

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

22   Baltimore.

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

21   Texas.

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
18   NASA.

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

2    suggestions.

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

17   wrong.
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.

22                  Chilo?

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

1    have.

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

5    there.

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

11   theme.

12                Judge?

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

16   committee.

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

11   flexibility.

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

11   meet.

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.


24                Dave?
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

12   government.

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.

22                 (Laughter.)

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!”

1                  (Laughter.)

2                  MR. DONALDSON:   And afterwards we had lunch,

3    and I asked him, “Why are you leaving this church and this

4    community?”

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

13   occurring.

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

6    fellowships.

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

3    want.

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

10   there.

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

5    replicated.

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.”

11                 (Laughter.)

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?”

24                 (Laughter.)
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

24   audiences.
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.

5                 (Laughter.)

6                 MS. WHITFIELD:    No, Dr. Clark is my favorite.

7    Okay.   Thank you, Dr. Clark.    You’re just so precious.

8    Okay.

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.

24                (Applause.)
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

14   development.

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

17   ahead.
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.

19               Val?

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.
25               (Laughter.)

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

21   out.

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.

19                Chilo?

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.

10               (Laughter.)

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

14   organizations.

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

20   communities.

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

11   dollars.

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

19   out.”

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

1    York.

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

20   organizations.

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

24   you.
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.

4                 Val?

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
25   practices?

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

7    effort.

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

17   do.
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
25   dramatically.

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.

5                 Frank?

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
25   adjourn.

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

8   adjourned.)

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