"SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES"
1 SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION CENTER FOR SUBSTANCE ABUSE TREATMENT NATIONAL ADVISORY COUNCIL Friday, May 20, 2005 Sugarloaf Mountain and Seneca Rooms Substance Abuse and Mental Health Services Administration 1 Choke Cherry Road Rockville, Maryland 2 IN ATTENDANCE: Chair H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment 1 Choke Cherry Road, Room 5-1015 Rockville, Maryland 20857 Executive Secretary Cynthia A. Graham, M.S. Public Health Analyst Center for Substance Abuse Treatment 1 Choke Cherry Road, Room 5-1036 Rockville, Maryland 20857 Members 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. Director Florida Department of Children and Families Substance Abuse Program 1317 Winewood Boulevard Tallahassee, Florida 32311 David P. Donaldson, M.A. CEO We Care America 44180 Riverside Parkway, Suite 201 Lansdowne, Virginia 20176 Bettye Ward Fletcher, Ph.D. Professor Jackson State University 1120 Andrew Chapel Road Brandon, Mississippi 39047 3 IN ATTENDANCE: Valera Jackson, M.S. CEO Village South/West Care Foundation, Inc. 3180 Biscayne Boulevard Miami, Florida 33137 Chilo L. Madrid, Ph.D. CEO Aliviane NO-AD, Inc. 7722 North Loop Road El Paso, Texas 79915 Francis A. McCorry, Ph.D. Director Clinical Services Unit Division of Health and Planning Services New York State Office of Alcoholism and Substance Abuse Services 501 7th Street New York, New York 10018 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 4 C O N T E N T S PAGE Welcome 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 5 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. 6 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. 7 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 8 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.) 9 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 10 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 11 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 12 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 13 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 14 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. 15 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. 16 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. 17 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 18 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? 19 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 20 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 21 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. 22 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 23 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 24 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 25 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 26 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 27 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 28 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 29 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. 30 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. 31 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 32 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 33 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?” 34 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 35 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 36 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 37 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, 38 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 39 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? 40 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 41 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 42 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, 43 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 44 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 45 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. 46 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 47 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 48 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 49 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. 50 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 51 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 52 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. 53 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 54 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.” 55 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 56 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 57 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, 58 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 59 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 60 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 61 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 62 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 63 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 64 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 65 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 66 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 67 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.) 68 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 69 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 70 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. 71 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. 23 24 Dave? 25 MR. DONALDSON: Thank you, Dr. Clark. 72 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!” 73 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 74 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, 75 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 76 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 77 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 78 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 79 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. 80 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. 81 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 82 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 83 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 84 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 85 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. 86 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 87 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. 88 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.) 89 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. 90 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 91 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 92 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 93 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 94 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 95 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 96 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 97 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? 98 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 99 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. 100 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. 101 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. 102 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.)