H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental H

1. Aligning Concepts, Practice and Contexts to Promote Long-term Recovery: An Action Plan “Recovery Oriented Systems of Care: SAMHSA/CSAT’s Public Health Approach to Substance Use Problems & Disorders” May 2, 2008 Philadelphia, PA H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services

2. President George W. Bush “…To build a future of quality health care, we must trust patients and doctors to make medical decisions and empower them with better information and better options.” 2008 State of the Union

3. Terry L. Cline, PhDAdministratorSubstance Abuse and Mental Health Services Administration “At SAMHSA, our mission includes helping prevention and treatment counselors, clinics, and health care providers develop ways to change their service systems to increase positive outcomes for their clients.” September 2007

4. An Introduction to the Substance Abuse and Mental Health Services Administration (SAMHSA) One of the eleven grant making agencies of the U.S. Department of Health and Human Services, with a budget of approximately 3 billion dollars. SAMHSA’s Mission: To build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness. Website: http://www.SAMHSA.gov

5. SAMHSA’s Role in Fighting Substance Misuse and Abuse • SAMHSA works to ensure that science, rather than ideology or anecdote, forms the foundation for the Nation’s addiction treatment system. • SAMHSA serves health professionals and the public by disseminating scientifically sound, clinically relevant information on best practices in the treatment of addictive disorders and by working to enhance public acceptance of that treatment.

6. The SAMHSA Matrix SAMHSA’s Matrix provides a graphic representation of the collaboration needed to promote holistic, integrated approaches that advance the health and well-being of individuals, families, and communities.

7. SAMHSA Centers Center for Mental Health Services Mission: To ensure access and availability of quality mental health services to improve the lives of all adults and children in this Nation. Center for Substance Abuse Prevention Mission: To decrease substance use and abuse by bringing effective substance abuse prevention to every community. Center for Substance Abuse Treatment Mission: To improve the health of the nation by bringing effective alcohol and drug treatment to every community.

8. Law Enforcement Public Health Substance Abuse Prevention Substance Abuse Treatment Mental Health SAMHSA Programs Support a Comprehensive Approach to Public Health

9. We Face Multiple Challenges • Reaching those in need of services • Providing adequate resources • Developing culturally-appropriate, evidence-based interventions • Building and sustaining a qualified workforce • Integrating substance use disorder services into the public health paradigm

10. Greater Burden on Public Sector Private Private Public Public 1986 All SA = $9.3B Public = $4.6 B Private = $4.6 B 2003 All SA = $20.7 B Public = $16.0 B Private = $4.7 B Source: Health Affairs, July-August 2007

11. A Public Health ImperativeSubstance Misuse can: • Lead to: • Worsened medical conditions (e.g. diabetes, hypertension) and • Worsened brain disorders (e.g. depression, psychosis, anxiety & sleep disorders) • Unintentional injuries & violence • Result in: • Dependence, which may require multiple treatment services • Low birth weight, premature deliveries, and developmental disorders, child abuse & neglect

12. A Public Health ImperativeSubstance Misuse can: • Contribute to or be associated with : • Homelessness • Criminal justice involvement • The effect and abuse of prescribed medications • Unemployment • Gambling • Bankruptcy • Legal Issues (e.g. DUI, DWI, domestic violence) • Dropping out of school

13. A Public Health ImperativeSubstance Misuse can: • Induce or facilitate: • Medical diseases (e.g. Stroke, dementia, hypertension, cancers) • Acquiring Infectious diseases & infections (e.g. HIV, Hepatitis C) • Suicide attempts or tendencies

14. Past Month Alcohol Use - 2006 Any Use: 51% (125 million) Binge Use: 23% (57 million) Heavy Use: 7% (17 million) (Current, Binge, and Heavy Use estimates are similar to those in 2002, 2003, 2004, and 2005) Source: NSDUH 2006

15. Drug Use Among the General Population – 2006 Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use & Health, 2005 & 2006

16. Illicit Drug Dependence or Abuse in Past Year among Persons Aged 12 or Older: Percentages, Source: Annual Averages Based on 2005-2006 NSDUHs

17. Non-Medical use of Pain Relievers in Past Year among Persons aged 12 or Older: Percentages Source: Annual Averages Based on 2005-2006 NSDUHs

18. Alcohol Dependence or Abuse in Past Year among Persons Aged 12 or Older: Percentages Source: Annual Averages Based on 2005-2006 NSDUHs

19. Past Year Perceived Need for and Effort Made to Receive Treatment among Persons Aged 12+ Needing But Not Receiving Specialty Treatment for Illicit Drug or Alcohol Use: 2006 Felt They Needed Treatment and Did Not Make an Effort (625,000) Did Not Feel They Needed Treatment(20,114,000) 95.5% 1.5% Felt They Needed Treatment and Did Make an Effort (314,000) The Challenge 21.1 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use

20. Identifying & Treating Substance Abuse Substance abuse is often observed, but ignored or excused, before the client is identified as needing treatment. Drug Courts Alcohol Treatment Public Health Treatment Strategies SBIRT HIV/AIDS Employer/ Co-Workers Family Friends Adolescent Treatment Women & Children Services SAPT Block Grant

21. Shifting our Paradigm to Recovery-Oriented Systems of Care 21

22. The Recovery Process Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Source: CSAT National Summit on Recovery, 2005

23. Recovery-Oriented Systems of Care: A Paradigm Shift Recovery-Oriented Systems of Care shift the question from “How do we get the client into treatment?” to “How do we support the process of recovery within the person’s environment?”

24. Person’s Entry into treatment Discharge A Traditional Course of Treatment for a Substance Use Disorder Severe Symptoms Remission Resource: Tom Kirk, Ph.D

25. A Traditional Service Response Severe Remission Acute symptoms Discontinuous treatment Crisis management Resource: Tom Kirk, Ph.D

26. Continuous treatment response A Recovery-Oriented Response Severe Remission Promote Self Care, Rehabilitation Resource: Tom Kirk, Ph.D

27. Recovery Zone Helping People Move Into A Recovery Zone Severe Symptoms Improved client outcomes Remission Time Resource: Tom Kirk, Ph.D

28. Benefits of Moving into a Recovery Zone • Most clients undergo 3 to 4 episodes of care before reaching a stable state of abstinence ¹ • Chronic care approaches, including self-management, family supports, and integrated services, improve recovery outcomes 2 • Integrated and collaborative care has been shown to optimize recovery outcomes and improve cost-effectiveness 3 ¹Dennis, Scott & Funk, 2003 2 Lorig et al, 2001; Jason, Davis, Ferrari, & Bishop; 2001; Weisner et al, 2001; Friedmann et al, 2001 3Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

29. Defining Recovery-Oriented Systems of Care 29

30. Recovery-Oriented Systems of Care Approach • In the recovery-oriented systems of care approach, the treatment agency is viewed as one of many resources needed for a client’s successful integration into the community. • No one source of support is more dominant than another. • Various supports need to work in harmony with the client’s direction, so that all possible supports are working for and with the person in recovery. Source: Addiction Messenger, November 2007, Vol. 10 Issue 11, published by the Northwest Frontier ATTC.

31. ROSC support person-centered and self-directed approaches to care that build on the personal responsibility, strengths, and resilience of individuals, families and communities to achieve health, wellness, and recovery from alcohol and drug problems. Recovery V Individual Family Community Wellness Health

32. ROSC offer a comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathways to recovery. Recovery Services & Supports Family/Child Care Alcohol/Drug Services Vocational Education Housing/ Transportation Individual Family Community PTSD &Mental Health Physical Health Care Spiritual HIV Services Financial VSO & Peer Support Health Wellness Legal Case Mgt

33. ROSC encompass and coordinates the operations of multiple systems… Recovery Systems of Care Addiction Services System Child Welfare and Family Services Social Services Services & Supports Mental Health System Family/Child Care Alcohol/Drug Treatment Housing System Vocational Individual Family Community Primary Care System Educational PTSD & Mental Health Housing/ Transportation Health Care Faith Community HIV Services Vocational Services Spiritual Indian Health Services Financial VSO & Peer Support Legal Case Mgt Health Insurance Criminal Justice System Wellness Health DoD & Veterans Affairs

34. …providing responsive, outcomes-driven approaches to care. Recovery Abstinence Evidence-Based Practice Systems of Care Addiction Services System Child Welfare and Family Services Employment Menu of Services Cost Effectiveness Social Services Family/Child Care Alcohol/Drug Treatment Mental Health System Vocational Individual Family Community Housing Authority Educational PTSD &Mental Health Reduced Crime Housing/ Transportation Health Care Primary Care System Perception Of Care HIV Services Faith Community Spiritual Vocational Services Indian Health Services Financial VSO & Peer Support Safe & Drug-free Housing Legal Case Mgt Retention Health Insurance Criminal Justice System Health Wellness DoD & Veterans Affairs Access/Capacity Social Connectedness

35. ROSC require an ongoing process of systems improvement that incorporates the experiences of those in recovery and their family members. Recovery Abstinence Evidence-Based Practice Systems of Care Addiction Services System Child Welfare and Family Services Employment Services & Supports Family/Child Care Alcohol/Drug Treatment Mental Health System Social Services Vocational Cost Effectiveness Individual Family Community Educational PTSD & Mental Health Reduced Crime Housing/ Transportation Primary Care System Housing Authority Health Care Perception Of Care Spiritual HIV Services Vocational Services Indian Health Services Financial VSO & Peer Support Legal Case Mgt Safe & Drug-free Housing Retention Health Insurance Criminal Justice System Health Wellness DoD & Veterans Affairs Access/Capacity Social Connectedness Ongoing Systems Improvement

36. Recovery-Oriented Systems of Care • Support person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families and communities to take responsibility for their sustained health, wellness, and recovery from alcohol and drug problems. • Offer a comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathway to recovery.

37. Recovery-Oriented Systems of Care • Encompass and coordinate the operations of multiple systems, providing responsive, outcomes-driven approaches to care • Require an ongoing process of systems improvement that incorporates the experiences of those in recovery and their family members

38. Elements of Recovery-Oriented Systems of Care • Person-Centered: • Individualized & Comprehensive Services • Responsive to Culture & Personal Belief Systems • Community-based • Commitment to Peer Services • Involvement of Family and other Allies • Ongoing Monitoring & Outreach

39. Elements of Recovery-Oriented Systems of Care • Cost Effective: • Outcomes Oriented • Integrated Services, resulting in Non-Duplication of Services • Competency-based • Effective use of Collaboration & Partnerships • Systems-wide Education and Training • Continuity of Care • Research-based • Flexible Funding

40. How do we “sell” treatment to those who need it? 40

41. Alcohol & Drug Related Emergency Department (ED) Visits • In 2005 there were an estimated 394,224 ED visits that involved alcohol in combination with another drug. • Alcohol was most frequently combined with one or more of the following: cocaine, marijuana, and heroin SOURCE: Office of Applied Studies, SAMHSA, Drug Abuse Warning Network, 2005 (04/2006 update).

42. 36,007 Heroin 5,694 Methadone 5,085 Hydrocodone* 5,066 Oxycodone* 225 Opiate Reports in Emergency Department Visits Related to Drug Misuse/Abuse Buprenorphine* * Includes single- and multi-ingredient products Unweighted reports from 243-445 U.S. hospitals Source: U.S. SAMHSA; DAWN Live! Oct 2, 2007

43. Traditional Substance Abuse Intervention 5% Alcoholics 20% At-Risk Drinkers 35% Low Risk Drinkers 40% Abstainers • Little attention has been given to the large group of individuals who use alcohol and other drugs but are not, or not yet, dependent . Adapted from Babor,T,F., Higgins-Biddle,J.C., (2001), Brief Intervention for Hazardous and Harmful Drinking: A manual for use in primary care . p 33. WHO/MSD/MSB/01.6b World Health

44. Screening, Brief Intervention & Referral to Treatment (SBIRT) • Embeds screening, brief intervention & treatment of substance abuse problems within primary care settings such as emergency centers, community health care clinics, and trauma centers. • Identifies patients who don’t perceive a need for treatment, • Provides them with a solid strategy to reduce or eliminate substance abuse, and • Moves them into appropriate services.

45. SBIRT Takes Advantage of the “Teachable Moment” “Teachable Moment” is the moment of educational opportunity – a time at which a person is likely to be particularly disposed to learn something or particularly responsive to being taught or made aware of something. Source: MSN Encarta Online Dictionary, Retrieved 3/25/08 from http://encarta.msn.com

46. Top Five Substances Reported by SBIRT Clients Source: Services Accountability Improvement System (SAIS)

47. CSAT SBIRT Initiative • Increases access to clinically appropriate care for nondependent as well as dependent persons. • Links generalist and specialist treatment systems. • Combines intervention and treatment toward a consistent continuum of care. 4. Builds a coalition between health care services and alcohol and drug treatment services.

48. SBIRT enhances State substance abuse treatment service systems by: Expanding the State’s continuum of care to include SBIRT in general medical and other community settings • community health centers • nursing homes • schools and student assistance programs • occupational health clinics • hospitals, emergency departments.

49. SBIRT enhances State substance abuse treatment service systems by: • Changing how substance abuse is managed in primary care settings • Treating substance abuse issues at the lowest level of acuity, before clients are diagnosed with substance use disorders

50. SBIRT: Core Clinical Components • Screening: Very brief screening that identifies substance related problems • Brief Intervention: Raises awareness of risks and motivation of client toward acknowledgement of problem • Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help • Referral: Referral of those with more serious addictions