Treatment of Alcohol and Other Substance Use Disorders What Legislators Need to Know

By Allison C. Colker

Contributing Authors Sheri Steisel Tim Whitney

William T. Pound, Executive Director

7700 East First Place Denver, Colorado 80230 (303) 364-7700

444 North Capitol Street, N.W., Suite 515 Washington, D.C. 20001 (202) 624-5400

January 2004

National Conference of State Legislatures 73 ii Treatment of Alcohol and Other Substance Use Disorders

The National Conference of State Legislatures is the bipartisan organization that serves the legislators and staffs of the states, commonwealths and territories.

NCSL provides research, technical assistance and opportunities for policymakers to exchange ideas on the most pressing state issues and is an effective and respected advocate for the interests of the states in the American federal system.

NCSL has three objectives:

• To improve the quality and effectiveness of state legislatures. • To promote policy innovation and communication among state legislatures. • To ensure state legislatures a strong, cohesive voice in the federal system.

The Conference operates from offices in Denver, Colorado, and Washington, D.C.

Printed on recycled paper

National Conference of State Legislatures iii

CONTENTS

List of Figures and Tables ...... iv

Acknowledgments ...... v

About the Authors...... vi

NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and Other Substance Use Disorders ...... viii

Executive Summary ...... ix

Users’ Guide ...... xii

1. What Are Alcohol and Other Substance Use Disorders? ...... 1 Defining Alcohol and Other Substance Use Disorders ...... 1 Chronic, Relapsing Disease ...... 3

2. What Are the Effects of Alcohol and Other Substance Use Disorders? ...... 9 National Survey on Drug Use and Health ...... 9 Standard Methodology for Rate of Alcohol and Other Substance Use Disorders by Substance, by State ...... 10 Healthy People 2010...... 13 State-by-State Treatment Gap Table ...... 16 Profile of a Typical Person with Alcohol and Other Substance Use Disorders ...... 18 Profiles of People with Alcohol and Other Substance Use Disorders Demonstrate that all Populations are Addicts ...... 18 Use-by-age Charts ...... 20 Adolescents ...... 21

3. Why Should State Legislators be Concerned about Alcohol and Other Substance Use Disorders? ...... 23 Economic Costs ...... 23 Health Consequences ...... 27 Social Consequences ...... 32 Solutions ...... 36

4. What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? ...... 37 The Science Behind the Treatment ...... 37 Continuum of Treatment ...... 40 Treatment for Specific Populations ...... 49 Culturally Competent Treatment ...... 53

National Conference of State Legislatures iii iv Treatment of Alcohol and Other Substance Use Disorders

Treatment in the Criminal Justice System ...... 56 Treatment of Co-occurring Mental Illness and Alcohol and Other Substance Use Disorders ...... 61 Barriers to Recovery ...... 62 Licensing of Providers ...... 62 Regulating Treatment ...... 62 Confidentiality ...... 62

5. What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? ...... 65 Overview of State and Federal Funding ...... 65 The State Role in Financing ...... 66 Federal Role in Funding Treatment ...... 68

Appendices A. Legislators’ Checklist ...... 81 B. National Resources ...... 83 C. “Hot Topic” Drugs ...... 87 D. PET Scans of Long-term Brain Changes in Abstinence and Brains on Drugs ...... 89 E. State and Jurisdictional Resources...... 91 F. Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols ...... 99 G. Quadrant System ...... 101 H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Treatment ...... 105 I. Alcohol Tax, by State ...... 117

Notes ...... 123

List of Figures and Tables

Figure 1. Activation Patterns to Spatial Working Memory Task for Adolescents ...... 7 2. Brain Activation in Young Women ...... 7 3. Use of Alcohol and/or Illicit Drugs, United States, 1994–98 ...... 14 4. Data Measures ...... 14 5. Co-occurring Disorders by Severity ...... 101 6. Service Coordination by Severity ...... 102 7. Primary Locus of Care by Severity ...... 103

Table 1. Rate of Alcohol and Other Substance Use by Substance, by State ...... 11 2. Rate of Substance Abuse and Dependence by Substance, by State ...... 12 3. Estimated Numbers and Percentages of Persons Aged 12 or Older Needing But Not Receiving Treatment for an Illicit Drug Problem in the Past Year, by State: 2000 ...... 17 4. Rate of Alcohol and Other Substance Use by Substance, by Age ...... 20 5. Rate of Substance Abuse and Dependence by Substance, by Age ...... 21 6. National Averages of Federal Block Grant Allocations and State Appropriations for Mental Health and Substance Abuse ...... 66 7. Per Capita State Spending on Alcohol and Other Substance Use Prevention, Treatment and Research ...... 66

iv National Conference of State Legislatures v

ACKNOWLEDGMENTS

The following National Conference of State Legislatures (NCSL) staff dedicated many hours to make this publication possible: Lee Dixon reviewed the summary; Helen Narvasa for- matted the tables; Laura Miller planned the marketing, publishing and distribution; and Leann Stelzer edited the summary.

This publication is made possible through a contract with the Center for Substance Abuse Treatment, SAMHSA, and a grant from the Robert Wood Johnson Foundation. Special thanks to Dr. Herman Diesenhaus, Dr. Al Getz, Dr. Rita Vandivort and Dr. Constance Pechura for reviewing the summary and providing guidance.

NCSL’s Advisory Committee on the Treatment and Prevention of Alcohol and Other Sub- stance Use Disorders oversaw the development of this guidebook from start to finish. Heart- felt thanks go to Rep. Martha Alexander (N.C.), John Coppola, Janice Ford Griffin, Melody Heaps, Sen. Jim Jensen (Neb.), Kenneth Stark, and First Lady Hope Taft (Ohio).

Every effort was made to ensure the accuracy of this report. Please notify Allison Colker at NCSL about mistakes or missing information. If you have any questions or requests for further information, call her at (202) 624-5400.

National Conference of State Legislatures v vi Treatment of Alcohol and Other Substance Use Disorders

ABOUT THE AUTHORS

Allison C. Colker, J.D., Esq. is a policy specialist for the National Conference of State Legislatures (NCSL). Mrs. Colker monitors, tracks and reports on behavioral health legislation and associated issues in the 50 states. Her topic areas include substance abuse treatment and prevention, parity and insurance benefits for substance abuse, and treatment in lieu of incarceration. This information is published for members—state legislators and their staff and major national substance abuse associations—in the form of articles, issue briefs and biweekly Snapshots. In addition, Mrs. Colker frequently provides technical assistance to state legislators and their staff, including state legislative committees that are directed to assess substance abuse policy issues. She also staffs NCSL’s Advisory Com- mittee on the Treatment and Prevention of Alcohol and Other Substance Use Disorders; members include two state legislators, a state substance abuse agency director, a state first lady, an advocate, a lobbyist, a provider association director, and a treatment provider. Prior to joining NCSL in July 2001, Mrs. Colker worked at the Center for Health Services Research and Policy of the George Washington University School of Public Health. While there, she worked on a research project funded by the Substance Abuse and Mental Health Services Administration (SAMHSA) that was a contract review of child welfare and Medic- aid managed care contracts from the 50 states. Mrs. Colker is a member of the Bar of the State of Maryland. She earned her Juris Doctorate at the George Washington University Law School, where she focused her course of study on health law and policy. She also holds a bachelor’s degree in biology from McDaniel College (formerly Western Maryland Col- lege).

Sheri Steisel is the senior director of the Human Services Committee of NCSL and has been on the NCSL staff since 1988. Ms. Steisel plays a key role in the development of policy and lobbying strategy on state-federal human services issues. Her work with the Human Services Committee concentrates on four major categories: income security and social services, food and nutrition, welfare reform and immigration. Currently, Ms. Steisel serves on the National Public Policy Committee for United Way of America. She received her master’s of public policy with concentrations in human services policy and press, poli- tics and public opinion from the John F. Kennedy School of Government at Harvard Uni- versity; her undergraduate degree is from Wellesley College.

Tim Whitney, J.D., is special counsel for policy for Illinois TASC (Treatment Alternatives for Safe Communities), a statewide social service agency specializing in linking criminal justice and other public systems with community-based clinical and other resources needed to support consumers of those systems. Mr. Whitney specializes in the development of policies and initiatives related to substance abuse, crime and related issues. He also serves as

vi National Conference of State Legislatures About the Authors vii

legislative liaison, preparing, analyzing and making recommendations on pending legislation, while participating in local, state and federal advocacy in the areas of crime and substance abuse. In addition to these activities, Mr. Whitney has served as a consultant for a number of state and federal policy matters. These include participation in the criminal justice component of the Center for Substance Abuse Treatment’s National Treatment Plan, the health and public safety transition committee for Illinois governor-elect Rod Blagojevich; and the advisory committee organized to develop a dedicated, evidence-based treatment and reentry prison in Illinois. Mr. Whitney earned his Juris Doctor from DePaul University and his bachelor of science in communication and public relations from Cornell University.

National Conference of State Legislatures viii Treatment of Alcohol and Other Substance Use Disorders

NCSL’S ADVISORY COMMITTEE ON THE TREATMENT AND PREVENTION OF ALCOHOL AND OTHER SUBSTANCE USE DISORDERS

Representative Martha Alexander Senator Jim Jensen North Carolina Nebraska

John Coppola, Executive Director Kenneth Stark, Director Alcoholism and Substance Abuse Providers Division of Alcohol and Substance Abuse of New York State Washington State Department of Social Albany, New York and Health Services Olympia, Washington Janice Ford Griffin, Deputy Executive Director First Lady Hope Taft Join Together Ohio Boston, Massachusetts Sue Thau, Public Policy Consultant Melody Heaps, President Community Anti-Drug Coalitions Treatment Alternatives for Safe of America Communities-Illinois Alexandria, Virginia Chicago, Illinois

viii National Conference of State Legislatures ix

EXECUTIVE SUMMARY

The term alcohol and other substance use disorders encompasses many disorders, including alcohol abuse, alcoholism, drug abuse and drug addiction. Although key differences exist between abuse and addiction, the effect on the states, the nature of treatment, and funding streams are collective; therefore, they are discussed collectively in this book. Ad- diction is a chronic relapsing disease that causes brain changes in the user. The initial choice to use alcohol or other drugs may be voluntary, but if a person becomes addicted, he or she is then suffering from a biological disease, one of the symptoms of which is a necessity to continue using.

The federal government measures the extent of alcohol and other drug use in many ways. The most comprehensive measure is the annual National Survey on Drug Use and Health. There are also measurements of use by state, by age, and by other demographic characteristics. Unfortunately, the need for treatment far exceeds the capacity to provide treatment in this country. The adolescent population is particularly affected by alcohol and other drug use.

States suffer many economic costs associated with untreated alcohol and other substance use disorders. Employers also suffer economic consequences. States and the public suffer many health consequences associated with alcohol and substance use disorders, including fetal alcohol syndrome and drug-affected babies, infectious diseases, mental health, medical conditions, death, and trauma. They also suffer many social consequences, including crime, TANF/welfare, accidents, auto crashes, suicide, homelessness, domestic violence, and child abuse and neglect. Some promising economic solutions for states can lead to cost avoidance or cost-offset, particularly in the criminal justice area.

To effectively treat alcohol and other substance use disorders, it is important to have available a comprehensive continuum of treatment and a full spectrum of services. The four steps of addressing alcohol and other substance use disorders are:

• Identification of the problem, • Assessment of its severity, • Treatment, and • Ongoing recovery management.

Treatment can involve medications (such as methadone), can be coerced by the criminal justice system, and should involve a variety of intensities and modalities. Detoxification is not treatment, but it is often a medically necessary first step to stabilize a patient and

National Conference of State Legislatures ix x Treatment of Alcohol and Other Substance Use Disorders

prepare him or her for treatment. Treatment should occur in the least restrictive setting appropriate, and a patient should be continually reassessed and moved through the continuum from most to least restrictive settings. The range of treatment intensities includes inpatient/residential, therapeutic communities, intensive outpatient, and outpatient. Ongoing recovery management includes relapse prevention, such as self-help groups; education, job and family support; and, sometimes, special living arrangements, such as sober living environments. Treatment for some specific populations must be tailored to meet the unique needs of each population, such as adolescents, women and older adults. It is important to provide culturally competent treatment for minorities, such as Native Ameri- cans, Asian and Pacific Islander Americans, Hispanic/Latino populations, African Ameri- cans, and rural populations. Treatment in the criminal justice system is a major issue for states because the majority of offenders have alcohol and other substance use disorders. Another significant issue is treatment of co-occurring mental illness and alcohol and other substance use disorders because this population is large and the co-occurring disorders complicate treatment.

Both state and federal governments fund alcohol and other substance use prevention and treatment services. States make general fund appropriations for treatment in addition to appropriating federal funds. Most states require some level of private insurance coverage for treatment. Parity and mandated benefits are economically advantageous for states because they create a cost shift from the public sector to the private sector. A significant source of state funds for treatment comes from alcohol taxes on liquor, wine and beer. The federal government funds alcohol and other substance use prevention and treatment through various federal agencies.

• The Substance Abuse and Mental Health Services Administration oversees the Sub- stance Abuse Prevention and Treatment Block Grant and various discretionary grant programs, which are appropriated to the single state agencies.

• The Centers for Medicare and Medicaid Services oversee Medicaid, Temporary Assis- tance to Needy Families, the State Children’s Health Insurance Program, and Medi- care, all of which can cover alcohol and other substance use treatment.

• The Administration for Children and Families oversee Title IVB and Title IVE funds, which can be used for a behavioral health demonstration program.

• The Department of Education oversees the Safe and Drug-Free Schools and Commu- nities State Grants Program, which addresses alcohol and other substance use prevention and education.

• The Department of Justice oversees the Residential Substance Abuse Treatment for State Prisoners Program, the Drug-Free Communities Program, the Byrne Formula Grant Program, the Drug Court Discretionary Grant Program, and the Reentry: Seri- ous and Violent Offender Reentry Initiative, all of which address crime related to alcohol and other substance use disorders.

• The Department of Veterans Affairs oversees the Veterans Health Administration, which provides alcohol and other substance use treatment for veterans.

National Conference of State Legislatures Executive Summary xi

• Housing and Urban Development oversees the Public Housing Drug Elimination Grants Program, which promotes safety from alcohol and other substance use and related crime in public housing projects.

• The Department of Defense oversees TRICARE, which provides alcohol and other substance use treatment for military personnel.

National Conference of State Legislatures xii Treatment of Alcohol and Other Substance Use Disorders

USERS’ GUIDE

This publication is meant to serve as a guidebook for state legislators and legislative staff. It is targeted specifically toward health, human services, criminal justice, insurance and appropriations committees; leadership; and legislative services and research staff. The format makes it a working document. The document is available online at http://www.ncsl.org/ programs/health/forum/SAguidebook.htm.

The purpose for the notebook binder is threefold. First, you will receive quarterly updates that will instruct you to replace, add or remove pages. Second, you can easily remove pages for duplication, or to take with you to a hearing or to the floor. Third, you can print out HPTS Issue Briefs and substance abuse SnapShots, and put them at the back of your binder, behind the Issue Briefs and SnapShots tabs.

The table of contents and chapter tabs are color-coded by chapter. Therefore, you can skim the table of contents to find the topic you are interested in and quickly flip to the appropriate chapter.

Updates for your guidebook will be e-mailed to you quarterly so that you can print them and update your guidebook. If you prefer to have the updates mailed to you, call Allison Colker at (202) 624-3581. The online version will be updated quarterly.

Appendix A is a legislators’ checklist for your use in evaluating your state’s treatment system.

Appendix B is a list of national resources that you can consult to get more specific information.

xii National Conference of State Legislatures What Are Alcohol and Other Substance Use Disorders? 1

1. WHAT ARE ALCOHOL AND OTHER SUBSTANCE USE DISORDERS?

Defining Alcohol and Other Substance Use • Nearly 14 million adult Americans—one of every 13—meet Disorders the diagnostic criteria for alcohol dependence or alcohol abuse.

The terms and definitions associated with alcohol and other • About 50 percent of adults have or have had a close family substance use disorders have changed over the years. Al- relative with one of those disorders. though the terms change, the fundamental problems asso- • More than 70 percent of individuals who consume alcohol ciated with these disorders remain constant. The accepted exceed moderate drinking guidelines (up to two drinks per Institute of Medicine terminology is “alcohol and other sub- day for men and one drink per day for women and older stance use disorders;” therefore, that term will be used people). throughout this book. • More than 50 percent of college students who drink alcohol Alcohol Abuse say that they drink to “get drunk.” • Approximately 12.8 percent of men and women experience According to the National Institutes of Health, nearly 14 symptoms of alcohol dependence at some time in their lives. million adult Americans—one of every 13— meet the di- Of those individuals, approximately 700,000 are treated agnostic criteria for alcohol dependence or alcohol abuse. annually. About 50 percent of adults have or have had a close family relative with one of those disorders. In addition, more than 70 percent of individuals who consume alcohol exceed moderate drinking guidelines (up to two drinks per day for men and one drink per day for women and older people). More than 50 percent of college students who drink alcohol say that they drink to “get drunk.”1

Experts use the following definition to identify an individual with an alcohol abuse problem.

• Alcohol Abuse is defined as a heavy and frequent alcohol problem that involves the continued use of alcohol—despite social, occupational, psychological or physical problems—in addition to recurrent alcohol use in physically hazardous situations.2

Although alcohol is not an illegal substance for adults, the abuse of alcohol has become a serious problem in the United States. Approximately 12.8 percent of men and women experience symptoms of alcohol dependence at some time in their lives. Of those individuals, approximately 700,000 are treated annually.3

National Conference of State Legislatures 1 2 Treatment of Alcohol and Other Substance Use Disorders

Alcoholism

Experts use the following definition to identify an individual with alcoholism.

• Alcohol Dependence, also termed “alcoholism” or “alcohol dependence syndrome,” is distinguished by cognitive, behavioral and physiologic symptoms, which indicate that a person continues to drink despite significant alcohol-related problems. These alcohol-related problems do not necessarily involve heavy drinking.4 Drug Abuse and Addiction

The diagnostic criteria used to identify drug use, similar to the ones used for alcohol use, are classified in three ways: use, abuse and dependence.

• Use is characterized by low or infrequent doses and can be considered experimental, occasional or social; damaging consequences are rare and minor.5

• Abuse describes higher doses or frequencies that are usually sporadically heavy and intensive; effects are unpredictable and sometimes severe.6

• Dependence defines the addiction to drugs and is associated with high or frequent doses, compulsion, craving and withdrawal; severe consequences are likely.7

Drug addiction involves a loss of control over drug-taking behavior and an overwhelming compulsion to take drugs. It is a chronic, relapsing disorder; relapse can occur long after drugs are gone from the body. An addict will ignore the adverse consequences of drug use and is tolerant, physically dependent and psychologically dependent.

Appendix C is a list of current “hot topic” drugs that you’ve been hearing about in the news. DSM-IV-TR

Two common and widely recognized criteria are used by clinicians and researchers to diag- nose alcohol and other substance use disorders. The first is the American Psychiatric Association’s Diagnostic and Statistics Manual of Mental Disorders; the most current is the fourth edition text revision, commonly referred to as the DSM-IV-TR. The other is the World Health Organization’s International Classification of Diseases (ICD-9). Both are used to help identify and classify alcohol and other substance use disorders. The codes contained in them also are used in patient medical records and for claims and billing purposes.

The most common tool used in the United States for diagnosing alcohol and other substance use disorders is the DSM-IV-TR. The ICD-9 is most often used as an international tool for diagnosing causes of death and disability. An ICD-9 diagnosis is required by HIPAA and by Medicaid. The DSM-IV-TR classifies alcohol and other substance use disorders as substance dependence, substance abuse and substance-induced disorders. Substance dependence is a pattern of substance abuse that leads to impairment or distress; substance abuse is related to the repeated use of substances; and a substance-induced disorder is a specific syndrome, such as a mood change that is related to ingesting the substance.8

National Conference of State Legislatures What Are Alcohol and Other Substance Use Disorders? 3

Understanding the scope and scale of drug use, abuse and addiction in the United States, determining its prevalence among various populations, and learning about the many health and social consequences are critical to solving this complex problem. Epidemiological research is one method used to identify and examine trends in both drug use and the attitudes that Americans have toward drug use. Many epidemiological studies—including a variety of surveys, experimental studies, and field investigations—are conducted on a continuing basis. These studies provide long-term data trends that can help measure the nation’s success in preventing and treating drug use.9, 10 Chronic, Relapsing Disease

Many people view alcohol and other substance use disorders as strictly a social problem. Parents, teens, older adults, and other members of the community tend to characterize alcohol and other substance users as morally weak or as having criminal tendencies. They believe that alcohol and other substance users should be able to stop using alcohol and other drugs if they are willing to change their behavior.11

These myths have stereotyped not only those with alcohol and other substance use disorders, but also their families, their communities, and the health care professionals who work with them. Alcohol and other substance use disorders comprise a public health problem that affects many people and has wide-ranging social consequences. The goal of the Na- tional Institute on Drug Abuse (NIDA) is to help the public replace its myths and long- held mistaken beliefs about alcohol and other substance use disorders with scientific evidence that addiction is a chronic, relapsing and treatable disease.12

Addiction begins with alcohol and other drug abuse when an individual makes a conscious choice to use alcohol and other drugs, but addiction is not simply “a lot of alcohol and other drug use.” Recent scientific research provides overwhelming evidence that not only do alcohol and other drugs interfere with normal brain functioning by creating powerful feelings of pleasure, but they also have long-term effects on brain metabolism and activity. At some point, changes occur in the brain that can turn alcohol and other drug abuse into addiction—a chronic, relapsing illness. Those addicted to alcohol and other drugs suffer from a compulsive carving for and use of alcohol and other drugs and cannot quit by themselves. Treatment is necessary to end this compulsive behavior.13

A variety of approaches are used in treatment programs to help patients deal with these cravings and possibly avoid alcohol and other drug relapse. NIDA research shows that addiction is clearly treatable. Through treatment that is tailored to individual needs, patients can learn to control their condition and live relatively normal lives.14

Treatment can have a profound effect not only on alcohol and other drug users, but also on society as a whole by significantly improving social and psychological functioning, decreas- ing related criminal behavior and violence, and reducing the spread of AIDS. It can also dramatically reduce the costs to society of alcohol and other drug abuse.15

A tremendous opportunity exists to effectively change how the public understands alcohol and other substance use disorders through the wealth of scientific data NIDA has amassed. Overcoming misconceptions and replacing ideology with scientific knowledge is the best hope for bridging the gap between the public perception of alcohol and other substance use disorders and the scientific facts.16

National Conference of State Legislatures 4 Treatment of Alcohol and Other Substance Use Disorders

Prevention of alcohol and other drug abuse in a crucial piece of the puzzle. Results from NIDA-funded prevention research have shown that comprehensive prevention programs that involve the family, schools, communities and the media are effective in reducing alcohol and other drug abuse. It is necessary to reiterate the message that it is better to not start at all than to enter rehabilitation if addiction occurs.17 PET Scans of Long-term Brain Changes in Abstinence and Brains on Drugs

The following text and pictures are taken from the National Institute on Drug Abuse (NIDA) Slide Teaching Packet, Bringing the Power of Science to Bear on Drug Abuse and Addiction, slides 7-10 and 14.18

This is literally the brain on drugs. When someone gets “high” on cocaine, where does the cocaine go in the brain? With the help of a radioactive tracer, this PET scan shows us a person’s brain on cocaine and the area of the brain, highlighted in yellow, where cocaine is “binding” or attaching itself. This PET scan shows us minute by minute, in a time-lapsed sequence, just how quickly cocaine begins affecting a particular area of the brain.19

We start in the upper left hand corner. You can see that 1 minute after cocaine is administered to this subject nothing much happens. All areas of the brain seem to be functioning normally. But after 3 to 4 minutes, we see areas highlighted in yellow where cocaine is starting to Photo courtesy of Nora Volkow, Ph.D. Mapping cocaine binding sites in human and 20 baboon brain in vivo. Fowler J.S., Volkow N.D., Wolf A.P., Dewey S.L., Schlyer D.J., bind to the striatum of the brain and activate it. Macgregor, Hitzemann R., Logan J., Bendreim B., Gatley S.T., et al. Synapse 1989;4(4):371-377. At the 5- to 8-minute interval, we see that cocaine is affecting a large area of the brain. After that, the drug’s effects begin to wear off. At the 9- to 10-minute point, the high feeling is almost gone. Unless the abuser takes more cocaine, the experience is over in about 20 to 30 minutes.21

Scientists are doing research to find out if the striatum produces the “high feeling” and controls our feelings of pleasure and motivation. One of the reasons scientists are curious about specific areas of the brain affected by drugs such as cocaine is to develop treatments for people who become addicted to these drugs. Scientists hope to find the most effective way to change an addicted brain back to normal functioning.22

Long-term effects of drug abuse. This PET scan shows us that once addicted to a drug like cocaine, the brain is affected for a long, long time. In other words, once addicted, the brain is literally changed.23

In this slide, the level of brain function is indicated in yellow. The top row shows a normal-functioning brain without drugs. You can see a lot of brain activity. In other words, there is a lot of yellow color.24

Photo courtesy of Nora Volkow, Ph.D. Volkow ND, Hitzemann R, Wang G-J, Fowler J.S., Wolf A.P., Dewey S.L.. Long-term frontal brain metabolic changes in cocaine abusers. The middle row shows a cocaine addict’s brain after 10 days without Synapse 11:184-190, 1992; Volkow ND, Fowler J.S., Wang G-J, Hitzemann R, Logan J, Schlyer D, Dewey S, Wolf A.P.. Decreased dopamine D2 receptor availability is asso- any cocaine use at all. What is happening here? Less yellow means less ciated with reduced frontal metabolism in cocaine abusers. Synapse 14:169-177, 1993.

National Conference of State Legislatures What Are Alcohol and Other Substance Use Disorders? 5 normal activity occurring in the brain—even after the cocaine abuser has abstained from the drug for 10 days.25

The third row shows the same addict’s brain after 100 days without any cocaine. We can see a little more yellow, so there is some improvement—more brain activity—at this point. But the addict’s brain is still not back to a normal level of functioning ... more than 3 months later. Scientists are concerned that there may be areas in the brain that never fully recover from drug abuse and addiction.26

Drugs have long-term consequences. Here is another example of what science has shown us about the long- term effects of drugs. What this PET scan shows us is how just 10 days of drug use can produce very dramatic and long-term changes in the brain of a monkey. The drug in these images is amphetamine, or what some people call “speed.” Remember the previous slide showed us what the brain of a chronic cocaine abuser looks like. This slide shows us what using a drug like amphetamine can do in only 10 days to the brain of a monkey. 27

This slide also gives us a better idea of what methamphetamine, a drug similar in structure, can do to the brain. Methamphetamine use is 28 Photo courtesy of NIDA from research conducted by Melega W.P., Raleigh M.J., becoming increasingly popular in certain areas of the country. Stout D.B., Lacan C., Huang S.C., Phelps M.E. Recovery of striatal dopamine function after acute amphetamine- and methamphetamine-induced neurotoxicity in the vervet monkey. Brain Res 1997 Aug 22;766(1-2);113-120. The top row shows us, in white and red, normal brain activity. The second row shows us that same brain 4 weeks after being given amphetamine for 10 days. There is a dramatic decrease in brain activity. This decreased brain activity continues for up to 1 year after amphetamine use. These continuous brain changes often trigger other changes in social and emotional behavior, too, including a possible increase in aggressive- ness, feelings of isolation, and depression.29

The memory of drugs. This slide demonstrates something really amazing—how just the mention of items associated with drug use may cause an addict to “crave” or desire drugs. This PET scan is part of a scientific study that compared recovering addicts, who had stopped using cocaine, with people who had no history of cocaine use. The study hoped to determine what parts of the brain are activated when drugs are craved.30

For this study, brain scans were performed while subjects watched two videos. The first video, a nondrug presentation, showed nature images—mountains, rivers, animals, flowers, trees. The second video showed cocaine and drug paraphernalia, such as pipes, needles, matches, and other items familiar to addicts.31 Photo courtesy of Anna Rose Childress, Ph.D.

This is how the memory of drugs works: The yellow area on the upper part of the second image is the amygdala, a part of the brain’s limbic system, which is critical for memory and responsible for evoking emotions. For an addict, when a drug craving occurs, the amygdala becomes active and a craving for cocaine is triggered.32

National Conference of State Legislatures 6 Treatment of Alcohol and Other Substance Use Disorders

So if it’s the middle of the night, raining, snowing, it doesn’t matter. This craving demands the drug immediately. Rational thoughts are dismissed by the uncontrollable desire for drugs. At this point, a basic change has occurred in the brain. The person is no longer in control. This changed brain makes it almost impossible for drug addicts to stay drug-free without professional help. Because addiction is a brain disease.33

Have you changed your mind? As we look at side-by-side PET scans of a person who has never used cocaine compared with a cocaine addict, can you tell which brain is more active and healthy? Yes, the brain on the left with an abundance of red is the healthy, active brain.34

With a little bit of knowledge about what drug addiction actually is, anyone—not just neuroscientists and neurobiologists—can see the changes in brain activity caused by drug abuse and addiction. The PET scans we’ve looked at today prove that.35

We’ve seen the scientific facts. We’ve learned that addiction is a brain Photo courtesy of NIDA. If You Change Your Mind. Student magazine. NIH Pub- lication No. 93-3474, 1993. disease. And we’ve also learned that scientists are making great strides in developing treatments for addiction. There will be no magic charm to make addiction go away. But educated and informed with the scientific facts about what drugs can do to the brain, we are each in a better position to decide whether or not to take drugs in the first place. Given the facts, have you changed your mind?36

Appendix D contains more PET scans related to specific drugs. MRI Scans of Long-term Brain Changes in Alcoholics and Adolescent Brains on Alcohol

As exhibited in the MRI scans below, the brains of alcoholics shrink. The brain of the alcoholic has visibly shrunk, compared to the brain of the healthy non-alcoholic. The brain matter is the lighter gray color. In the alcoholic’s MRI scan, you can see that the brain has receded (shrunk) around the sides.

Healthy non-alcoholic woman (age 43)

Alcoholic woman (age 43) Photos courtesy of Daniel Hommer, M.D., NIAAA.

National Conference of State Legislatures What Are Alcohol and Other Substance Use Disorders? 7

As exhibited in the MRI scans below, alcohol affects adolescents’ brains in several ways. The first set of MRI scans (figure 1) demonstrates that there is greater activation of a normal adolescent brain during a spatial working memory task than of an adolescent brain on alcohol. The second set of MRI scans (figure 2) demonstrates that there is under- activation in the brain of an alcohol-dependent adolescent when compared to the brain of a light drinker adolescent.

Figure 1. Activation Patterns to Spatial Working Memory Task for Adolescents

Normal Alcohol

Greater activation during spatial working memory

Greater activation during vigilance

Photos courtesy of Sandra Brown, Ph.D., University of California, San Diego.37

Figure 2. Brain Activation in Young Women

Light Drinker Alcohol-Dependent Female, Age 20 Female, Age 20

Greater activation

Under- activation

Photos courtesy of Sandra Brown, Ph.D., University of California, San Diego.37

National Conference of State Legislatures 8 Treatment of Alcohol and Other Substance Use Disorders

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 9

2. WHAT ARE THE EFFECTS OF ALCOHOL AND OTHER SUBSTANCE USE DISORDERS?

Alcohol and other substance use disorders are equal oppor- • Approximately 70 percent of people with alcohol and other sub- tunity diseases. The public perception is that they are stance use disorders are employed full-time. largely poor, unemployed persons’ diseases; however, employed persons are also affected. • Of the 15.2 million Americans age 18 and older who were heavy drinkers in 2002, 12 million (79 percent) were either full-time or Alcohol and other substance use disorders disproportion- part-time workers. ately affect full-time working individuals. Approximately • Of the 16.6 million illicit drug users age 18 and over, 12.4 mil- 70 percent of people with alcohol and other substance use lion (74.6 percent) were employed either full-time or part-time. disorders are employed full-time. This is problematic for employers because even moderate drinking results in lost • Approximately 120 million Americans over age 12 were current productivity. drinkers in 2002. • Of those who were current drinkers, approximately 54 million Although documented rates of heavy alcohol and illicit drug Americans were binge drinkers. use are highest for the unemployed, alcohol and other substance use is a problem that disproportionately affects work- • Of those who were current or binge drinkers, approximately ing Americans. Of the 15.2 million Americans age 18 and 15.9 million Americans were heavy drinkers. older who were heavy drinkers in 2002, 12 million (79 1 • An estimated 19.5 million Americans over age 12 (8.3 percent) percent) were either full-time or part-time workers. Of reported using illicit drugs in the past month during 2002 and the 16.6 million illicit drug users 18 and over, 12.4 mil- thus are considered current users. lion (74.6 percent) were employed either full-time or part- time.2 • Marijuana, the most common illicit drug, was used by 75 percent of current drug users.

The federal government has adopted several means by which • Of the 15.9 million heavy drinkers, approximately one third— to measure the number of people with alcohol and other 5.2 million—also were current illicit drug users. substance use disorders. National Survey on Drug Use and Health

The National Survey on Drug Use and Health (NSDUH) indicates that alcohol is the most common substance use disorder problem. According to the 2002 survey, approximately one of every two Americans over age 12 was a current alcohol user, about one of five was a binge drinker, and about one of every 15 was a heavy drinker. Current, binge and heavy alcohol use are defined as follows.

National Conference of State Legislatures 9 10 Treatment of Alcohol and Other Substance Use Disorders

Current use: At least one drink in the past month. • Approximately 120 million Americans over age 12 were current drinkers in 2002.

Binge use: Five or more drinks on the same occasion at least once in the past month. • Of those who were current drinkers, approximately 54 million Americans were binge drinkers.

Heavy use: Five or more drinks on the same occasion on at least five different days in the past month. • Of those who were current or binge drinkers, approximately 15.9 million Americans were heavy drinkers.3

According to the same survey, an estimated 19.5 million Americans over age 12 (8.3 percent) reported using illicit drugs in the past month during 2002 and are thus considered current users. Marijuana, the most commonly used illicit drug, was used by 75 percent of current drug users.4 Studies show that some individuals who use alcohol also may use other drugs. Of the 15.9 million heavy drinkers, approximately one third or 5.2 million also were current illicit drug users.5

Although documented rates of heavy alcohol and illicit drug use are highest for the unemployed, alcohol and other substance use is a problem that disproportionately affects working Americans. Of the 15.2 million Americans age 18 and older who were heavy drinkers in 2002, 12 million (79 percent) were either full-time or part-time workers.6 Of the 16.6 million illicit drug users 18 and over, 12.4 million (74.6 percent) were employed either full-time or part-time.7 Standard Methodology for Rate of Alcohol and Other Substance Use Disorders by Substance, by State

The 2002 NSDUH does not included state-by-state information. The most current survey to include this information is the 2000 survey. Estimates in the report, State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse, have been adjusted to reflect the probability of selection, record nonresponse, poststratification to known bench- marks, item imputation, and other aspects of the estimation process.8

In the report, state model-based estimates are portrayed in U.S. maps showing all 50 states and the District of Columbia. These estimates also are provided in tables that include all 50 states and the District of Columbia by four age categories and in individual state tables arranged to display all of the estimates discussed in this report by the four age categories for a given state.9

Each table contains a “national” total that represents the (weighted) sum of the estimates from the 50 states and the District of Columbia. Those totals are generally slightly different from the corresponding national estimates calculated by summing the sample-weighted records across the entire sample. The latter estimates are the preferred unbiased estimates for the nation and are used in the text for comparison with the state-level estimates.10 Tables 1 and 2 show rates of alcohol and other substance use and dependence by substance, by state.

To obtain your state’s need assessments, contact your own single state agency director. For a listing of single state agency directors, please refer to appendix E.

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 11

Table 1. Rate of Alcohol and Other Substance Use by Substance, by State Annual Averages Based on 1999 and 2000 NHSDAs

State/ Past Month Past Month Past Month Past Year Past Month Users Past Month Juris- Users of Any Users of Users of Any Users of of Alcohol “Binge” diction Illicit Drug Marijuana Illicit Drug Cocaine Alcohol Users Other Than Marijuana # % # % # % # % # % # % Total 13,968 6.28 10,675 4.80 5,935 2.67 3,658 1.64 102,758 46.25 45,349 20.41 Ala. 196 5.38 140 3.84 96 2.63 64 1.76 1,341 36.87 657 18.05 Alaska 43 8.80 31 6.35 15 3.16 11 2.20 258 52.87 105 21.49 Ariz. 233 6.10 173 4.53 118 3.10 81 2.11 1,769 46.36 786 20.59 Ark. 117 5.44 84 3.89 55 2.56 32 1.51 758 35.32 406 18.91 Calif. 1,954 7.62 1,459 5.69 778 3.04 443 1.73 11,917 46.49 4,913 19.16 Colo. 300 8.86 264 7.80 106 3.15 83 2.45 1,975 58.51 777 22.99 Conn. 196 7.26 154 5.70 76 2.83 41 1.51 1,510 56.01 575 21.34 Del. 53 8.45 45 7.24 19 3.08 16 2.48 328 52.46 140 22.40 Fla. 745 5.92 597 4.74 311 2.47 213 1.69 5,799 46.08 2,334 18.54 Ga. 396 6.28 281 4.45 174 2.75 113 1.79 2,722 43.23 1,284 20.39 Hawaii 75 7.67 59 6.07 24 2.44 18 1.81 421 43.28 197 20.22 Idaho 58 5.37 44 4.12 25 2.32 14 1.33 444 41.54 199 18.65 Ill. 612 6.27 465 4.77 250 2.57 147 1.51 4,938 50.66 2,238 22.96 Ind. 293 5.93 219 4.43 130 2.62 71 1.43 1,957 39.69 915 18.55 Ia. 102 4.28 67 2.79 52 2.17 32 1.33 1,230 51.60 568 23.82 Kan. 110 5.12 79 3.68 54 2.52 32 1.48 1,019 47.48 436 20.30 Ky. 192 5.87 138 4.21 95 2.91 54 1.66 1,128 34.41 632 19.28 La. 216 6.09 133 3.74 107 3.01 61 1.71 1,558 43.88 828 23.32 Maine 72 6.88 62 5.95 28 2.67 14 1.31 521 49.90 223 21.29 Md. 242 5.69 190 4.46 101 2.38 55 1.29 2,097 49.23 738 17.33 Mass. 581 11.35 463 9.03 175 3.42 105 2.06 3,097 60.33 1,305 25.54 Mich. 545 6.89 448 5.66 213 2.69 122 1.54 3,714 46.99 1,690 21.37 Minn. 236 5.97 187 4.73 99 2.51 65 1.64 2,115 53.76 912 23.15 Miss. 118 5.21 72 3.16 56 2.48 34 1.49 675 29.83 379 16.76 Mo. 239 5.27 196 4.33 98 2.16 59 1.30 2,024 44.81 911 20.15 Mt. 49 6.32 38 4.89 19 2.52 12 1.54 425 55.32 182 23.64 Neb. 61 4.47 47 3.45 30 2.20 20 1.46 718 52.44 326 23.80 Nev. 114 7.49 81 5.31 49 3.21 32 2.10 798 52.62 357 23.55 N.H. 66 6.55 60 5.96 27 2.67 14 1.82 573 57.23 207 20.68 N.J. 410 6.13 310 4.63 168 2.50 98 1.27 3,446 51.47 1,397 20.87 N.M. 105 7.13 88 5.93 42 2.83 41 3.19 751 50.92 348 23.54 N.Y. 855 5.79 665 4.50 361 2.44 221 1.38 7,314 49.51 2,990 20.24 N.C. 422 6.68 347 5.50 164 2.60 100 1.41 2,336 37.01 1,064 16.85 N.D. 22 4.19 17 3.17 11 2.14 7 1.62 303 56.69 155 29.06 Ohio 520 5.60 399 4.30 238 2.57 140 1.16 4,221 45.50 2,033 21.91 Okla. 137 4.99 83 3.02 78 2.87 40 1.39 1,001 36.62 490 17.93 Ore. 212 7.52 184 6.53 84 2.97 42 1.83 1,387 49.48 527 18.78 Pa. 591 5.85 451 4.47 261 2.59 145 1.37 4,924 48.74 2,193 21.70 R.I. 67 8.12 59 7.20 23 2.77 14 1.47 435 53.10 182 22.24 S.C. 160 5.15 125 4.02 73 2.33 51 1.31 1,117 35.89 576 18.50 S.D. 29 4.75 23 3.73 14 2.21 10 2.20 312 50.66 158 25.67 Tenn. 275 5.94 200 4.31 123 2.65 84 1.67 1,564 33.81 775 16.75 Texas 774 4.86 536 3.36 409 2.56 310 2.56 6,857 43.04 3,380 21.22 Utah 85 5.01 54 3.15 51 3.01 25 1.68 475 28.07 233 13.73 Vt. 43 8.50 37 7.26 15 3.03 9 1.77 287 56.50 113 22.13 Va. 271 4.82 232 4.13 113 2.01 84 1.30 2,581 45.95 1,037 18.46 Wash. 356 7.51 267 5.62 136 2.87 71 2.02 2,233 47.03 843 17.76 W.V. 73 4.69 54 3.49 40 2.55 20 1.62 508 32.70 276 17.78 Wis. 293 6.68 230 5.24 125 2.87 76 1.82 2,493 57.24 1,176 26.95 Wyo. 24 5.67 19 4.40 11 2.64 6 1.68 212 50.22 104 24.66 D.C. 30 7.05 22 5.23 14 3.20 9 2.08 191 44.90 80 18.86

Key: # = Estimated numbers (in thousands) % = Percentages reporting Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based Estimates (50 states and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.

National Conference of State Legislatures 12 Treatment of Alcohol and Other Substance Use Disorders

Table 2. Rate of Substance Abuse and Dependence by Substance, by State Annual Averages Based on 1999 and 2000 NHSDAs

State/ Past Year Alcohol Past Year Alcohol Past Year Any Past Year Any Past Year Juris- Dependence or Dependence Illicit Drug Illicit Drug Dependence or diction Abuse Dependence or Dependence Abuse for Any Abuse Illicit Drug or Alcohol # % # % # % # % # % Total 12,384 5.54 5,225 2.34 4,504 2.01 2,869 1.28 14,701 6.58 Ala. 197 5.39 94 2.58 68 1.86 47 1.28 231 6.33 Alaska 34 6.91 13 2.74 13 2.59 6 1.31 39 7.85 Ariz. 230 5.95 101 2.62 111 2.87 67 1.73 287 7.43 Ark. 105 4.84 48 2.21 43 1.98 26 1.18 130 5.98 Calif. 1,561 6.07 668 2.59 621 2.41 410 1.59 1,895 7.36 Colo. 216 6.34 77 2.27 82 2.42 54 1.58 253 7.42 Conn. 183 6.77 73 2.70 58 2.12 40 1.48 217 8.01 Del. 36 5.69 15 2.33 14 2.28 10 1.57 44 6.89 Fla. 700 5.52 288 2.27 226 1.78 148 1.17 818 6.45 Ga. 319 5.01 159 2.50 125 1.96 77 1.20 394 6.19 Hawaii 53 5.40 22 2.30 18 1.87 11 1.16 63 6.51 Idaho 62 5.74 28 2.60 21 1.90 14 1.28 71 6.51 Ill. 610 6.24 243 2.48 176 1.81 115 1.17 665 6.80 Ind. 257 5.18 116 2.33 86 1.74 58 1.17 304 6.15 Ia. 137 5.74 55 2.30 33 1.37 23 0.97 144 6.04 Kan. 122 5.65 50 2.31 40 1.83 25 1.14 145 6.71 Ky. 168 5.12 74 2.26 67 2.04 41 1.26 207 6.28 La. 216 6.07 103 2.90 77 2.16 53 1.48 267 7.50 Maine 52 4.95 22 2.14 20 1.91 12 1.15 64 6.09 Md. 224 5.23 87 2.03 92 2.14 60 1.41 278 6.48 Mass. 366 7.12 125 2.44 125 2.43 90 1.75 424 8.26 Mich. 441 5.56 171 2.16 148 1.86 87 1.10 526 6.64 Minn. 219 5.52 96 2.43 71 1.79 46 1.15 253 6.37 Miss. 125 5.52 71 3.11 45 1.95 30 1.32 157 6.92 Mo. 237 5.22 98 2.16 77 1.70 50 1.11 286 6.29 Mt. 54 6.96 18 2.36 16 2.02 8 1.09 59 7.61 Neb. 95 6.85 34 2.50 24 1.70 16 1.17 104 7.51 Nev. 89 5.76 34 2.18 35 2.25 21 1.34 106 6.84 N.H. 64 6.33 24 2.36 22 2.21 13 1.25 71 7.06 N.J. 326 4.86 140 2.08 119 1.78 73 1.09 380 5.65 N.M. 97 6.51 43 2.86 32 2.12 19 1.25 118 7.92 N.Y. 704 4.76 300 2.03 307 2.07 195 1.32 895 6.06 N.C. 285 4.48 145 2.28 114 1.80 67 1.05 327 5.14 N.D. 40 7.37 13 2.48 9 1.65 5 0.98 45 8.29 Ohio 454 4.89 196 2.11 173 1.87 102 1.10 549 5.91 Okla. 145 5.28 64 2.32 62 2.27 33 1.20 170 6.21 Ore. 167 5.87 71 2.52 68 2.38 38 1.33 201 7.07 Pa. 559 5.52 237 2.34 181 1.79 128 1.27 662 6.54 R.I. 53 6.40 19 2.31 16 1.93 10 1.23 61 7.36 S.C. 144 4.61 74 2.36 55 1.76 36 1.15 174 5.55 S.D. 47 7.52 18 2.83 11 1.71 7 1.10 48 7.79 Tenn. 249 5.34 115 2.47 89 1.90 61 1.31 287 6.14 Texas 913 5.69 361 2.25 324 2.02 187 1.17 1,050 6.54 Utah 86 4.98 34 1.96 41 2.35 24 1.39 107 6.21 Vt. 30 5.93 12 2.33 11 2.10 8 1.57 37 7.24 Va. 268 4.74 116 2.05 99 1.75 67 1.18 316 5.60 Wash. 259 5.41 106 2.21 109 2.28 68 1.42 332 6.94 W.V. 72 4.66 34 2.20 28 1.83 18 1.15 80 5.16 Wis. 264 6.00 98 2.24 85 1.92 55 1.24 303 6.89 Wyo. 25 5.97 9 2.20 8 1.96 5 1.13 29 6.75 D.C. 25 5.94 12 2.90 10 2.46 6 1.45 30 7.11

Key: # = Estimated numbers of persons reporting (in thousands) % = Percentages reporting Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based Estimates (50 states and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 13

Healthy People 2010

Healthy People 2010 is a set of health objectives for the nation to achieve over the first decade of the new century. It can be used by many different people, states, communities, professional organizations, and others to help them develop programs to improve health.11

Healthy People 2010 builds on initiatives pursued over the past two decades. The 1979 surgeon general’s report, Healthy People, and Healthy People 2000: National Health Promo- tion and Disease Prevention Objectives both established national health objectives and served as the basis for the development of state and community plans. Like its predecessors, Healthy People 2010 was developed through a broad consultation process, built on the best scientific knowledge and designed to measure programs over time.12

Healthy People 2010 is designed to achieve two overarching goals:

• Goal 1: Increase Quality and Years of Healthy Life

The first goal of Healthy People 2010 is to help individuals of all ages increase life expectancy and improve their quality of life.

• Goal 2: Eliminate Health Disparities

The second goal of Healthy People 2010 is to eliminate health disparities among different segments of the population.

Each of the 28 focus area chapters also contains a concise goal statement. This statement frames the overall purpose of the focus area.13

One of the focus areas is “substance abuse.” Of the 28 focus areas, 10 are also Leading Health Indicators. The Leading Health Indicators (LHIs) are 10 major health issues for the nation.14 One LHI is “substance abuse.”

Alcohol and illicit drug use are associated with many of this country’s most serious problems, including violence, injury, and HIV infection. The annual economic costs to the United States from alcohol abuse were estimated to be $167 billion in 1995, and the costs from drug abuse were estimated to be $110 billion. 15

In 1998, 79 percent of adolescents between the ages of 12 and 17 reported that they did not use alcohol or illicit drugs in the past month. In the same year, 6 percent of adults age 18 and older reported using illicit drugs in the past month; 17 percent reported binge drinking in the past month, which is defined as consuming five or more drinks on one occasion.16

The objectives selected to measure progress among adolescents and adults for this leading health indicator are presented below. These are only indicators and do not represent all the substance abuse objectives in Healthy People 2010.17

National Conference of State Legislatures 14 Treatment of Alcohol and Other Substance Use Disorders

Figure 3. Use of Alcohol and/or Illicit Drugs, United States, 1994–1998

Source: Substance Abuse and Mental Health Services Administration, Office of the Assistant Secretary, National Household Survey on Drug Abuse. 1994–98 (Rockville, Md.: SAMHSA, 1994-98).

26-10a. Increase the proportion of adolescents not using alcohol or any illicit drugs during the past 30 days.

26-10c. Reduce the proportion of adults using any illicit drug during the past 30 days.

26-11c. Reduce the proportion of adults engaging in binge drinking of alcoholic beverages during the past month.

Figure 4. Data Measures 26-01a Alcohol-related motor vehicle crash deaths (per 100,000 population) 26-01b Alcohol-related motor vehicle crash injuries (per 100,000 population) 26-01c Drug-related motor vehicle crash deaths 26-01d Drug-related motor vehicle crash injuries 26-02 Cirrhosis deaths (age adjusted per 100,000 standard population) 26-03 Drug-induced deaths (age adjusted per 100,000 standard population) 26-04 Drug-related hospital emergency department visits (thousands) 26-05 Alcohol-related hospital emergency department visits 26-06 Adolescents riding with a driver who has been drinking alcohol - Students (grades 9 through 12) 26-07 Intentional injuries from alcohol and drug- related violence 26-08 Lost productivity due to alcohol and drug use 26-09a Average age at first use of alcohol - Adolescents (aged 12 to 17 years) 26-09b Average age at first use of marijuana - Adolescents (aged 12 to 17 years) 26-09c High school seniors never consuming alcoholic beverages 26-09d High school seniors never using illicit drugs 26-10a Adolescents not using alcohol or illicit drugs in past 30 days (aged 12 to 17 years) 26-10b Adolescents using marijuana in past 30 days (aged 12 to 17 years) 26-10c Adults using illicit drugs in past 30 days (aged 18 years and over) 26-11a Binge drinking - High school seniors 26-11b Binge drinking - College students 26-11c Binge drinking - Adults (aged 18 years and over)

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 15

Figure 4. Data Measures (continued) 26-11d Binge drinking - Adolescents (aged 12 to 17 years) 26-12 Average annual alcohol consumption (gallons per person, aged 14 years and over) 26-13a Adult females exceeding guidelines for low-risk drinking (aged 21 years and over) 26-13b Adult males exceeding guidelines for low-risk drinking (aged 21 years and over) 26-14a Steroid use among adolescents - 8th graders 26-14b Steroid use among adolescents - 10th graders 26-14c Steroid use among adolescents - 12th graders 26-15 Inhalant use among adolescents (aged 12 to 17 years) 26-16a Peer disapproval of substance abuse - 8th graders 26-16b Peer disapproval of substance abuse - 10th graders 26-16c Peer disapproval of substance abuse - 12th graders 26-16d Peer disapproval of trying marijuana or hashish once or twice - 8th graders 26-16e Peer disapproval of trying marijuana or hashish once or twice - 10th graders 26-16f Peer disapproval of trying marijuana or hashish once or twice - 12th graders 26-17a Perception of risk associated with consuming 5+ alcoholic drinks once or twice a week - Adolescents (aged 12 to 17 years) 26-17b Perception of risk associated with smoking marijuana once per month - Adolescents (aged 12 to 17 years) 26-17c Perception of risk associated with using cocaine once per month - Adolescents (aged 12 to 17 years) 26-18 Treatment gap for illicit drugs in the general population 26-19 Substance abuse treatment in correctional institutions 26-20 Treatment admissions for injection drug use (thousands) 26-21 Treatment gap for alcohol problems 26-22 Hospital emergency department referrals for alcohol or drug problems and suicide attempts 26-23 Community partnerships and coalitions to prevent substance abuse 26-24 Administrative license revocation laws for persons who drive under the influence of intoxicants (number of States and D.C.) 26-25 Blood alcohol concentration levels of 0.08 for motor vehicle drivers (number of States and D.C., aged 21 years and over)18

Source: “DATA2010 ... the Healthy People 2010 Database—October 2003 Edition— 10/20/03—10:16:57AM Focus area: 26-Substance Abuse,” http://wonder.cdc.gov/scripts/broker.exe.

Trends in Substance Abuse

Adolescents Alcohol is the drug most frequently used by adolescents between the ages of 12 and 17. Although the trend from 1994 to 1998 showed some fluctuations, about 77 percent of adolescents between the ages of 12 and 17 report being both alcohol free and drug free in the past month. In 1998, 19 percent of adolescents in this age group reported drinking alcohol in the past month. Alcohol use in the past month for this age group has remained at about 20 percent since 1992. Eight percent of this age group reported binge drinking, and 3 percent were heavy drinkers (five or more drinks on the same occasion on each of five or more days in the past 30 days).19

Data from 1998 show that 10 percent of adolescents between the ages of 12 and 17 reported using illicit drugs in the past 30 days. This rate remains well below the all-time high of 16 percent in 1979. Current illicit drug use had nearly doubled for those between the ages of 12 and 13 between 1996 and 1997 but then decreased between 1997 and 1998. Youth are experimenting with a variety of illicit drugs, including marijuana, cocaine, crack, heroin,

National Conference of State Legislatures 16 Treatment of Alcohol and Other Substance Use Disorders

acid, inhalants and methamphetamines, and also misuse prescription drugs and other “street” drugs. The younger a person is when he or she becomes a habitual user of illicit drugs, the stronger the addiction becomes and the more difficult it is to stop use.20

Adults Binge drinking has remained at the same approximate level of 17 percent for all adults since 1988, with the highest current rate of 32 percent among adults between the ages of 18 and 25. Illicit drug use has been near the present rate of 6 percent since 1980. Men continue to have higher rates of illicit drug use than women, and rates of illicit drug use in urban areas are higher than in rural areas.21 State-by-State Treatment Gap Table

Table 3 presents state estimates of treatment gaps, which are the percentages and numbers of people who need but do not receive treatment for illicit drug use. It does not include alcohol. A discussion follows about the methodology used to calculate the state estimates of the treatment gap.22

For each respondent in the sample, one can determine whether a person needed but did not receive treatment for an illicit drug problem based on the following definition: An individual was counted in the treatment gap if he or she was dependent on or had abused an illicit drug but had not received treatment for his or her illicit drug problem at a “specialty” substance abuse facility in the past 12 months (i.e., in the 12 months before being interviewed). “Specialty” substance abuse facilities include drug and alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient only), and mental health centers.23

The state estimates are based on a model that has two components. One component is a national model using data from the 2000 National Household Survey on Drug Abuse (NHSDA). The national model includes demographic information (such as age and race), socioeconomic information on the local area (such as the percentage below the poverty level), and information specific to drug use (such as the marijuana possession arrest rate for the county). The information used in the national model is available at the census block, census tract or county level.24

The second component of the model is the information collected from the NHSDA re- spondents in each state. This direct sample component adjusts the results to reflect state- and local-level differences. Together, these two components produce the final estimate. In effect, for each state, two estimates of the treatment gap—one from a national model and one from the sample data from the state—are combined to make the best estimate for the state. If a state is represented in the survey by a relatively small sample and the direct sample estimate from the state is subject to significant sampling variation, more weight is given to the national component.

When the process is complete, the results are validated by comparing the estimates produced by the model with estimates based entirely on the sample data. This is done for areas that have very large samples that can be assumed to produce “accurate” estimates without the need for models. The validation results showed that the model-based estimates for all those age 12 or older were quite accurate compared with the true state value—on average, within about 4 percent of the true value. For example, if the true value in a state was 2 percent, the estimate would typically be within 0.08 of a percent of the true value.25

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 17

Table 3. Estimated Numbers and Percentages of Persons Aged 12 or Older Needing But Not Receiving Treatment for an Illicit Drug Problem in the Past Year, by State: 2000

State/Jurisdiction Estimated Numbers Estimated Percentages Total 3,994,321 1.79% Alabama 60,846 1.66 Alaska 10,381 2.12 Arizona 88,686 2.29 Arkansas 34,202 1.58 California 563,676 2.19 Colorado 71,131 2.09 Connecticut 52,010 1.92 Delaware 11,100 1.76 Florida 196,128 1.55 Georgia 100,012 1.73 Hawaii 16,838 1.73 Idaho 19,700 1.81 Illinois 164,309 1.68 Indiana 82,093 1.66 Iowa 32,845 1.37 Kansas 35,310 1.63 Kentucky 53,647 1.63 Louisiana 65,208 1.83 Maine 18,817 1.80 Maryland 80,734 1.89 Massachusetts 108,669 2.11 Michigan 137,607 1.74 Minnesota 75,663 1.90 Mississippi 37,181 1.63 Missouri 67,487 1.48 Montana 12,396 1.60 Nebraska 22,267 1.61 Nevada 27,941 1.81 New Hampshire 19,883 1.97 New Jersey 110,186 1.64 New Mexico 25,748 1.73 New York 285,054 1.93 North Carolina 98,671 1.55 North Dakota 8,019 1.49 Ohio 150,150 1.62 Oklahoma 43,449 1.58 Oregon 54,906 1.92 Pennsylvania 160,117 1.58 Rhode Island 13,983 1.70 South Carolina 48,469 1.54 South Dakota 9,262 1.49 Tennessee 78,992 1.69 Texas 287,765 1.79 Utah 36,474 2.11 Vermont 9,810 1.92 Virginia 87,768 1.55 Washington 94,245 1.97 West Virginia 22,959 1.47 Wisconsin 75,832 1.71 Wyoming 6,872 1.61 District of Columbia 8,820 2.08

Source: “National and State Estimates of Drug Abuse Treatment Gap, Chapter 3. Estimates of the Treatment Gap, by State,” http://www.samhsa.gov/oas/TXgap/ chapter3.htm.

National Conference of State Legislatures 18 Treatment of Alcohol and Other Substance Use Disorders

Profile of a Typical Person with an Alcohol and Other Substance Use Disorders

Analyses of available statistics reveal that the typical addict is a 35-year-old white male who is employed full-time. However, many people think that the typical addict is a 16-year- old black female who is unemployed and on welfare. One reason for this misperception is that an addict who is able to function and go to work is invisible—nobody knows that he is an addict. This is part of the stigma of addiction. Profiles of People with Alcohol and Other Substance Use Disorders Demonstrate that all Populations are Addicts Lori R.

“I am going to continue being a mom,” Lori R. said as she spoke proudly about her three children. But, until recently, the idea of parenting created anxiety for Lori. On May 1, 2000, the Department of Children and Family Services (DCFS) took Lori’s children into custody because she was using drugs. “I just kept going into their empty rooms and cry- ing,” said Lori.

After that day, Lori said she saw the damage that using drugs had inflicted on her life. She started a treatment program and in October 2000, Lori began to work for JCPenney. As she progressed in her recovery and became self-sufficient, Lori shifted her focus to her children’s return.

The reunification process is a difficult one, especially for those who are trying to maintain their abstinence from alcohol and other drugs. Lori’s recovery coach knows this is true. “During the process of trying to get their kids back, they are also working to maintain their sobriety, they are in counseling, and they are going to work every day; it can be really overwhelming.”

Lori knew she wanted her children home, but they had been away for so long that she was nervous about their homecoming. “I felt like I had let my children down,” said Lori. Her recovery coach was there to help guide her through the reunification process. “That’s the reason I was there—to ensure things went smoothly, like an advocate.”

Lori continues to work at JCPenney, where she has been promoted three times. She hopes to become a first-time homeowner sometime this summer. But, most importantly, she has her children back in her life. “I’m a mom now,” she said. Mari L.

Mari L. is learning a new way of life. Her drug use led to criminal behavior, and a judge finally ordered treatment overseen by an independent case manager as part of her probation sentence. “I was an addict for 20 years. My case manager set up a treatment plan that took me through the stages of addiction, but also taught me there’s a difference between abstinence and sobriety. I stopped using before, once for a couple of years, but now I see I have to recover from my old way of life.”

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 19

For Mari, that meant leaving behind certain friends and family members, many of whom were in denial about her addiction, while others served as her “enablers.”

“I knew they would give me $20, $30 because they liked me as a person, and in a day I could get $100.” Even then, Mari was beginning to realize that brief highs weren’t worth the more enduring consequences of withdrawal, but she couldn’t stop using. “My case manager got me into treatment that was right for me. I needed structure in my life and not every program works for everybody.”

Mari went to a recovery home where she underwent four months of residential treatment. Now, she is living one year of sobriety at the recovery home before getting her own apart- ment. A telemarketing job, plus some overtime, covers her rent and she looks forward to parlaying this experience into a higher-level position as an emergency operator.

“I’m learning to come up with solutions to deal with my problems instead of making excuses,” she says. “Today, I know I have a lot of options and the choices are mine. There’s nothing I can do about yesterday, except to learn from it.” To people new to the treatment process, Mari advises, “It will work for you, if you work at it and believe you can be productive for the rest of your life.” Jim

“I was one of those drunks who never saw the inside of a jail, nor was I ever ticketed for any offense that I could attribute to alcohol. I have never been hospitalized for any reason. Drinking never cost me a job or my wife.”26

“My favorite expression was, ‘I can quit drinking any time I want to.’ It got to the point where I started to believe it. I was able to quit drinking each Lent except for the one just prior to my coming into the A.A. program. I believed God would punish me more in the hereafter if I didn’t do some penance for my sins here on earth. Abstaining from alcohol was the toughest penance I knew of. Sheer determination, bullheadedness, willpower, and ego- tism carried me through.

Bullheadedness was a part of my nature. When I had made up my mind to do something, hell or high water couldn’t change it. Many times during Lent, my wife pleaded with me to drink, just because I was so miserable to her and the kids when I wasn’t drinking.”27

“All my friends knew I always quit during Lent. Their adulation of my willpower sustained me through those days and nights. The fear of what they might say or think if I happened to fall off the wagon kept me going till Easter. I lived on the comments of my drinking buddies’ wives: ‘Oh, how I wish my Jack (or Tom, or Steve) could quit like you.’ My wife was probably thinking, ‘If they only knew what his sobriety is costing me!’” 28

“I was also the smartest man in the world, in the company I worked for, in the departments I worked in, and at home as the head of the family.” 29

“I had only one problem that was a little difficult to understand, let alone solve. After waking so many mornings feeling so terribly lousy and sick, and telling and promising myself I would not be that stupid again, why would I go right out and be stupid again?

National Conference of State Legislatures 20 Treatment of Alcohol and Other Substance Use Disorders

Why couldn’t I stop after only one or two, like some guys I knew? Why was I almost always thinking about booze one way or another? Why couldn’t I fall asleep unless I was at least half gooned-up?” 30

“What would I do with my time if I quit? What would people say or think if I quit? What would customers say? What about Christmas, New Year’s, and my birthday without booze? How come I couldn’t quit when I wanted to, when I’d always said I could? How come I lied so much? I was tired of lying, I was tired of trying to be someone else. It hurt me to think I was hooked on booze like an addict on dope.” 31

“One beautiful Saturday afternoon in July, when I was 34 years old, I blurted out to a priest that alcohol might be the root of my troubles. I had never before admitted such a thing to anyone. The priest suggested I try A.A.” 32

“I think one of the extraordinary yet simple points of A.A. is that I didn’t have to quit drinking—in the sense that I understood quitting—before entering the program. I think if the program had advocated quitting as I understood it, I would not be sober today.” 33

“A.A. teaches us how to live without alcohol, how unnecessary alcohol is, and how it increases our problems.” 34

“It is a perfectly natural thing for most of us to say thank you to other people for whatever we receive. That’s why it is important that I say thanks for the most precious gift I can receive—24 hours of sobriety.” 35 Use-by-Age Charts

Tables 4 and 5 quantify rates of alcohol and other substance use, abuse and dependence by substance, by age.

Table 4. Rate of Alcohol and Other Substance Use by Substance, by Age (Annual Averages Based on 1999 and 2000 NHSDAs)

Past Month Past Month Past Month Past Year Past Month Past Month Users of Any Users of Users of Any Users of Users of Alcohol “Binge” Illicit Drug Marijuana Illicit Drug Cocaine Alcohol Users Age Other Than Group Marijuana (Yrs.) # % # % # % # % # % # % Total 13,968 6.28 10,675 4.80 5,935 2.67 3,658 1.64 102,758 46.25 45,349 20.41 12-17 2,280 9.79 1,687 7.24 1,058 4.54 389 1.67 3,819 16.40 2,387 10.25 18-25 4,598 16.01 3,932 13.69 1,713 5.96 1,358 4.73 16,318 56.81 10,850 37.78 26 or 7,091 4.17 5,056 2.97 3,164 1.86 1,910 1.12 82,621 48.55 32,112 18.87 older

Key: # = Estimated Numbers (in Thousands) % = Percentages Reporting

Source: “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, Appendix A: Tables of Model-Based Estimates (50 States and the District of Columbia), by Substance,” http://www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf.

National Conference of State Legislatures What Are the Effects of Alcohol and Other Substance Use Disorders? 21

Table 5. Rate of Substance Abuse and Dependence by Substance, by Age (Annual Averages Based on 1999 and 2000 NHSDAs)

Past Year Alcohol Past Year Alcohol Past Year Any Past Year Any Past Year Dependence or Dependence Illicit Drug Illicit Drug Dependence or Abuse Dependence or Dependence Abuse for Any Age Abuse Illicit Drug or Group Alcohol (Yrs.) # % # % # % # % # % Total 12,384 5.54 5,225 2.34 4,504 2.01 2,869 1.28 14,701 6.58 12-17 1,225 5.24 432 1.85 1,061 4.54 564 2.41 1,806 7.73 18-25 3,750 12.94 1,337 4.61 1,062 5.53 1,015 3.50 4,479 15.45 26 or 7,409 4.33 3,456 2.02 1,841 1.08 1,289 0.75 8,416 4.92 older

Key: # = Estimated Numbers of Persons Reporting (in Thousands) % = Percentages Reporting

Adolescents

Adolescents are a population that is uniquely affected by alcohol and other substance use disorders. Many adolescents themselves use alcohol and some use other drugs. Adoles- cents whose parents use substances are at greater risk of developing alcohol and other substance use disorders. It is important to note that, although it is legal for adults to use alcohol, it is illegal for adolescents. Adolescents’ Use

Since 1975, the Institute for Social Research at the University of Michigan has conducted an annual national survey on drug and alcohol of approximately 16,000 high school seniors. In 1993, the wording of alcohol-related questions was changed to indicate that a “drink” meant “more than a few sips.”

According to the survey results, the number of seniors who have ever tried alcohol remained stable at 80 percent between 1993 and 1999. However, the number of seniors who used alcohol in the past year or in the past 30 days both increased slightly between 1993 and 1999. The number of seniors who have been drunk in the last 30 days also rose by 4 percent from 1993 to 32.9 percent in 1999. The 1998 NHSDA indicates rates of underage drinking were highest among white males between the ages of 18 and 20.36

The University of Michigan results found more than half (54.7 percent) of high school seniors surveyed in 1999 had used an illicit drug in their lifetime. This is a marked increase from the 42.9 percent reported in 1993. The number of seniors who had used an illicit drug in the past 30 days also rose substantially from 18.3 percent in 1993 to 25.9 percent in 1999. Rates of illicit drug use in the 1998 NHSDA were highest among 18- to 20-year-olds and decreased thereafter.37

Youth alcohol and other substance use continues to be a problem that states are attempting to address. The number of adolescents under age 18 who are receiving alcohol and other substance use treatment on any given day in the United States almost doubled from 44,000 people in 1991 to 77,000 people in 1996, according to the Substance Abuse and Mental Health Services Administration’s Office of Applied Studies.

National Conference of State Legislatures 22 Treatment of Alcohol and Other Substance Use Disorders

Parents’ or Custodial Adults’ Use

Alcoholism and other drug addiction have genetic and environmental causes. Both have serious consequences for children who live in homes where parents are involved. More than 28 million Americans are children of alcoholics; nearly 11 million are under age 18. This figure is magnified by the countless number of others who are affected by parents who are impaired by other psychoactive drugs. Alcoholism and other drug addiction tend to run in families. 38

• Children of addicted parents are more at risk for alcoholism and other drug addiction than are other children. Family interaction is defined by alcohol and other substance use or addiction in a family. A relationship between parental addiction and child abuse has been documented in a large proportion of child abuse and neglect cases.

• Children of drug addicted parents are at higher risk for placement outside the home.

• Children of addicted parents exhibit symptoms of depression and anxiety more than do children from non-addicted families.

• Children of addicted parents experience greater physical and mental health problems and higher health and welfare costs than do children from non-addicted families.

• Children of addicted parents have a high rate of behavior problems.

• Children of addicted parents score lower on tests measuring school achievement and they exhibit other difficulties in school. Maternal consumption of alcohol and other drugs during any time of pregnancy can cause birth defects or neurological deficits.

• Children of addicted parents may benefit from supportive adult efforts to help them.

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 23

3. WHY SHOULD STATE LEGISLATORS BE CONCERNED ABOUT ALCOHOL AND OTHER SUBSTANCE USE DISORDERS?

National expenditures for the treatment of alcohol and other substance use disorders exceeded $12 billion in 1996. This • National expenditures for the treatment of alcohol and other amount is relatively low when compared to the $246 bil- substance use disorders exceeded $12 billion in 1996. lion that alcohol and other substance use cost society.1 • This amount is relatively low when compared to the $246 State governments spend billions of dollars each year on billion that alcohol and other substance use cost society. alcohol and other substance use treatment. Additional billions are spent on alcohol and other drug-related crimes, • The costs of alcohol and other substance use disorders were accidents and social problems that arise in the work place, estimated in 1992 by the National Institute on Drug Abuse the community and the home. Problems include lost and the National Institute on Alcohol Abuse and Alcoholism worker productivity, increased homelessness, and mental to be more than $246 billion annually. health and family problems. • States spent $81.3 billion in 1998 to deal with this issue— Studies from several states have shown that drug treatment 13.1 percent of their budgets. is cost effective. These state experiences demonstrate that alcohol and other substance use treatment results in • Furthermore, of every dollar states spent on substance abuse, 96 cents went to shovel up the wreckage in state programs marked decreases in drug use, medical expenses and illegal and only four cents went to prevent and treat the problem. behavior, which translates into savings for employers, for 2 the health care system and for taxpayers. • An estimated 8.2 million people were dependent on alcohol in 2002, and 2.44 million people reported receiving treat- State legislators will want to be aware of the economic, ment or counseling for their alcohol use. health and social consequences of alcohol and other substance use disorders in order to make cost-effective public • In 2002, 19.5 million Americans were current illicit drug policy decisions. users. This represents 8.3 percent of the population age 12 and older. Economic Costs

Alcohol and other substance use disorders place financial burdens on states and taxpayers. Untreated alcohol and other substance use cost the nation billions of dollars each year as a result of increasing health care costs, loss of productivity at work, judicial and law enforcement costs, unemployment and the costs of social services. The costs of alcohol and other substance use disorders were estimated in 1992 by the National Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism to be more than $246 billion

National Conference of State Legislatures 23 24 Treatment of Alcohol and Other Substance Use Disorders

annually. The costs of alcoholism are expected to increase every year due to population growth and inflation.3 States bear the greatest financial burden.

Many ancillary costs also are associated with alcohol and other substance use disorders. These include health, social service, criminal justice, education, mental health and public safety. These costs result from untreated alcohol and other substance use disorders because, left untreated, people with alcohol and other substance use disorders are likely to have medical problems, consume social services, commit crimes, have children with learning disabilities, have co-occurring mental illnesses and impede the safety of the community. States are employing multiple approaches to avoid, shift and offset these costs, particularly in the criminal justice system via treatment in lieu of incarceration, i.e., drug courts, diversion programs and sentencing reform. Associated Costs

The National Center on Addiction and Substance Abuse at Columbia University (CASA) published a January 2001 report, Shoveling Up: The Impact of Substance Abuse on State Budgets, the first comprehensive analysis of how much substance abuse and addiction cost each state budget. This analysis shows that states spent $81.3 billion in 1998 to deal with this issue—13.1 percent of their budgets. Furthermore, of every $1 states spent on substance abuse, 96 cents went to shovel up the wreckage in state programs and only four cents went to prevent and treat the problem. This report provides state specific estimates for 45 responding states, the District of Columbia and Puerto Rico for 16 categories of programs, including health, social service, criminal justice, education, mental health and public safety. CASA estimated aggregate spending in the five states that did not respond to the survey (Indiana, Maine, New Hampshire, North Carolina and Texas).4

Among the findings of the report are these.5

• State governments spent $81.3 billion in 1998 to deal with substance abuse. This amounts to more than 13 cents of every state budget dollar. Substance abuse is among the largest cost in state budgets, although its effects are hidden in departments and activities that typically do not deal with substance abuse.

• Each American paid $277 per year in state taxes to deal with the burden of substance abuse and addiction in their social programs, and only $10 per year for prevention and treatment.

• Of every $1 states spend on substance abuse:

- 95.8 cents goes to pay for the burden of this problem on public programs. Un- treated substance abuse increases, for example, the cost of every state’s criminal justice system; elementary and secondary schools; Medicaid; child welfare, juvenile justice and mental health systems; highways; and state payrolls. These costs totaled $77.9 billion in 1998.

- Only 3.7 cents goes to fund prevention, treatment and research programs aimed at reducing the incidence and consequences of substance abuse. State spending for prevention, treatment and research amounted to $3 billion in 1998.

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 25

- One-half of one cent covers costs of collecting alcohol and tobacco taxes and regulating alcohol and tobacco products. Regulation and taxation are untapped resources that could help control spending on the consequences of alcohol and tobacco abuse and addiction. State spending on regulation and compliance was $433 million in 1998.

• States spent $24.9 billion in 1998 on the costs of substance abuse to children—an amount comparable to the entire state budget of Pennsylvania. For every $113 states spend on the consequences of substance abuse just for children, they spend only $1 on prevention or treatment.

• States spent $30.7 billion in 1998 on the burden of substance abuse on the justice system—for incarceration, probation and parole, juvenile justice and criminal and family court costs of substance-involved offenders. These costs total 4.9 percent of state budgets, more than 10 times the total amount that states spent for substance abuse treatment and prevention.

• Other areas of significant state spending for failing to prevent or treat substance abuse include:

- $16.5 billion in education (2.7 percent of state spending),

- $15.2 billion in health (2.4 percent of state spending),

- $7.7 billion in child and family assistance (1.2 percent of state spending), and

- $5.9 billion in mental health and developmental disabilities (0.9 percent of state spending).

• States spend more on the consequences of substance abuse than they do on Medicaid ($60.4 billion or 9.7 percent of state budgets) or on transportation ($51.4 billion or 8.3 percent of state budgets). They spend as much on substance abuse as on higher education ($81.3 billion or 13.1 percent of state budgets).

• The drug linked to the largest percentage of state substance abuse costs is alcohol. At least $9.2 billion is spent on alcohol alone, $7.4 billion on tobacco alone and $1.1 billion on illicit drug use only. The remaining spending, $63.6 billion, could not be differentiated by drug, but most of this amount is linked to both alcohol and illegal drug abuse.

• States collected $4 billion in alcohol taxes and $7.4 billion in tobacco taxes in 1998 for a total of $11.4 billion. For each $1 in alcohol and tobacco taxes that reached state coffers, states spent $7.13 on the problem of alcoholism and drug addiction—$6.83 to cope with the burden, $0.26 for prevention and treatment and $0.04 to collect taxes and run licensing boards. Few states dedicate revenues to the burden of untreated substance abuse or use alcohol and tobacco tax increases as a way to reduce use by teens.

• On average, of every $100 states spend on substance abuse, they spend $95.80 on the burden of substance abuse to public programs, compared to $3.70 for prevention,

National Conference of State Legislatures 26 Treatment of Alcohol and Other Substance Use Disorders

treatment and research ($0.50 is spent on regulation and compliance), but state spending varies widely. The proportion spent on shoveling up the wreckage compared to prevention and treatment ranges from to $89.71 vs. $10.22 in North Dakota to $99.94 vs. $0.06 in Colorado. Elements that Measure Associated Costs

To survey states for its Shoveling Up report, CASA identified several elements of state budgets to examine to assess the cost of untreated addiction to the states. Those elements are:6

• Justice - Adult Corrections - Juvenile Justice - Judiciary • Education • Health • Child and Family Assistance - Child Welfare - Income Support Programs • Mental Health/Developmental Disabilities - Mental Health - Developmental Disabilities • Public Safety • State Workforce Employment Consequences

Alcohol and other substance use disorders are generally recognized to be a major, global public health problem of particular concern. There are many reasons for this concern, including the likelihood that: 1) employees with alcohol and other substance use disorders damage their own and others’ health and well being; 2) employee alcohol and other substance use may decrease productivity and contribute to absenteeism, accidents, injuries, death or violence in the workplace; and 3) a workplace that tolerates or ignores employee alcohol and other substance use disorders does not reflect the interests of the vast majority of employees who do not use substances or who are in recovery.7

• Alcoholism alone accounts for 500 million lost work days each year. Casual drinkers, in aggregate, account for far more incidents of absenteeism, tardiness, and poor quality of work than those who are regarded as alcohol dependent.8

• Between 20 percent and 40 percent of all general hospital patients are admitted for complications related to alcoholism and other forms of alcohol and other substance use disorders.9

• The human costs to the individual, family, and community are incalculable.10

• Today, almost 73 percent of all current drug users between the ages of 18 and 49 are full- or part-time employed—more than 8.3 million workers.11

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 27

• About 7 percent of full-time workers use illicit drugs (6.3 million), and about 7 percent are heavy drinkers.12

• About 1.2 million full-time workers both use illicit drugs and are heavy alcohol users.13

• The highest rate of documented or reported illicit drug use and heavy alcohol use is among those who are between the ages of 18 and 25, males, Caucasian, and those with less than a high school education.14 Health Consequences

According to the National Household Survey on Drug Abuse, an estimated 8.2 million people were dependent on alcohol in 2002, and 2.44 million people reported receiving treatment or counseling for their alcohol use.15 Although alcohol and other drugs are implicated in deaths caused by motor vehicle crashes, drownings, falls and fires, it is difficult to measure the connection between alcohol and morbidity. Excessive use of alcohol is harmful to every organ and tissue in the body. Alcohol affects the liver, esophagus, stom- ach, intestines, heart, brain, nerves, hormones and immune system and also can lead to other health problems.16 Some studies also show that moderate use of alcohol is good for an individual’s heart because it boosts HDL cholesterol levels. However, aerobic exercise and weight loss also provide the same result. Alcohol intake is not recommended solely to have a healthier heart because alcohol can raise blood pressure and cause many other negative health effects.

The Substance Abuse and Mental Health Services Administration estimates that, in 2002, 19.5 million Americans were current illicit drug users. This represents 8.3 percent of the population age 12 and older.17 Alcohol and other substance use causes damage to the health of an alcohol and other substance user and can impede his or her ability to function at a normal level.

According to a research study conducted by Rutgers University, treatment of alcohol and other substance use disorders causes sharp reductions in medical care utilization and en- courages more appropriate utilization when services are delivered. These cost offsets are a stable, long-term effect of treatment from which society will reap benefits for a period longer than any research team has followed to date.18 Fetal Alcohol Syndrome and Drug-Affected Babies

Drinking alcohol during pregnancy can produce infants with fetal alcohol syndrome (FAS) or infants with fetal alcohol effects (FAE). Characteristics of FAS include prenatal and postnatal growth retardation, evidence of craniofacial anomalies, central nervous system dysfunction and malformations in the major organ systems. FAE is a lesser set of the same symptoms that make up FAS. At least 5,000 infants are born each year with FAS; another 50,000 children show symptoms of FAE.19

Alcohol-related neurodevelopmental disorder (ARND) is a term used to describe individuals who have mental but no physical abnormalities. Alcohol-related birth defects (ARBD) refers to those who have physical defects of the body from prenatal alcohol exposure.

National Conference of State Legislatures 28 Treatment of Alcohol and Other Substance Use Disorders

Studies have examined babies born with FAS at later developmental stages to determine its long-term effects. Overall improvement could be seen in some areas: the appearance of the children, their clumsiness, impaired concentration, difficulties with siblings, tantrums, negativity and phobias. Other factors persisted, however, including hyperactivity, speech defects and anxiety. There was a greater need for special education for these children as they reached school age and, the more mentally challenged these children were at birth, the less improvement they showed as they grew older. Most of these children continue to need special health, education and social services as they grow older.20

Drug and alcohol use by pregnant women has gained national attention. When pregnant women use drugs, alcohol or cigarettes, the substances cross the placenta and affect the developing fetus. Cocaine use can cause miscarriage, fetal stroke, premature delivery, and maternal and infant hemorrhaging. Narcotics such as opium and heroin can cause fetal addiction, which can lead to infant withdrawal, respiratory distress and convulsions. In addition to physical abnormalities, drug-affected babies use costly medical services and a variety of other support services.

In 1997, the Substance Abuse and Mental Health Services Administration released the first major analysis of alcohol, illicit drug and tobacco use in a nationally representative sample of women. The findings indicated:

• About 21.5 percent of pregnant women under age 44 had used alcohol in the past month and, of this group, nearly one-third reported having three or more drinks on the days they drank.

• An estimated 62,000, or 2.3 percent, of all pregnant women under age 44 reported using an illicit drug in the past month.21

A 1998 study by the National Institute on Drug Abuse (NIDA) showed an increase from 1997 in the use of illicit drugs by pregnant women who used an illicit drug during pregnancy to 5.5 percent, or 221,000 women.22 Infectious Disease

According to the U.S. Centers for Disease Control and Prevention, although the number of cases of acute hepatitis C virus (HCV) among injection drug users has declined dramatically since 1989, both incidence and prevalence of HCV infection remain high in this group. The reasons are not fully understood but may be due to safer injection practices resulting from intensive HIV prevention programs and to the very high proportion of drug users who already are infected. Injection drug use currently accounts for most HCV transmission in the United States, and has accounted for a substantial proportion of HCV infections during the past decades. Many people with chronic HCV infection might have acquired their infection 20 to 30 years ago as a result of limited or occasional illegal drug injecting. Injection drug use leads to HCV transmission in a manner similar to that for other blood borne pathogens (i.e., through transfer of HCV-infected blood by sharing syringes and needles either directly or through contamination of drug preparation equipment). However, HCV infection is acquired more rapidly after initiation of injecting than other viral infections (i.e., hepatitis B virus (HBV) and human immunodeficiency virus (HIV)), and rates of HCV infection among young injecting drug users are four times higher than rates of HIV infection. After five years of injecting, as many as 90 percent of users are

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 29

infected with HCV. More rapid acquisition of HCV infection, compared with other viral infections among injection drug users is likely caused by high prevalence of chronic HCV infection among injecting-drug users, which results in a greater likelihood of exposure to an HCV-infected person.23

• A study conducted among volunteer blood donors in the United States documented that HCV infection has been independently associated with a history of intranasal cocaine use. (The mode of transmission could be through sharing contaminated straws.) Data from NHANES III indicated that 14 percent of the general population have used cocaine at least once. Although NHANES III data also indicated that cocaine use was associated with HCV infection, injection drug use histories were not ascertained.24

• Among patients with acute hepatitis C identified in CDC’s sentinel counties viral hepatitis surveillance system since 1991, intranasal cocaine use in the absence of injection drug use was uncommon.25

Thus, at least in the recent past, intranasal cocaine use rarely appears to have contributed to transmission. Until more data are available, whether those with a history of noninjecting illegal drug use alone (e.g., intranasal cocaine use) are likely to be infected with HCV remains unknown.26

The incidence of reported HIV cases among injection drug users (IDU) is accelerating at an alarming rate. According to the U.S. Centers for Disease Control and Prevention, sharing syringes and other equipment for drug injection is a well-known route of HIV transmission, yet injection drug use contributes to the epidemic’s spread beyond the circle of those who inject. Since the epidemic began, injection drug use has directly and indirectly accounted for more than 36 percent of AIDS cases in the United States. This disturbing trend appears to be continuing. Of the 48,269 new cases of AIDS reported in 1998, 31 percent were IDU-associated. People who have sex with an IDU also are at risk of infection through the sexual transmission of HIV. Children born to mothers who contracted HIV through sharing needles or having sex with an IDU may become infected as well.27

Alcohol and other substance use also places individuals at risk for sexually transmitted diseases (STDs). While experiencing the effects of the substance, individuals are likely to engage in unprotected sex. (This also leads to more unintended pregnancies.) Further- more, substances suppress inhibitions; therefore, individuals are likely to engage in more risky behaviors. Mental Health

Estimates suggest that each year up to 10 million people across the nation are suffering from at least one co-occurring mental health and alcohol and other substance use disorder.28 The National Comorbidity Study results indicate that 41 percent to 65 percent of individuals with a lifetime alcohol and other substance use disorder also have a lifetime history of at least one mental disorder. In addition, almost 51 percent of individuals with one or more lifetime mental disorders also have a history of at least one alcohol and other substance use disorder.29 Although a causality relationship between alcohol and other substance use disorders and mental disorders has yet to be established, there are indications that individuals who suffer from mental illnesses may self-medicate with alcohol and other drugs, leading to alcohol and other substance use disorders.

National Conference of State Legislatures 30 Treatment of Alcohol and Other Substance Use Disorders

President George W. Bush established the President’s New Freedom Commission on Men- tal Health in April 2002. The commission is chaired by Michael F. Hogan, director of the Ohio Department of Mental Health. The commission submitted its final report to the president on July 22, 2003. The commission established 15 subcommittees to examine specific aspects of mental health services and offer recommendations for improvement. The subcommittee on Co-occurring Disorders, chaired by Rodolfo Arredondo, submitted its summary report, An Outline for the Draft Report of the Subcommittee on Co-occurring Sub- stance Abuse and Mental Disorders, on Dec. 2, 2002. The report can be found at http:// www.mentalhealthcommission.gov/subcommittee/Co_Occurring_Outline.doc. Medical Conditions

Alcohol-related problems—such as liver disease, heart disease, certain forms of cancer and pancreatitis—often develop more gradually and may become evident only after many years of heavy drinking. Women may develop alcohol-related health problems sooner than men, and from drinking less alcohol than men. Because alcohol affects nearly every organ in the body, long-term heavy drinking increases the risk for many serious health problems. More than 2 million Americans suffer from alcohol-related liver disease.30

• Some drinkers develop alcoholic hepatitis, or inflammation of the liver, as a result of heavy drinking over a long period of time. Its symptoms include fever, jaundice (abnor- mal yellowing of the skin, eyeballs and urine) and abdominal pain. Alcoholic hepatitis can cause death if drinking continues. If drinking stops, the condition may be reversible.31

• About 10 percent to 20 percent of heavy drinkers develop alcoholic cirrhosis, or scar- ring of the liver. People with cirrhosis should not drink alcohol. Although treatment for the complications of cirrhosis is available, a liver transplant may be needed for someone with life-threatening cirrhosis. Alcoholic cirrhosis can cause death if drinking continues. Cirrhosis is not reversible, but if a person with cirrhosis stops drinking, the chances of survival improve considerably. People with cirrhosis often feel better, and liver function may improve, after they stop drinking.32

• About 4 million Americans are infected with hepatitis C virus (HCV), which can cause liver cirrhosis and liver cancer. Some heavy drinkers also have HCV infection. As a result, their livers may be damaged not only by alcohol but by also HCV-related problems. People with HCV infection are more susceptible to alcohol-related liver damage and should think carefully about the risks when considering whether to drink alcohol.33

• Moderate drinking can have beneficial effects on the heart, especially among those at greatest risk for heart attacks, such as men over age 45 and women after menopause. However, heavy drinking over a long period of time increases the risk for heart disease, high blood pressure, and some kinds of stroke.34

• Long-term heavy drinking increases the risk of certain forms of cancer, especially cancer of the esophagus, mouth, throat and larynx (voice box). Research suggests that, in some women, as little as one drink per day can slightly increase the risk of breast cancer. Drinking also may increase the risk of developing cancer of the colon and rec- tum.35

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 31

• The pancreas helps regulate the body’s blood sugar levels by producing insulin. The pancreas also has a role in digesting the food we eat. Long-term heavy drinking can lead to pancreatitis, or inflammation of the pancreas. Acute pancreatitis can cause severe abdominal pain and can be fatal. Chronic pancreatitis is associated with chronic pain, diarrhea and weight loss.36

High doses of cocaine and/or prolonged use can trigger paranoia. Smoking crack cocaine can produce a particularly aggressive paranoid behavior in users. When addicted individuals stop using cocaine, they often become depressed. This also may lead to further cocaine use to alleviate depression. Prolonged cocaine snorting can result in ulceration of the mu- cous membrane of the nose and can damage the nasal septum enough to cause it to col- lapse. Cocaine-related deaths often are a result of cardiac arrest or seizures followed by respiratory arrest.37

Research findings for long-term marijuana use indicate some changes in the brain similar to those seen after long-term use of other major drugs of abuse.38

• A study of 450 individuals found that people who smoke marijuana frequently but do not smoke tobacco have more health problems and miss more days of work than do nonsmokers. Many of the extra sick days among the marijuana smokers in the study were for respiratory illnesses. Even infrequent use can cause burning and stinging of the mouth and throat, often accompanied by a heavy cough. Someone who smokes marijuana regularly may have many of the same respiratory problems as tobacco smokers, such as daily cough and phlegm production, more frequent acute chest illness, a heightened risk of lung infections, and a greater tendency to obstructed airways. Can- cer of the respiratory tract and lungs also may be promoted by marijuana smoke.39

• A study comparing 173 cancer patients and 176 healthy individuals produced strong evidence that smoking marijuana increases the likelihood of developing cancer of the head or neck, and the more marijuana smoked the greater the increase. A statistical analysis of the data suggested that marijuana smoking doubled or tripled the risk of these cancers. Marijuana use has the potential to promote cancer of the lungs and other parts of the respiratory tract because it contains irritants and carcinogens. In fact, marijuana smoke contains 50 percent to 70 percent more carcinogenic hydrocarbons than does tobacco smoke. It also produces high levels of an enzyme that converts certain hydrocarbons into their carcinogenic form—levels that may accelerate the changes that ultimately produce malignant cells. Marijuana users usually inhale more deeply and hold their breath longer than tobacco smokers do, which increases the lungs’ exposure to carcinogenic smoke. These facts suggest that, puff for puff, smoking marijuana may increase the risk of cancer more than smoking tobacco.40 Death

Alcoholic hepatitis can cause death if drinking continues. Alcoholic cirrhosis can cause death if drinking continues. Acute pancreatitis can cause severe abdominal pain and can be fatal.41

In rare instances, sudden death can occur on the first use of cocaine or unexpectedly thereafter. However, there is no way to determine who is prone to sudden death. Cocaine- related deaths often are a result of cardiac arrest or seizures followed by respiratory arrest.42

National Conference of State Legislatures 32 Treatment of Alcohol and Other Substance Use Disorders

One study has indicated that a user’s risk of heart attack more than quadruples in the first hour after smoking marijuana. The researchers suggest that such an effect might occur from marijuana’s effects on blood pressure and heart rate and reduced oxygen-carrying capacity of blood.43 Trauma

Alcohol and other substance use disorders are major contributing factors in thousands of traumatic injuries each year. The Drug Abuse Warning Network (DAWN) is a national probability survey of hospital emergency departments (EDs) conducted annually by the Substance Abuse and Mental Health Services Administration to capture data about emergency department episodes induced by or related to the use of an illegal drug or the non- medical use of a legal drug. Data for 2001 showed an estimated 638,484 drug-related ED episodes and 1,165,367 drug mentions.44 (A drug mention refers to a substance that was mentioned during a drug-related ED episode.) In drug-related ED episodes, overdose (264,086) was the most frequently cited reason for the visit. The most frequently cited motives for taking the substance were dependence (228,994) and suicide (194,324).45 Social Consequences

Families, friends, associates and communities—the entire fabric of society—are affected by the problems associated with alcohol and other substance use disorders. People who misuse drugs and alcohol often are less productive on their jobs than others. Alcohol and other substance use disorders contribute to crime, TANF/welfare, accidents, auto crashes, suicide, homelessness, domestic violence and child abuse. Crime

Alcohol and other substance use and crime are inextricably linked. Research conducted in major cities across the country reveals that an average of 64 percent of arrestees—male and female, young and old, regardless of the type of offense—used substances in the days leading up to their crime and arrest.46 Throughout the last 20 years of the twentieth century, in a political and ideological climate that favored tougher penalties, states attempted to curb alcohol and other substance use and their attendant social harm through the widespread enactment of determinate and mandatory minimum sentencing provisions and “three strikes and you’re out” laws.47

The result—a prison population that now stands at more than 1.3 million, and that qua- drupled from 1980 to 2000.48 During that same time period, the United States consistently ranked in the top three industrialized nations in rate of incarceration.49 Enhance- ments to sentences and reductions in access to rehabilitative options, particularly for low- level drug offenses, continued unabated, despite little evidence that incarceration had any meaningful effect on recidivism rates among addicted offenders.50

The single most important cause of the explosive rise in the nation’s prison population is the burgeoning number of prison inmates admitted for drug offenses.51 From 1980 to 2000, the number of inmates in state and federal prisons for drug offenses increased by 1,222 percent. At the same time, drug offenders went from 6 percent of the total incarcerate population to 20 percent.52 Most state drug offense incarcerations are the result of low- level possession or sales violations.

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 33

Massive increases in the numbers of incarcerated people have disproportionately involved minority communities, particularly African Americans.53 African Americans currently constitute 45 percent of the prison population in the United States, and more than 10 percent of the African American males between the ages of 25 and 29 currently are incarcerated.54 At the beginning of the 1990s, more African American men were under the control of the criminal justice system than were enrolled in college.55 The likelihood of incarceration for a male born in 1991 is 29 percent for African Americans, 16 percent for Hispanics, and 4 percent for whites.56 In 1995, nearly one in three African American men between the ages of 20 and 29 was under some form of correctional supervision on any given day in the United States.57 Nationwide, the percentages of incarcerated African Americans are higher than their representations in every state’s general population.58

The massive imprisonment of African American men for drug offenses has taken a toll on African American communities throughout the United States. Large numbers of incarcerations for drug offenses have undermined the deterrent effects of prison.59 Imprisonment has led to fewer numbers of African American men available to care for children, leading to higher rates of children born out of wedlock, single-parent households, and overall family disruption.60 The continually growing numbers of African American women incarcerated for drug offenses also has had a devastating effect on family stability and well-being in the African American community.61 Prison terms for felony drug offense convictions also have foreclosed employment prospects and disenfranchised millions of African Americans. It is estimated that 40 percent of African American men will temporarily or permanently lose their right to vote as the result of a felony conviction.62

The effects of imprisonment are, of course, not limited to minority communities. Research has demonstrated that the effect of imprisonment on family stability, neighborhood cohesion and employment might actually increase crime rates in some communities.63 Convic- tions for felony drug offenses also prohibit many ex-offenders from being eligible for student loans, public housing assistance and drivers’ licenses, resulting in deleterious, lifelong consequences for those who already have served their sentences for drug law violations.64 TANF/Welfare

Alcohol and other substance use disorders are one of the barriers to self-sufficiency for welfare recipients.65 Alcohol and other substance use pose a particular challenge for state welfare reform efforts. It is difficult for addicted welfare recipients to follow welfare rules. It is even more difficult for these recipients to find and retain employment. Failure in work and job placements also can contribute to an already low self-esteem in these recipients. Addicted recipients often face sanctions for noncompliance with welfare rules. These sanctions may include a reduced amount of cash assistance or denial of aid, leaving the children of addicted welfare recipients vulnerable to neglect and abuse.

Welfare caseloads have dramatically declined since welfare reform. Those who remain on the caseload face multiple barriers to employment because of problems that often include alcohol and other substance use disorders. Thirty percent of the caseload has an alcohol or other substance use disorder or a mental health diagnosis. These recipients face time limits—a federal limit of 60 months of assistance and some state time limits of shorter duration. Welfare recipients with alcohol and other substance use disorders jeopardize state efforts to meet increasingly strict federal work participation requirements, which could result in federal financial penalties.

National Conference of State Legislatures 34 Treatment of Alcohol and Other Substance Use Disorders

Accidents

Alcohol and other drugs have been implicated in the four leading causes of accidents: motor vehicle collisions, falls, drowning, and burns and fires.

Burns and fires are accountable for at least 5,000 deaths and 1.4 million injuries every year.66 Further, a review of five recent studies shows that between 33 percent and 61 percent of those who died as a result of burns from fires were drinking.67

Another means of alcohol-related accidental death and injury is drowning. Drownings, including boating accidents, are the third most common cause of unintended death for all ages.68 Data from seven general population studies indicated than an average of 34 percent of 2,151 drownings involved alcohol use.69

Alcohol may increase the risk factors that contribute to injury or death in any of these activities as a result of slower response time, decreased coordination, desensitization to pain, and drowsiness. All these are effects of alcohol consumption. Auto Crashes

Automobile crashes are the leading cause of death by injury in the United States for people between the ages of 1 and 34. The National Highway Traffic Safety Administration (NHTSA) estimates alcohol was involved in 39 percent of fatal crashes and 7 percent of all crashes in 1998.70 The 15,935 fatalities in alcohol-related crashes represent an average of one alcohol-related fatality every 33 minutes. Police reported alcohol was a factor in more than 305,000 crashes that resulted in personal injury. This averages to approximately one person injured in an alcohol-related accident every two minutes.71 Suicide

Suicide is the eighth leading cause of death in the United States and the third leading cause of death for youth, according to a 1997 report released by the American Association of Suicidology. The results of one such study indicated that almost 36 percent of suicide victims had a positive blood alcohol content (BAC) level.72 Although the data did not prove a causal relationship between alcohol and suicide, the authors suggested that, for some people, alcohol may have contributed to the decision to commit suicide. Homelessness

Most national surveys involve data taken from households; therefore, alcohol and other substance use among the homeless population is not captured. The U.S. Census Bureau in 1996 surveyed homeless assistance programs and the clients who use them. These data indicate that 38 percent of homeless people who sought assistance had an alcohol problem in the past month and 26 percent had a drug problem in the past month.73 In 1999, the National Law Center on Homelessness estimated that more than 2 million people are homeless during a one-year period. Of these, 2 million, or 40 percent, are drug or alcohol dependent.

Closely related to alcohol and other substance use disorders in the homeless population are mental health problems. In 1996, more than 20 percent of the homeless population who

National Conference of State Legislatures Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders? 35

sought assistance reported using alcohol and/or other drugs in the past month in conjunction with a mental health problem.74

According to the National Coalition for the Homeless (NCH), surveys of homeless populations conducted during the 1980s found high rates of alcohol and other substance use disorders. Although there is no “ ... magic number with respect to the prevalence of addiction disorders among homeless adults,” untreated alcohol and other substance use disorders are highly correlated with homelessness.75 Homeless and alcohol and other substance use disorders are interrelated because some people are more predisposed to poverty and homelessness because of their alcohol and other substance use disorders. There are also indications that some homeless people begin to use substances to escape the reality of their homelessness and helplessness. Domestic Violence

Based on victim reports, 183,000 (37 percent) rapes and sexual assaults involve alcohol use by the offender, as do 661,000 (27 percent) of aggravated assaults and nearly 1.7 million (25 percent) simple assaults each year.76

Researchers have found that one-fourth to one-half of men who commit acts of domestic violence also have alcohol and other substance use disorders and that a sizable percentage of convicted batterers were raised by parents who used drugs or alcohol. Studies also show that women who use alcohol and other drugs are more likely to be victims of domestic violence.77

The Joint Commission on Accreditation of Healthcare Associations (JCAHO) requires screening for domestic violence in emergency departments as a condition of accreditation. Child Abuse and Neglect

Alcohol and other substance use disorders affect the entire family, not only the individual who suffers from the addiction. Evidence drawn from numerous studies across the nation indicates that 40 percent to 80 percent of the parents of the families in the child welfare system (child protection, abuse and neglect, foster care, adoption, family preservation and support services) have alcohol and other substance use disorders and that those problems are connected with the abuse and neglect experienced by their children.78 Day-to-day abuse and neglect can result in long-term emotional and psychological problems. In addition, children of alcoholics are four times more likely to develop alcoholism than are children of non-alcoholics.79 Children who live with a non-recovering alcoholic score lower on measures of family cohesion, intellectual-cultural orientation, active-recreational orientation and independence. They also usually experience higher levels of conflict within the family.80

In addition, a survey conducted by CASA in 1997 revealed that, when children in America are being abused or neglected, it is likely that their parents are drunk or high from alcohol or other drugs or suffering from a hangover or withdrawal symptoms.81 Almost three of four child welfare professionals in the survey cited alcohol and other substance use disorders as one of the top three causes for the dramatic rise in child maltreatment since 1985. Also, in a study that controlled for income, family size, degree of social support, parental depression and anti-social personality, children whose parents were using substances were

National Conference of State Legislatures 36 Treatment of Alcohol and Other Substance Use Disorders

three times more likely to be abused and four times more likely to be neglected than were children whose parents were not alcohol and other substance users.82

Children are not the only family members who are affected by alcohol and other substance use disorders. Separated and divorced men and women were three times as likely to say that they had been married to an alcoholic or problem drinker.83 Solutions Cost Avoidance

The value of imprisonment as a crime control tool has yielded diminishing returns because greater numbers of offenders are being imprisoned for less serious crimes, especially drug offenses.84 The high costs of building and operating prisons are not offset by dollars saved in terms of preventing the most serious and costly crimes. Research has shown, however, that shifting economic resources from prison systems and into community-based programs, can produce appreciable reductions in crime.85

Funding justice treatment options, particularly those that divert offenders out of prisons and into community-based treatment, should not be viewed as a direct cost offset. Few jurisdictions have so few offenders that the diversion of one offender out of prison and into a treatment alternative will leave that prison bed unfilled. Epidemiological data demonstrate that there are more offenders who need treatment than there are either treatment slots or prison beds. Simple Cost-Offset Methodology

An offset occurs if a cost (such as medical utilization or incarceration) decreases as a result of treatment for alcohol and other substance use disorders. Studies can measure differences in the cost (such as medical utilization or incarceration) of treated vs. untreated alcohol and other substance users.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 37

4. WHAT STRATEGIES ARE AVAILABLE FOR THE TREATMENT OF ALCOHOL AND OTHER SUBSTANCE USE DISORDERS?

The Science Behind the Treatment • The National Institute on Drug Abuse’s Drug Abuse Treat- ment Outcome Study found that methadone treatment re- For many years, researchers have been defining the short- duced participants’ heroin use by 70 percent and criminal activity by 57 percent, while increasing full-time employ- and long-term effects of alcohol and other substance use ment by 24 percent. disorders. Scientific tools and knowledge now exist on how to best modify the behaviors of addicted individuals to im- • Methadone maintenance therapy helps keep more than prove treatment strategies and reduce negative health con- 100,000 addicts off heroin, off welfare, and on the tax rolls as 1 sequences of individuals and, in the long run, society. law-abiding, productive citizens. Researchers now can pinpoint the effects of alcohol and other substance use disorders on an individual’s cells, nerves, cul- • According to the Drug Abuse Treatment Outcome Study tural susceptibility, inheritance of disorders and the effects (DATOS), follow-up of Therapeutic Community (TC) of genetic influences on future generations.2 Science and graduates showed a 67 percent decrease in the number of research cross many scientific, social and cultural bound- weekly cocaine users and a 53 percent decline in heavy drink- aries. Research must be transferred from the laboratory to ers. Unemployment dropped 13 percent, suicidal ideation the clinic to the community and back.3 Research, the basic fell by 46 percent and illegal activity declined by 61 percent. foundation for advances in treatment, leads the way to more • A 1987 review of several studies of the outcomes for people effective alcohol and other substance use treatment services. attending AA found that, overall, 46.5 percent to 62 percent Recent developments in pharmocotherapy also have changed of active AA members had at least one year of continuous the future of alcohol and other substance use treatment and sobriety. Thirty-five percent to 40 percent of subjects reported its role is expected to expand in the future. Research into abstinence of less than one year. Twenty-six percent to 40 alcohol and other substance use disorders will continue to percent were sober from one to five or six years, and 20 per- identify new technologies and new avenues for treatment cent to 30 percent maintained abstinence five or six years or approaches. more.

Denial is a common facet of alcohol and other substance • In 2002, 57.4 percent of men had used alcohol in the past use disorders, as individuals (and often other significant month, compared with 44.9 percent of women. people in their lives) tend to minimize both the nature and • Men were twice as likely as women to have used illicit drugs, the amount of their drug or alcohol use. Often, those in including marijuana and cocaine, in the past month during denial actually convince themselves that alcohol and other 2002 (10.3 percent versus 6.4 percent). substance use is not a serious problem, although objective indicators suggest serious consequences. Thus, reports from • In 2002, 0.8 percent of those age 65 and older currently were people in treatment often are more credible than those from using illicit drugs individuals in the criminal justice system. Assurance of con-

National Conference of State Legislatures 37 38 Treatment of Alcohol and Other Substance Use Disorders

fidentiality is an important factor that enhances self-reporting, while potential prosecution and other sanctions are likely to diminish disclosures. Although screening interviews and instruments may not give a true picture of drug and alcohol use in all cases, some people will be truthful. Coupled with other screening methods, such as chemical tests, these measures help distinguish users from nonusers.4 National Institute on Drug Abuse (NIDA) Principles of Effective Treatment

Based on their research, the National Institute on Drug Abuse has developed principles of effective treatment.5

1. No single treatment is appropriate for all individuals. Matching treatment settings, interventions, and services to each individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace and society.

2. Treatment needs to be readily available. Because individuals who are addicted to drugs may be uncertain about entering treatment, taking advantage of opportunities when they are ready for treatment is crucial. Potential treatment applicants can be lost if treatment is not immediately available or is not readily accessible.

3. Effective treatment attends to multiple needs of the individual, not just to his or her drug use. To be effective, treatment must address the individual’s drug use and any associated medical, psychological, social, vocational and legal problems.

4. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person’s changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient at times may require medication, other medical services, family therapy, parenting in- struction, vocational rehabilitation, and social and legal services. It is critical that the treatment approach be appropriate to the individual’s age, gender, ethnicity and culture.

5. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. The appropriate duration for an individual depends on his or her problems and needs. Research indicates that, for most patients, the threshold of significant improvement is reached at about three months in treatment. After this threshold is reached, additional treatment can produce further progress toward recovery. Because people often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.

6. Counseling (individual and/or group) and other behavioral therapies are critical components of effective treatment for addiction. In therapy, patients address issues of motivation, build skills to resist drug use, replace drug-using activities with construc- tive and rewarding nondrug-using activities, and improve problem-solving abilities. Behavioral therapy also facilitates interpersonal relationships and the individual’s ability to function in the family and community.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 39

7. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. Methadone is very effective in helping individuals who are addicted to heroin or other opiates stabilize their lives and reduce their illicit drug use. Naltrexone also is an effective medication for some opiate addicts and some patients with co-occurring alcohol dependence. For those who are addicted to nicotine, a nicotine replacement product (such as patches or gum) or an oral medication (such as bupropion) can be an effective component of treatment. For patients with mental disorders, both behavioral treatments and medications can be critically important. [Buprenorphine is a partial opiate agonist that was approved by the FDA on Oct. 8, 2002, for the treatment of heroin addiction. The FDA approved two applications for buprenorphine as a treatment for narcotic addiction in a tablet form. A recent federal law will allow qualified physicians to dispense buprenorphine from their offices.]

8. Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way. Because addictive disorders and mental disorders often occur in the same individual, patients who present for either condition should be assessed and treated for the co-occurrence of the other type of disorder.

9. Medical detoxification is only the first stage of addiction treatment and, by itself, does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. Although detoxification alone is rarely sufficient to help addicts achieve long-term abstinence, for some individuals it is a strongly indicated precursor to effective drug addiction treatment.

10. Treatment does not need to be voluntary to be effective. Strong motivation can facilitate the treatment process. Sanctions or enticements in the family, employment setting, or criminal justice system can significantly increase both treatment entry and retention rates and the success of drug treatment interventions.

11. Possible drug use during treatment must be monitored continuously. Lapses to drug use can occur during treatment. The objective monitoring of a patient’s drug and alcohol use during treatment, through urinalysis or other tests, can help the patient withstand urges to use drugs. Such monitoring also can provide early evidence of drug use so that the individual’s treatment plan can be adjusted. Feedback to patients who test positive for illicit drug use is an important element of monitoring.

12. Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases, and counseling to help patients modify or change behaviors that place themselves or others at risk of infection. Counseling can help patients avoid high-risk behavior. Counseling also can help people who are already infected manage their illness.

13. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug use can occur during or after successful treatment episodes. Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and fully restored functioning. Participation in self-help support programs during and following treatment often is helpful in maintaining abstinence.

National Conference of State Legislatures 40 Treatment of Alcohol and Other Substance Use Disorders

To share the results of this extensive body of research and foster more widespread use of scientifically based treatment components, the National Institute on Drug Abuse held the National Conference on Drug Addiction Treatment: From Research to Practice in April 1998 and prepared this guide. The first section of the guide summarizes basic, overarching principles that characterize effective treatment. The next section elaborates on these principles by providing answers to frequently raised questions, as supported by the available scientific literature. The next section describes the types of treatment, and is followed by examples of scientifically based and tested treatment components.6 Center for Substance Abuse Treatment (CSAT) Treatment Improvement Protocols

The Treatment Improvement Protocols (TIPs) are best practice guidelines for the treatment of alcohol and other substance use disorders. CSAT’s Office of Evaluation, Scientific Analysis, and Synthesis draws on the experience and knowledge of clinical, research and administrative experts to produce the TIPs, which are distributed to a growing number of facilities and individuals across the country. The audience for the TIPs is expanding beyond public and private alcohol and other substance use treatment facilities as alcohol and other substance use disorders are increasingly recognized as a major problem.7 (For more information on CSAT TIPs, please refer to appendix F.) Continuum of Treatment

The word “treatment” may be a misnomer as applied to substance use and addiction because it implies a one-time strategy to eliminate the adverse effects of a physiological condition. Like other chronic and potentially fatal conditions such as heart disease or diabetes, treatment of substance use and addiction actually refers to an extended process of diagnosis, treatment of acute symptoms, identification and management of circumstances that may have promoted the drug use in the first place, and development of life-long strategies to minimize the likelihood of ongoing use and its attendant consequences. In this context, treatment is best viewed as a continuum of different types and intensities of services over a long period of time. A phrase commonly used in the current treatment field is “recovery management,” referring to the structured process of accessing and completing the range of services on the road to health and self-sufficiency.

Under the continuum of care model, individuals with alcohol and other substance use disorders move through the spectrum of treatment and other social services. A service network of different programs that provide a multifaceted and multidisciplinary approach is ideal. These services should encompass the various types of alcohol and other substance use occurring in the community, should account for differences in client characteristics (e.g., age, gender, racial or ethnic group identification, socioeconomic level), and should be for- mally linked with other agencies that provide other supportive services—such as health care, education and housing programs—to ensure that patients can obtain help with associated physical, social and psychological problems.8 In fact, measures of success in treatment systems should be based not only reduction or elimination of drug use, but also on the ability of the individual to gain access to and make progress in other types of services (job training, housing, family skills, etc.) to minimize future reliance on public systems.

Some agencies and organizations are comprehensive enough to provide several types and modalities of treatment; however, most treatment providers specialize in one or a few treat-

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 41 ment modalities. Clinical case management can be an effective tool for ensuring linkages with various agencies and for ensuring that individuals have access to the most appropriate types of services to meet their needs.9

Research clearly indicates that treatment for alcohol and other substance use does work. With treatment, substance-dependent people enjoy healthy and productive lives. Instead of creating health risks, committing crimes and requiring public support, individuals in recovery can and do make positive contributions to their communities. Recovery is a viable goal, but also is complex and challenging, requiring personal and relational changes and a significant investment of effort. Whether an individual is addicted to or abusing alcohol, illegal drugs, prescription drugs, or a combination of these, the most important goal is to discontinue the use of alcohol and/or drugs.10

The continuum of treatment involves four key stages:

1. Identification, 2. Assessment, 3. Treatment, and 4. Ongoing recovery management. Stage 1: Identification

For an individual with an alcohol and other substance use disorder to receive treatment, the disorder must first be identified. Many individuals and professionals who come into contact with potential clients are in a position to set them on the road to recovery. Some may self-identify their disorder, but commonly spouses, parents, employers and teachers are the first line of identification. In other cases, health care institutions, the criminal justice system, or the child welfare system will identify potential clients as a result of adverse consequences stemming from substance or alcohol use. An important principle that has emerged in the treatment field is “no wrong door to treatment,” meaning that, regardless of the source or type of identification, clients will be given access to the full continuum of treatment and recovery management. This is absolutely critical, as many public and private institutions will address alcohol or substance use disorders only to the extent that they affect the client’s present involvement in those institutions. This acute, episodic approach cannot appropriately address the range of complex issues facing clients with these disorders. As a result, they are much less likely to demonstrate long-term effectiveness.

Screening, Brief Intervention, and Referral Screening, brief intervention, and referral (SBIR) is a model of identification that can occur in any setting, including physicians’ offices, hospitals, community health centers, school- based health clinics and student assistance programs, occupational health clinics, hospitals, emergency departments, the criminal justice system, children’s services and TANF.11

Screening refers to brief procedures used to determine the presence of a problem, substantiate that there is reason for concern, or identify the need for further evaluation. Interview tech- niques and screening instruments may be designed to attempt to get alcohol- or other drug- involved people to reveal information about their alcohol and other substance use. These self- reports can be helpful in determining whether there is a need for further assessment and intervention. Screening interviews and instruments may be developed by a given agency, or they may be obtained from other sources that provide them as a service or for profit.12

National Conference of State Legislatures 42 Treatment of Alcohol and Other Substance Use Disorders

Screening, whether via interviews or written instruments, relies on the self-report of the potential client to prompt further action.13 Screening does not need to be identified as such. It might include something as simple as a few brief questions asked during physician intake procedures that query the individual about the use of alcohol or other drugs.

The final steps of SBIR are brief intervention and referral. If a screening results in a determination that an individual has an alcohol or other substance use disorder, then the screening entity intervenes to the extent of their authority and either refers the individual to treatment or engages the services of an independent clinical referral agent who will conduct a comprehensive clinical assessment and make a referral to the appropriate level of treatment. The screening entity may even help place the individual in treatment and follow up to ensure that the individual received treatment.

Uniform Accident and Sickness Policy Provision Law (UPPL) The prevalence of alcohol problems is higher in trauma patients than in any other medical setting. The leading cause of death for substance abusers is injury, not cirrhosis, pancreatitis, or other related disease. Trauma patients with alcohol problems have high reinjury rates and deaths due to reinjury. Opportunistic screening and intervention in health care settings where there is a high proportion of patients with alcohol problems is perhaps the most promising means of closing the gap between the number of patients who might benefit from treatment and the number who actually receive it. Studies demonstrate that routine alcohol screening and intervention in trauma centers and emergency rooms reduce both subsequent alcohol intake and the risk of injury recurrence. A variety of federal, expert and consensus panels recommend routine screening and intervention in trauma centers.

Currently, most trauma centers treat the patient’s injuries and ignore the underlying alcohol problem. This would be similar to the case of a 55-year-old male with a myocardial infarction due to hypertension who receives therapy for his heart attack but not for his high blood pressure, who is discharged with a high expectation of having another myocardial event.

In most states, if a trauma or emergency room physician screens a patient for an alcohol problem and the patient screens positive, the insurance company can deny responsibility for the medical bill. This not only affects trauma centers, but it also affects patients, who may have to declare bankruptcy due to the costs of major medical treatment.

The UPPL started as a model law adopted by the National Association of Insurance Com- missioners (NAIC) in 1947. Its intent is to decrease insurance costs. It has not had that effect. Instead, physicians counteract it by simply refusing to screen. Thus, the insurance company pays anyway. The only effect of the law is to cause the problem to be ignored. In testimony to the NAIC and the National Conference of Insurance Legislators (NCOIL), insurers were unable to provide claims data to demonstrate any savings. That is because, where the law is in effect and enforced, physicians have nullified it by refusing to screen.

Surveys demonstrate that trauma centers are willing to institute alcohol screening and intervention programs, and trauma clinicians support it. However, they cannot do this due to the financial consequences of the UPPL.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 43

One does not need to be breaking a law to be affected by the UPPL. A person can go out to dinner to celebrate an anniversary or birthday, have a few drinks, and take a cab home. If there is a crash and the person is found to be under the influence of alcohol (not even defined as intoxicated in a legal sense), the insurer can deny payment.

There are approximately 2 million hospital discharges for trauma each year, and 25 million emergency department visits for injury treatment. Of these patients, 25 percent to 40 percent meet criteria for an alcohol problem and may benefit from treatment. Currently, about 1 million people receive treatment for an alcohol problem each year in the United States. The implementation of routine alcohol screening and intervention in emergency rooms and trauma centers could dramatically increase both case detection and the number of people who receive counseling or a referral to counseling. Implementation of such a plan would require removal of the severe financial penalties to trauma centers and to patients that the UPPL represents.14 Stage 2: Assessment

Clinical assessment is the first stage of formal intervention with those who are chemically dependent. A comprehensive appraisal of the individual’s alcohol and other substance use disorder, how it affects his or her health and functioning, and the other types of social services required are vital for selecting treatment resources that best meet his or her needs. Assessment includes a determination of many factors, including:

• The severity of the problem; • Possible influences that have perpetuated chemical use, culminating in addiction; • Related difficulties; and • The individual’s perceptions of and attitude toward treatment.15

When an individual is assessed, an initial treatment plan is devised, placing the individual in the appropriate treatment setting for the appropriate time frame and securing services that match his or her needs and strengths. Under the care model, the individual is continually reassessed throughout treatment, and any necessary changes in the treatment setting, time frame and/or services are made. Use of the care model ensures that individuals are receiving the most appropriate treatment in the least restrictive treatment setting and the services that address their needs and strengths.

American Society of Addiction Medicine (ASAM) Patient Placement Criteria The American Society of Addiction Medicine published the ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, (Second Edition-Revised ): (ASAM PPC-2R) in April 2001. It is the most widely used and comprehensive national guidelines for placement, continued stay and discharge of patients with alcohol and other substance use disorders. It was written in response to requests for criteria that better meet the needs of patients with co- occurring mental and alcohol and other substance use disorders (“dual diagnosis”), for revised adolescent criteria and for clarification of the residential levels of care.16

The ASAM PPC-2R provides two sets of guidelines, one for adults and one for adolescents, and five broad levels of care for each group. The levels of care are: Level 0.5, Early Interven- tion; Level I, Outpatient Treatment; Level II, Intensive Outpatient/Partial Hospitalization; Level III, Residential/Inpatient Treatment; and Level IV, Medically-Managed Intensive Inpa- tient Treatment. Within these broad levels of service is a range of specific levels of care.17

National Conference of State Legislatures 44 Treatment of Alcohol and Other Substance Use Disorders

For each level of care, a brief overview of the services available for particular severities of addiction and related problems is presented, as is a structured description of the settings, staff and services, and admission criteria for the following six dimensions: acute intoxication/withdrawal potential; biomedical conditions and complications; emotional, behavioral or cognitive conditions and complications; readiness to change; relapse, continued use or continued problem potential; and recovery environment.18

The diagnostic terminology used in the ASAM PPC-2R is consistent with the most recent language of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The “unbundling” of clinical services is addressed, recognizing that these services can be and often are provided separately from environmental supports. With unbundling, the type and intensity of treatment are based on the patient’s needs, not on limitations imposed by the treatment setting. Criteria also are included that attempt to match a patient’s severity of illness along dimension 1 (acute intoxication and/or withdrawal potential) with five intensities of detoxification service.19

Many states have adopted ASAM or ASAM-modified patient placement criteria in rules of licensure for treatment. Stage 3: Treatment

Treatment is designed to help the patient reduce his or her dependence on alcohol or other drugs and attain a higher level of physical, psychological and social functioning. A successful program may involve a combination of specific treatments and may change over time, depending on the individual. Incorporating management of psychological problems as a component of any rehabilitation program is crucial to the ongoing success of a patient’s treatment.

Successful outcomes depend on retaining patients in treatment programs for a sufficient length of time. Whether a patient stays in a program can be attributed to individual factors—such as motivation and support from family or friends-and factors associated with the treatment program—such as positive relationships between counselors and patients. Counselors who establish such a relationship will be better equipped to identify and address patients’ needs and ensure successful treatment.20

The availability of different treatment options is important in achieving the overall goal of rehabilitation for the patient. Because each patient is different, a particular modality of treatment that may work best for one individual will not work for another. Because new research is being conducted daily, treatment strategies and options for patients are improving.21 Rehabilitation and treatment can occur in both residential and outpatient settings, depending on the needs of the patient.

The medical component of treatment settings has implications for funding. For instance, health insurance procedures require medical control. Funding for community service agencies does not necessarily require medical involvement. In order to increase accessibility and broaden the range of reimbursement mechanisms, some states have developed new licensing standards to permit reimbursement of detoxification and rehabilitation services for ambulatory patients in non-hospital settings.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 45

The Role of Medications in Treatment Scientific research has advanced to the degree that the underlying effects of alcohol and other drugs can be identified. Different pharmaceuticals are being used effectively to target different neurotransmitter systems. Physicians now are able to prescribe medications for patients to manage withdrawal, foster sobriety, decrease alcohol and other substance use by managing effects related to psychological disorders, and weaken problem behaviors.

Prescriptions for benzodiazepines such as Valium or Xanax have been widely used for the manage alcohol withdrawal. Research continues on the use of benzodiazepines for the effective management of withdrawal delirium. Because benzodiazepines are known for their sedative effects, research continues on the possible use of other classes of drugs. Medi- cations such as ReVia (naltrexone) and Antabuse (disulfiram) also are also being used as anti-craving agents in the treatment of alcoholism.22

Using pharmacotherapies is an effective way to maximize efficacy in other drug use treatment programs. The most widely used medication for opioid addicts is methadone. Buphenorphine and naltrexone are the other major medications that are available for opiate dependence. Because of the lack of reimbursement, however, buphenorphine and naltrexone are under utilized. Methadone often is prescribed for drug users as an alternative to heroin addiction and has proven effective for many people. The National Institute on Drug Abuse’s Drug Abuse Treatment Outcome Study found that methadone treatment reduced participants’ heroin use by 70 percent and criminal activity by 57 percent, while increasing full- time employment by 24 percent.23

Methadone maintenance programs usually are more successful at retaining clients with opiate dependence than are therapeutic communities, which, in turn, are more successful than outpatient programs that provide only psychotherapy and counseling. Methadone maintenance therapy helps keep more than 100,000 addicts off heroin, off welfare, and on the tax rolls as law-abiding, productive citizens.24 Within various methadone programs, those that provide higher doses of methadone (usually a minimum of 60 mg.) have better retention rates. Also, those that provide the full range of other services—such as counseling, therapy and medical care—along with methadone generally achieve better results than the programs that provide minimal services.25

Methadone maintenance, naltrexone, buprenorphine and disulfiram assist individuals with alcohol and other substance use disorders to maintain a drug-free existence. Reducing alcohol and other substance use through pharmacological therapies diminishes the spread of infectious diseases, reduces the level of criminal activity, improves the rate of employment, reduces intake and affects the demand for drugs.26 New medications are still being studied and researched and will continue to make great inroads into the treatment of alcohol and other substance use disorders. In the future, the role of pharmacologic interventions is expected to greatly expand and revolutionize treatment for individuals with alcohol and other substance use disorders.

Coerced vs. Voluntary Treatment Coerced participation in drug or alcohol treatment is just as effective—or more effective— than non-coerced treatment.27 The most visible type of coercion is criminal justice involvement. However, the most common type of coercion is family member insistence. A RAND study has shown that many individuals who enter treatment voluntarily are actually being coerced by one or more family members and/or by supervisors or employers. Research

National Conference of State Legislatures 46 Treatment of Alcohol and Other Substance Use Disorders

indicates that compulsory treatment in the form of civil commitment increases treatment retention for intravenous drug abusers.28

Treatment Intensities and Modalities Detoxification. Detoxification seeks to provide safe withdrawal from alcohol or other drugs in a dignified and humane manner during which the patient becomes free from toxins under controlled conditions. It is not a treatment in and of itself, but sometimes is the first step in a comprehensive treatment strategy. The process of detoxification from alcohol and other drugs includes removing toxins from the body and the period of time when a person’s physiology is adjusting to the absence of alcohol or other drugs. For most patients, detoxification from alcohol takes three to five days. The time frame for detoxification from other drugs varies depending on the drug and the severity of addiction.29 Detoxification can be provided in residential or outpatient settings.

Inpatient/Residential. Inpatient treatment may be comprised of a combination of the following: medical treatment, nursing and supportive services, including counseling and other daily activities, on a 24-hour basis in a hospital or other licensed medical facility.30 Inpatient hospitalization is the most expensive, closely supervised, restrictive service and the one with the highest percentage of medical staff. It is reserved for individuals with medical complications such as short-term treatment and crisis stabilization, for individuals in acute distress, or for comprehensive evaluations of people with multiple disorders.

Therapeutic Communities. In some areas, therapeutic communities (TCs) are a popular form of rehabilitation in the longer term, community-based residential settings for individuals who need this level of care to work toward increased levels of responsibility in the community over time. The populations that a TC program targets are individuals who need a safe environment in which to function, including, but not limited to, individuals with serious, chronic, recurring alcohol and other substance use disorders; parents; pregnant women; homeless people; and juveniles. The basic goal of a TC is to offer a lifestyle that includes abstinence from drugs; elimination of anti-social (criminal) behavior; development of employable skills; and development of positive attitudes, values and behaviors.31

The TC model is based on the assumption that successful rehabilitation is best achieved in a “community” where socially acceptable behaviors will be learned to replace the antisocial behaviors, lifestyles involved with addictions, and criminal behaviors. The support often includes:

• Self-help through learning stages and gradual assumption of responsibility;

• A self-help network that replaces the gangs and/or antisocial peers with a new healthier community of peers;

• Prescribed rewards and punishments to reinforce socially acceptable behavior;

• Individual commitment to the “community,” in which members accept the idea that their individual problems have an effect on others;

• Role modeling accomplished through the clinical and other staff, who might include successfully rehabilitated ex-offenders or ex-drug addicts; and

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 47

• Links with support programs for continuing care, as well as employment as a means of assisting the individual to become established outside the residential program.32

TC clients demonstrate less criminal activity during treatment and after discharge. Length of stay in programs remains the strongest predictor of success. Attrition is high and rates are below participation rates in outpatient, non-methadone programs but are higher than methadone programs. However, TC graduates demonstrate more positive outcomes than those who did not enter the programs and have better outcomes than those individuals who dropped out of the program.

According to the Drug Abuse Treatment Outcome Study (DATOS), follow-up of TC graduates showed a 67 percent decrease in the number of weekly cocaine users and a 53 percent decline in heavy drinkers. Unemployment dropped 13 percent, suicidal ideation fell by 46 percent and illegal activity declined by 61 percent.33

Outpatient. Outpatient treatment may be comprised of a combination of the following: treatment services, as needed, including medical services, nursing services, counseling, and supportive services for those who can live independently and benefit from ambulatory care settings.34

Intensive Outpatient. Intensive outpatient treatment, or day treatment programs, is comprised of the services described for inpatient treatment for those who require care or support in a treatment or recovery setting for less than 24-hour a day supervision; this generally means more intensive care, treatment and support during the day in a special setting and sometimes is referred to as partial day treatment.35 Stage 4: Ongoing Recovery Management

Relapse Prevention Addiction is a chronic, relapsing disorder, making prevention of relapse a critical element of effective treatment. It is not unusual for addicts to relapse within one month following treatment, nor is it unusual for addicts to relapse 12 months after treatment; 47 percent will relapse within the first year after treatment. Although relapse is a symptom of addiction, it is preventable. Relapse prevention methodologies are critical to the success of alcohol and other substance use treatment.36 Principles underlying relapse prevention therapy include:

• Self-regulation and stabilization. As the patient’s capacity to self-regulate thinking, feeling, memory, judgment and behavior increases, the risk of relapse will decrease. Self- regulation can be achieved through stabilization. Stabilization may include: - Detoxification from alcohol and other drugs; - Recuperation from the effects of stress that preceded the chemical use; - Resolution of immediate interpersonal and situational crises that threaten sobriety; or - Establishment of a daily structure including proper diet, exercise, stress management and regular contact with both treatment personnel and self-help groups.37

Chemical addiction is a disease and, like many diseases, the possibility of relapse always exists. The process of alcohol and other drug use is complex, and is affected by social, clinical and medical factors. The solutions to the problem of chemical addiction are multi-

National Conference of State Legislatures 48 Treatment of Alcohol and Other Substance Use Disorders

faceted. Treatment strategies benefit from a relapse prevention component in virtually every case. It is a definite means of stretching the effectiveness of state treatment funds. For relapse prevention to work, agencies and systems must cooperate and communicate in their search for the best means of successfully intervening with substance using patients.38

Self-Help Self-help or 12-step organizations involve mutual help among peers who are experiencing similar problems. With the development of the first Alcoholics Anonymous group in 1935, a long tradition of the use of self-help groups for alcohol and other substance users was launched. Self-help groups often meet in churches, community facilities, prisons and other locations, but they generally claim no political or religious affiliation. Alcoholics Anony- mous (AA) describes itself as a voluntary, self-run fellowship. An important characteristic for many people is its promise of anonymity, protecting the right to privacy of its members.39

Members of AA believe that addiction is a disease that can never be cured. However, they maintain that progression of the disease can be arrested, and those in remission are recovering alcoholics. Groups function to reinforce social and cognitive behaviors that are incom- patible with addictive behaviors.40 The primary goals of AA and similar self-help groups are to:

• Achieve total abstinence from alcohol or other drugs; • Effect changes in personal values and interpersonal behavior; and • Continue participation in the fellowship to both give and receive help from others with similar problems.41

Self-help groups may be the only intervention used by some people to end chemical dependency. However, self-help groups often are used in tandem with other treatment modalities, such as residential or outpatient treatment programs.42 Often, experienced members act as “sponsors” to newer members, creating a person-to-person guidance system in times of crisis and creating bonds between members.43

Narcotics Anonymous (NA) is modeled on the Alcoholics Anonymous concept and, although the two programs are not affiliated, they use the same 12-step program. NA is a different organization with diverse jargon, style, substance and social traditions. It is concerned with the problem of addiction, and members may have had experience with any or all of the entire range of abusable psychoactive substances.44

Alcoholics Anonymous is now a worldwide organization with groups in the United States and 114 other countries. Its membership is estimated at 1.5 million. Narcotics Anony- mous is international as well, with groups in at least 36 countries. Estimates of its membership total approximately 250,000.45

Although there is ample anecdotal testimony to the effectiveness of self-help organizations, especially Alcoholics Anonymous, there is little in the way of objective data to support these claims. However, opinions of many clinicians and individuals who have been helped by the approach strongly support it for the recovery of some alcohol and other substance users.46

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 49

A 1987 review of several studies of the outcomes for people attending AA found that, overall, 46.5 percent to 62 percent of active AA members had at least one year of continuous sobriety. Thirty-five percent to 40 percent of subjects reported abstinence of less than one year. Twenty-six percent to 40 percent were sober from one to five or six years, and 20 percent to 30 percent maintained abstinence five or six years or more.47

Education Effective recovery management involves education. Many recovering individuals obtain their high school graduation equivalency degrees (GED) and/or embark upon higher education.

Jobs Effective recovery management involves job training and employment. Many recovering individuals receive job skills training and/or employment placement services.

Family Although continuing research is needed, available data support the efficacy of family therapy interventions. Adolescents involved in family therapy have been shown to have half the recidivism rate of those who do not receive this service. Evidence also exists that family therapy improves adolescent retention in residential treatment programs. Family treatment also has been favorably correlated with days free of methadone, illegal opiates and marijuana. A 1986 study found that alcoholics who received treatment with their spouses, including both alcohol-related interventions and marital therapy, were more compliant, decreased their drinking more rapidly, and relapsed more slowly than did study participants who received only alcohol-focused treatment with their spouses. They also maintained better marital satisfaction and were more likely to stay in treatment than were those who received treatment with minimal spouse involvement. In general, family involvement enhances assessment and intervention and increases motivation in treatment.48

Special Living Arrangements Maintenance consists of relapse prevention and other continuing care services. To maintain the gains of rehabilitation, a plan of therapeutic services to help a person stabilize is critical to full recovery. Continued contact and therapeutic activities are essential to avoid a return to negative patterns of drinking and other alcohol and other substance use. In some instances, people who are too disabled by alcohol and other substance use disorders to live independently can be provided with supported housing to ensure the continuance of necessary supportive services in a structured environment. This prevents dangerous relapses to addictive behavior.

Sober Living Environments. Sober living environments (SLEs) are housing for individuals in recovery from alcohol and other substance use disorders. SLEs offer a stable, supportive and sober environment that is conducive to sobriety and recovery and serves as a bridge to independent living. They typically do not provide any type of treatment or recovery services. These environments are referred to as supportive living environments, halfway houses, recovery homes, sober living homes or sober living housing. Treatment for Specific Populations

Most alcohol and other substance use disorders are multidimensional. An individual may be a member of several different population groups, which makes the identification of an

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appropriate treatment group more difficult. Brief descriptions of several populations that may require special consideration for treatment are included below. Adolescents

Although drug use in the general population of adolescents who are attending school and living at home has declined in recent years, there is sufficient justification to be concerned about youth. Dropouts constitute an estimated 15 percent to 20 percent of youth the age of high school seniors, and these youth tend to be at high risk for alcohol and other substance use and delinquency.49

Youth who become involved in delinquent behaviors and the use of drugs and alcohol come from all social strata, from both large and small communities, and from healthy as well as dysfunctional families. They may be gifted or limited in intellectual abilities, have few or many talents, and vary markedly in personality. There is no easy predictor of delinquency or alcohol and other substance use.50

Indeed, research indicates that a complex array of cognitive, psychological, attitudinal, social, personality, pharmacological and developmental factors foster initiation of adolescent drug use. Some characteristics that are typical of adolescent development appear to increase the chances that some youth will at least begin the process of experimenting and taking risks with drugs, alcohol and illegal behaviors. Young people are establishing their identity and independence. As part of this process, they need to explore different behaviors and values. Experimentation and opposition to adult norms and values, within limits, is typical adolescent behavior. For some youth, however, these behaviors plunge them into a world of activities that can become very dangerous. The pleasure, thrill or excitement may be so stimulating that they continue to seek it. For some, the acts of rebellion against parents or society are particularly satisfying. Others acquiesce to peer influences from youth who offer friendship and acceptance to those who will engage in similar activities.51

As with other special populations, alcohol- and drug-involved youth need treatment programs that are sensitive to their needs and appropriate for their developmental stage. As- sessment is the first critical phase of treatment. The multiple assessment approach—including interviews, observations, specialized testing, and written reports—is recommended for obtaining the most valuable information for informed treatment planning. Treatment programs for youth should not merely duplicate programs that have been successful with adult groups. They need to be formulated with particular attention to adolescent developmental levels, family situations, educational needs, and many other factors. Appropriate interventions for youth may include:

• School-based prevention; • Drug education classes; • Outpatient treatment; • Partial hospitalization; and • Residential treatment.52

Drug Strategies’ Treating Teens: A Guide to Adolescent Drug Treatment is a guide to the following nine key elements of effective teen treatment:

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 51

• Assessment and treatment matching; • Comprehensive, integrated treatment approach; • Family involvement in treatment; • Developmentally appropriate program; • Engage and retain teens in treatment; • Qualified staff; • Gender and cultural competence; • Continuing care; and • Treatment outcomes. Women

Women’s roles of child-bearer and mother complicate treatment for women. Many women need to bring their children to treatment with them. Many inpatient treatment programs are designed specifically for women with their children. When treating pregnant users, treatment providers have the extra liability of addressing the effect of drugs on the fetus. Many women lose custody of their children due to their alcohol and other substance use. However, treatment works, restores children to their families and produces healthy babies.

In 2002, 57.4 percent of men had used alcohol in the past month compared with 44.9 percent of women.53 Men are more likely to drive drunk or be involved in an alcohol- related fatal traffic crash.54

The above figures indicate that women drink less frequently and less heavily than men. However, it is important to note that women metabolize alcohol differently than men and are likely to feel a stronger effect from the same amount of alcohol. They become intoxicated faster and are addicted more easily.55 In addition, women develop alcoholic liver disease at a lower cumulative dose of alcohol than men.56 Risk factors for problem drinking in women include a partner or spouse who drinks, depression, and sexual dysfunction or abuse.57

Men were twice as likely as women to have used illicit drugs, including marijuana and cocaine, in the past month during 2002 (10.3 percent verses 6.4 percent).58

Women, especially pregnant women, have a difficult time obtaining treatment for alcohol and other substance use disorders. Very few public treatment programs accept pregnant women or mothers with children, largely because these facilities are not equipped to deal with the health, housing and education needs of mothers and their families.

Pregnant women who are alcohol and other substance users are a difficult population to treat. They often are afraid to admit to alcohol and other substance use and seek treatment for their illness because they fear they will be prosecuted for child abuse and will lose their children once they are born. In addition, many treatment programs do not provide day care for children, which places a burden on mothers who are seeking to receive treatment for their illness.59

No state currently has a law that can be specifically used to prosecute a mother for using drugs or alcohol during pregnancy. However, existing laws that apply to child abuse and neglect, assault, murder or drug dealing have been used to attempt to penalize these mothers for their alcohol and other substance use. Despite various attempts to apply these laws

National Conference of State Legislatures 52 Treatment of Alcohol and Other Substance Use Disorders

to women’s prenatal conduct, all appellate courts have held these statutes inapplicable to women’s prenatal conduct.

• The lone exception is Whitner vs. the State of South Carolina, in which the state prosecuted two women for using crack while pregnant. The case was based on the South Carolina law that makes it a crime to neglect or refuse to provide a child with proper care and attention so that the child is or is likely to be endangered. In May 1998, the U.S. Supreme Court refused to hear, on appeal, arguments by the two women that South Carolina should not be able to use this child endangerment law for their unborn children.60

Among the important questions raised by the option of incarceration are: Who will care for these children while their mothers are in jail and how will incarceration provide or lead to treatment and recovery?

On the other side of the criminalization vs. treatment issue are the two states—Wisconsin and South Dakota—that currently have laws that provide for pregnant alcohol and other substance users to be involuntarily ordered into treatment.

• In 1997, Wisconsin enacted the first law in the nation to allow judges to issue a court order for treatment of pregnant women.61 The law, which became effective July 1, 1998, allows an individual who believes an expectant mother has harmed or may harm her unborn child through alcohol and other substance use to file a report. Local law enforcement and child protection workers must immediately investigate the report and may take the expectant mother into custody. The county social services department may offer services to the mother and, if the services are refused, the department may request the district attorney to file a petition with the juvenile court. The juvenile court has jurisdiction over both the mother and her unborn child, and it may order her into custody if she refuses treatment. The court may order counseling, supervision by a social services agency, out-of-home placement, or participation in an inpatient or outpatient treatment program.62

• A South Dakota law enacted in 1998 briefly states that any pregnant drug user may be committed by the circuit court upon the petition of the person’s spouse or guardian, a relative, a physician, the administrator of any approved treatment facility or any other responsible person. Older Adults

Older Americans consume more prescribed and over-the-counter medication than any other age group in the United States. In combination with an aging body that is more vulnerable to the effects of medication, this often leads to misuse of prescription drugs among the elderly. Health care providers often overlook this misuse or abuse because of insufficient knowledge, limited research data and short primary care visits.63

Research consistently shows that, as people age, consumption of alcohol decreases and there is less alcohol use. Longitudinal studies indicate alcohol use may decrease slightly as light drinkers grow older, and abstinence becomes more prevalent. Heavy drinking also declines with increasing age.64 Use of illicit drugs follows similar trends. In 2002, 0.8 percent of those age 65 and older currently were using illicit drugs.65

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 53

Although the rate of alcohol and other substance use is low among older Americans as compared to the total population, abuse of alcohol and prescription drugs among adults age 60 and older is one of the fastest growing problems in the country. Until relatively recently, alcohol and prescription drug abuse, which affects up to 17 percent of older adults, was not discussed in either alcohol and other substance use or gerontological literature.66

A recent study suggests that alcohol and other substance use for women over age 59 is a serious problem that does not receive adequate attention. Abuse of alcohol and psychoactive prescription drugs are most common among older, affluent white women.67 Culturally Competent Treatment

Available data reveal different patterns of alcohol and other substance use among various racial and ethnic groups. Black and Hispanic alcohol and other substance users tend to use heroin and cocaine more than white addicts; whites tend to abuse a greater variety of substances. The results of some studies have led to the hypothesis that whites’ use of drugs tends to be the result of emotional problems or deviance.68 Native Americans

There is considerable variation in the settings in which Native Americans live. Some live in urban areas, while others reside on isolated reservations. These factors influence the rates and types of alcohol and other drug addiction found among Native Americans. Treatment approaches must be sensitive to the particular cultural heritage of people who enter programs.69

There is a significant problem of alcohol and other substance use among Native Americans in the United States. The age at first involvement with alcohol is younger for Indian youths, and the frequency and amount of drinking are greater. Well-established during adolescence, these trends continue into young adulthood.70

Although alcohol and marijuana use are common among Native American youth, inhalant use is almost twice as high as among all other youth between the ages of 12 and 17. Use of inhalants peaks during the early and middle teens, then tapers off in later years as the availability of marijuana, alcohol and other substances increases.71

The serious consequences of inhalants make this trend alarming. Use of inhalants can result in organic brain damage, a condition that can be very severe, and possibly permanent. Other risks include respiratory depression; cardiac arrhythmia; and irreversible damage to the kidneys, liver and bone marrow. Sniffing of gasoline has caused lead poisoning, which can have lasting adverse effects on an individual’s physical and emotional development.72

It is theorized that these high rates of alcohol and other substance use among Native Ameri- cans are related to socioeconomic conditions, including poverty; prejudice; and lack of economic, educational and social opportunities. Family influences also are conjectured to play a significant role in early use of substances. 73

National Conference of State Legislatures 54 Treatment of Alcohol and Other Substance Use Disorders

Available research suggests that intervention efforts need to be aimed at enhancing the health of Native American families. Successful programs have included key elements of community ownership, agency collaboration and tribal determination.74 Asian and Pacific Islander Americans

Statistical evidence of alcohol and other drug use among Asian Americans is generally low compared with other subgroups of the population. However, alcohol and other substance use may be greater than survey reports indicate because Asian Americans tend to handle problems within the family and community. They are not as likely to use public treatment services, due to the stigma attached to seeking professional help in their culture.75

Overall, Asian Americans have fewer alcohol-related problems than any other major ethnic group. However, there are indications that the use of alcohol and other drugs may be increasing. Traditionally, drinking takes place in controlled settings, rarely alone. However, drinking patterns among various groups of Asian Americans differ greatly.76 Hispanic/Latino Populations

Spanish speaking people are not a homogeneous group, and Hispanic/Latino populations from each country bring with them distinctive habits, customs, values and cultural traditions.77

Drug use among Hispanic/Latino youth has been significantly associated with high school dropout rates.78 Hispanic/Latino youth appear to use alcohol at a rate similar to that of Anglo youth. Boys are more likely to begin drinking at a younger age and to drink more than girls. For other drugs, the level of use among Hispanic/Latino youth is comparable to, or slightly less than, that of Anglo youth. Hispanic/Latino youth between the ages of 12 and 17 are more likely than Anglo or African American youth to have used cocaine.79

Specific recommendations for treatment planning for this population include:

• Targeting the entire family and religious leaders because of the strong ties and influences these entities have;

• Developing materials and programs in Spanish and making them culturally appropriate; and

• Targeting efforts through community leaders and organizations to increase the accept- ability of programs.80 African Americans

African American high school students have lower levels of reported drug and alcohol use compared to other groups. African American youth also begin the use of alcohol and other drugs at later ages than the general population.81

Yet, alcohol and other drug use is a leading health and social problem for African Ameri- cans. When alcohol-related health problems—such as cirrhosis of the liver and certain

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 55 types of cancer—are examined, there is a greater prevalence among African American men than among white men. 82

Although African Americans are more likely to abstain from using alcohol, studies have found that those who do use also are more likely to use other drugs concurrently. The relative availability of illegal drugs in the inner city may play a role in drug use among African American youth.83

The relationship between alcohol use among African American youth and crime is well- documented. Delinquent behavior appears to begin before drug use. However, those who use alcohol are more likely to engage in delinquent behavior than are those who do not drink. Cocaine use, which is on the rise in some African American neighborhoods, appears to be associated with higher crime rates.84 Rural Populations

The U.S. General Accounting Office (GAO) conducted a study of several issues related to substance abuse in rural areas in preparing a report for Congress. In 1990, the GAO found that:

• Alcohol is by far the most widely used drug in rural areas.

• Prevalence rates for some drugs (such as cocaine) appear to be lower in rural than nonrural areas. Prevalence rates for other drugs (such as inhalants) may be higher in rural areas than elsewhere.

• Total alcohol and other substance use (alcohol use plus other drug use) rates in rural states are about as high as in nonrural States. 85

Treatment of alcohol and other substance users in rural settings presents a variety of special issues and problems.

• Rural treatment programs may be more expensive to administer than metropolitan programs. Although fewer people may need a particular program or service, the cost of operation may be similar because comparable staff, facilities and supplies are needed. This results in higher per-patient treatment costs.

• Treatment may not be as accessible due to the distance patients and program staff must travel to meet.

• Programs may not be accepted by the community or community agencies. In some rural communities, there may be a stigma related to alcohol and other drug addiction that is not as noticeable in urban areas. Those who need treatment may be more visible than they would be in a more populated area; therefore, there may be more concern about confidentiality on the part of those who need treatment. The importance of treatment may not be understood or supported as well as in metropolitan areas that have greater resources.

• There may be a lack of trained and experienced staff in the area of alcohol and other substance issues. Rural areas may have a difficult time attracting and holding such

National Conference of State Legislatures 56 Treatment of Alcohol and Other Substance Use Disorders

professionals. Limited resources mean professionals in many agencies must perform a variety of tasks. Individuals in education and health care may not have sufficient time or expertise to devote specifically to drug issues. 86

It is clear that treatment has as vital a role to play in rural areas as it does in metropolitan, urban areas.87 There are special challenges to developing a continuum of care in rural areas. This is not unique to alcohol and other substance use treatment, but is true for all rural health care.

Methamphetamine and prescription drug abuse are significant problems in rural areas. Treatment in the Criminal Justice System

In most jurisdictions, “criminal justice” refers not to a singular, all-encompassing system, but to a continuum of often independent entities and subsystems, including police departments, state or district attorneys, public and private defenders, county jails, courts, probation, state corrections, community corrections, and parole or supervised release. In most cases, as a defendant/offender proceeds through the justice process, he or she will come under the supervision of the local municipality, the county and the state, all within several months.

The last two decades of the twentieth century saw escalation in the punishment of drug offenders that, in turn, has led to an over-burdened justice system. However, drug offenders are not the only offenders for whom alcohol and other substance use is a problem. Up to three-fourths or more of all offenders may demonstrate problems related to alcohol and other substance use issues.

The approaches to dealing with the complex challenges of substance-involved offenders are as varied as the jurisdictions in which they are employed. Research has demonstrated the need for five key constructs in developing treatment programs for justice populations.

Principle #1: Active Collaboration between Justice and Treatment Systems At the intersection of the justice and treatment systems, the overarching goals of the two systems often appear inconsistent—i.e., public safety vs. rehabilitation. Yet, the goals of both systems are equally important in reducing drug use and criminal behavior. As a result, active collaboration is the cornerstone of any successful drug and crime reduction strategy. Partnerships ensure maximum availability of services, capitalizing on existing programs, inter-system efforts and other community strengths.88 The partners are able to leverage existing knowledge and expertise and direct resources through a unified strategy.89 Partnerships also increase ownership and accountability for suc- cess90 and can more effectively influence public policy and open or gain access to funding streams without duplicating effort.91

Principle #2: Formal Systemic and Programmatic Infrastructure Systemic approaches require a solid foundation of procedure, protocols, information management and exchange, and standards of performance to support long-term effectiveness.92 Some measure of formality is critical, regardless of the size of the jurisdiction. The specifics of the infrastructure should remain the purview of the systems, based on the needs and nuances of their jurisdiction.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 57

Principle #3: Clinical Case Management Linking Justice and Treatment Case management of drug-involved offenders through the treatment milieu has been demonstrated to effectively assist offenders as they move through the continuum of care. It also has been proven to result in more rapid access to necessary services, longer lengths of stay, and more positive long-term outcomes.93 This is particularly important for offenders who demonstrate an array of behavioral and social needs over an extended period of time and who otherwise would likely be unable to gain access to those services.94 The case manager can play a critical role in the ongoing determination of client need, in securing services suitable for the individual client, and in coordinating and engaging of multiple service systems.95

Principle #4: Appropriate and Effective Use of Treatment Once the treatment needs have been identified via a comprehensive clinical assessment, referrals must be made to treatment programs that employ the most recent evidence-based methodologies structured to the unique needs of the offender. For justice populations, length and continuity of treatment can be a major determinant of long-term success.96 It also is important to recognize addiction as chronic disease, subject to frequent relapses, that often may require multiple interventions over an extended period of time.97

Principle #5: Commitment to Science-Based Models of Treatment Delivery and Mecha- nisms for Ongoing Knowledge Transfer New research is continually emerging that helps us better understand the nature of drug use, its effect on criminal behavior, the special needs of offender populations, and strategies for effective treatment and other interventions. A formal system for ongoing inter- and intra-disciplinary education is key to ensuring that the partnership between the systems is continually operating with the most relevant and most recent information.

General discussions follow of the types of strategies that currently are being employed across the country. These strategies include sentencing reform, prosecutorial and court- ordered diversion, corrections-based treatment, reentry and reintegration, and juvenile justice. Sentencing Reform

Many states recognize that enhancements in penalties for drug offenses have had little effect on the commission of substance-related crimes or on stemming the tide of recidivism. Some states are now reversing the trend of enhancing drug law violations by adjusting or eliminating mandatory minimum sentences and other penalties in order to create a more appropriate sentencing response. Although these changes may ultimately result in smaller prison populations, they do not in and of themselves address the root of the problem—the alcohol and other substance use. They are therefore best used in conjunction with a treatment intervention.

Some states—such as Arizona,98 California,99 Illinois100 and New York—have enacted legislation that requires access to treatment interventions for drug or drug-involved offenders. In some cases, sentences may be stayed pending the outcome of treatment. In others, a guilty plea is required, usually prompting a sentence of probation and treatment supervision. These legislative strategies reflect a wholesale reversal of earlier policies and, as such,

National Conference of State Legislatures 58 Treatment of Alcohol and Other Substance Use Disorders

may be difficult to enact. However, they do result in systemic responses, meaning that prosecutors, public defenders, judges, probation agencies and the community treatment providers who deliver the services must work together. Prosecutorial and Court-Ordered Diversion

Diversion programs usually refer to those programs that halt a given defendant’s/offender’s progression through the justice system or remove him or her from the justice system alto- gether. These programs are based on established research that clearly demonstrates the benefits of treatment or drug education over incarceration. Examples include the following.

Prosecutorial Diversion or Deferment. The local prosecuting office will defer pressing of formal charges pending successful completion of drug education or other type of treatment intervention.

Drug Courts/Sentencing. Drug courts are based on a non-adversarial, team-oriented approach. Defendants are selected for the drug court by virtue of their charge or demonstrated substance use. The judge generally will mandate the offender to treatment, and all the court professionals will monitor progress and contribute to ongoing supervision and compliance. Drug courts may be pre- or post-sentence, and the judge may use the leverage of additional justice sanctions to compel compliance with treatment. Initial research on drug courts suggests positive outcomes in terms of reduction of alcohol and other substance use and recidivism.101

TASC. Originally known as Treatment Alternatives to Street Crime, TASC is a model for providing independent clinical assessment, treatment referral and case monitoring functions as a link between the justice systems and community treatment. The independent nature allows for objective assessment of each defendant’s needs and for a balance between the justice system’s goals and priorities and the offender’s clinical concerns. The clinical expertise of the TASC case manager complements the public safety role of the probation or parole officer. TASC programs may be pre- or post- sentence, and may be statewide or local.102

Breaking the Cycle. Breaking the Cycle is built upon the TASC model of independent evaluation and case management, employing judicial review and sanctions, but without the eligibility requirements present in other diversion programs. Evaluation of the Breaking the Cycle program revealed some challenges to implementation but also demonstrated positive outcomes.103 Corrections-Based Treatment

During the last decade, access to treatment options among inmates has dropped sharply. In 1991, 34 percent of offenders who reported drug use prior to incarceration reported access to treatment in a prison environment. In 1997, that number had dropped to 13 percent. Among the factors contributing to this drop are ever-increasing numbers of offenders, limited staff expertise, and lack of coordination among the necessary agencies.

Among the most common and promising approaches for prison-based treatment is the use of the therapeutic community, modified to include the unique issues facing inmate popu-

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 59

lations. A “Therapeutic Community” (TC)104 is a model of treatment that is based on social learning theory.105 The TC addresses the whole person, not only the substance abuse. It creates a highly structured environment with norms, language, rules, expectations, sanctions for negative behaviors, and rewards for positive behaviors. In a TC, everyone involved becomes part of the treatment, including the inmates, treatment staff and correctional officers. Mistakes are confronted and used as learning experiences; similarly, good behaviors are recognized, reinforced and rewarded. Research on the effectiveness of TCs demonstrates that those who complete the programs are significantly less likely to relapse or recidivate.106 Reentry and Reintegration

Research clearly demonstrates that the most positive long-term results in reducing alcohol and other substance use and recidivism occur when prison-based treatment is matched with strategic transition and reentry services. Federally funded studies with measured long- term results show that three states—California, Delaware and Texas—have reduced recidivism and improved cost-effectiveness through a three-phase treatment continuum that includes in-prison TCs, a community-based transitional living center with substance abuse treatment, and community-based aftercare. In each case, the research has shown that the best results occur with participants who complete all stages of programming.107

Here again, the models and strategies are as unique as the jurisdictions in which they are implemented. Some of the models employed successfully include:

Transitional Housing. Transitional housing may be operated by state corrections or an independent agency. The goal is to provide a continuum of services after release and to continue the TC strategy until the releasee demonstrates some measure of self sufficiency. Other services—such as job training and readiness, general education, family skills, gang and violence intervention, and others targeted to specific needs of the local community—may be provided.

Independent Clinical Reentry Management. Very similar to the TASC court and probation strategy, independent clinical reentry management involves a third party that conducts comprehensive clinical assessments of returning offenders, designs individualized case plans to help them navigate the range of services they need to access, then helps them through the process of achieving stability and self-sufficiency. The case manager maintains links with all the necessary community providers and works closely with the releasee, the community, and the supervisory authority (usually parole or similar entity) to balance the releasee’s restorative needs with the community’s public safety concerns.

Winners Circle Support Groups. Developed in Texas, the Winners Circle is a peer-led support group for ex-offenders, most of whom also demonstrate alcohol and other substance use issues. The groups create a safe, non-judgmental environment for sharing challenges and concerns and creates opportunities for mentorship relationships wherein ex-offenders who have overcome the barriers to reintegration forge personal support and guidance relationships with those just being released.

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Juvenile Justice

For juvenile offenders, the principles of delivering effective treatment programs and alternatives are the same as those described above. Likewise, the range of opportunities for intervention mirrors the adult justice system, although generally with different terminology. As with the adult system, the juvenile justice system involves law enforcement agencies, the courts, detention or probation agencies, and community reintegration. As a result, the types of strategies—whether they be statutory, diversion, institutional treatment or reentry—also can be applied.

The one distinct difference is the enhanced complexity of the juvenile client. Many juveniles come from abusive situations or broken families, and thus have few prospects for returning to their community. Some may even be wards of the state. Many are gang- involved. Their juvenile status also affects the course of their education. Their ability to achieve any measure of stability may be tenuous, but their juvenile involvement also offers the opportunity to address issues that may manifest themselves more seriously later in life if they remain unaddressed.

Options for treatment of juveniles generally will occur in one of two settings—non-detention or detention. Options such as 12-step groups, outpatient treatment or day treatment are the most widely used programs to address alcohol and other substance use in a non- detention setting.108 Models such as drug courts, TASC and intensive case management also have been employed in a number of jurisdictions. Within these programs, treatment modalities may include family or individual therapy, skills training, conflict resolution and violence prevention, peer mediation or adult mentoring programs.109 Research indicates interpersonal skills training, family therapy and individual counseling have the most positive effect on reducing adverse outcomes such as police contacts and recidivism.110

Detention serves one of two roles in the juvenile justice system. First, a juvenile offender may be held in a detention facility while a case is being processed (similar to an adult jail) if it is believed he or she is a threat to the community, will be at risk if returned to the community or may fail to reappear at a hearing. About one-quarter of these cases involved a drug offense,111 but alcohol and other substance use treatment in this type of detention setting is not common.

A juvenile offender may receive a mandatory referral for treatment while in a longer-term detention setting, used much in the same way as a prison for adults. Options include inpatient treatment and residential therapeutic communities (TCs).112 TCs provide 24-hour settings where a variety of rehabilitation services are provided, including personality restruc- turing, social education, and economic and survival skills. Research indicates adolescents who are involved in these programs exhibit significantly reduced alcohol and other substance use, as well as a reduction of criminal activity and improvement in educational achievement. The most significant predictor of successful treatment is the amount of time spent in the treatment program. Positive outcomes are associated with stays of 90 days or more.113

Short-term residential programs have more questionable outcomes than long-term alternatives. The recent trend in the juvenile justice system is to place youths in large, frequently crowded short-term programs. Evidence suggests these programs serve primarily to isolate youth from society and inadequately address rehabilitation needs. As a result, their effectiveness in reducing recidivism is limited.114

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 61

As with adults, the process of reentry into the community following detention is often the most critical in determining long-term success; it may be exacerbated by additional challenges in home, school and social settings. These settings require full cooperation by a collaborative team of stakeholders to design individualized reentry strategies to leverage the strengths of the youth and the services available in the community.115 Treatment of Co-occurring Mental Illness and Alcohol and Other Substance Use Disorders

An estimated 10 million people in the nation have combinations of co-occurring mental illnesses and alcohol and other substance use disorders. This population is especially difficult to treat because of the complexity of issues that face them and the system of care provided to them. According to the National Association of State Alcohol and Drug Abuse Directors (NASADAD), numerous barriers exist to providing appropriate treatment to dually diagnosed individuals. Most troubling is the fact that no single point of responsibility for treatment exists. Mental health and alcohol and other substance use treatment systems operate independently of each other, almost as separate cultures. Each has its own treatment methods and philosophies, administrative structures and funding. The lack of coordination that often occurs makes it difficult for providers and consumers caught between the two systems.116 One possible solution involves the concept of a “no wrong door” system that is available and accessible no matter where and how the individual enters the system. In addition, the use of common data and assessment tools, staff who are trained in each other’s disciplines, and flexible funding mechanisms will lead to the comprehensive, coordinated system of care that is critical for success in treating co-occurring disorders. One issue is funding, whether mental health or substance abuse money should be used. Another issue is the cross-training on mental health and substance abuse providers. Quadrant System

A conceptual framework for treatment that is flexible, cost-effective, client-centered and evidence-driven was developed by the NASMHPD-NASADAD Task Force on Co-occurring Mental Health and Substance Use Disorders. Use of the framework helps key stakeholders speak the same language about symptom severity, locus of care, and the level of service coordination needed to address co-occurring disorders. The vast majority of the research literature and the bulk of the money invested tends to focus on people with serious mental illnesses who also have alcohol and other substance use disorders. This framework, which takes a much broader approach, is designed to ensure enough flexibility to address the needs of all individuals with co-occurring disorders; to fit into any service setting; and to allow policymakers, providers and funders to plan and fund services for individuals regardless of the current structure of a state’s or community’s health care delivery system.117 More information about the quadrant system is contained in appendix G.

Mental illness is only one of several illnesses that co-occur with alcohol and other substance use disorders. Many physical illnesses commonly co-occur, such as fetal alcohol syndrome (FAS), Hepatitis C virus (HCV), human immunodeficiency virus (HIV), sexually transmitted diseases (STDs), liver disease, heart disease, certain forms of cancer and pancreatitis.

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Barriers to Recovery

Many consequences of former alcohol and other substance use, particularly if a crime was involved, act as barriers to recovery. Sanctions for various crimes include losing Medicaid and/or social security disability insurance (SSDI) benefits. Ex-felons are barred from public housing. There are many job restrictions; ex-convicts are not permitted to have certain jobs. Most job applications and higher education applications ask whether the applicant has ever been convicted of a crime. Licensing of Providers

State legislators may establish licensing requirements for treatment facilities, including standards for the physical plant and requirements for services provided. State legislators also may establish licensing requirements for individual providers, such as education requirements and supervised work experience requirements. Regulating Treatment

State legislators set regulations regarding quality of care at state-run treatment facilities. State legislators legislate on certificate of need requirements (CON) that often apply to treatment facilities, particularly methadone clinics. Confidentiality

The federal confidentiality laws and regulations prohibit disclosure of information about patients who have applied for or received any alcohol or other drug use-related services— including assessment, diagnosis, counseling, group counseling, treatment, or referral for treatment—from a covered program. The restrictions on disclosure apply to any information that would identify a patient as an alcohol or other drug user, either directly or by implication. The general rule applies from the time the patient makes an appointment. It also applies to patients who are civilly or involuntarily committed, minor patients, patients who are mandated into treatment by the criminal justice system, and former patients. The rule applies whether the person making an inquiry already has the information, has other ways of getting it, has official status, is authorized by state law, or has a subpoena or search warrant.118

Any program that specializes, in whole or in part, in providing treatment, counseling and/ or assessment, and referral services for patients with alcohol or other drug problems must comply with the federal confidentiality regulations (§§2.12(e)). The federal regulations apply only to programs that receive federal assistance, including indirect forms of federal aid such as tax-exempt status, or state or local government funding coming (in whole or in part) from the federal government.119

The federal confidentiality regulations provide three ways by which researchers can obtain information from AOD programs:120

• The regulations permit AOD use treatment programs to give researchers access to information about patients when no patient identifying information is revealed.

National Conference of State Legislatures What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders? 63

• The regulations permit AOD programs to give researchers patient identifying information without patients’ consent when certain criteria are met.

• Researchers also may obtain information that is protected by the federal confidentiality regulations if patients sign proper consent forms.

The federal regulations permit programs to disclose information about patients if the programs reveal no patient identifying information. Patient identifying information is information that identifies an individual as an alcohol or other drug user. Thus, a program can give researchers aggregate data about its population or some portion of its population. For example, a program staff member could tell a researcher engaged in outcomes monitoring that, during the last year, 42 patients completed the treatment program, 67 dropped out in less than six months, and 25 left the program between six and 12 months. 121

The confidentiality regulations permit programs to disclose patient identifying information to researchers, auditors and evaluators without patient consent, providing certain safe- guards are met (§§2.52, 2.53). 122

Alcohol and other substance programs can disclose patient identifying information to those who are conducting “scientific research” if the program director determines that the researcher 1) is qualified to conduct the research, 2) has a protocol under which patient identifying information will be kept in accordance with the regulations’ security provisions (see §§2.16),6 and 3) has provided a written statement from a group of three or more independent individuals who have reviewed the protocol and determined that it protects patients’ rights. 123

Researchers are prohibited from identifying any individual patient in any report or otherwise disclosing any patient identities except to the program. This provision is addressed more fully below, because it is particularly important when a research design calls for follow-up research with the patient or collateral sources or for tracking patients in other health, social welfare or criminal justice systems. 124

Patient records may be reviewed on the program’s premises for the purposes of conducting an audit or evaluation by the following entities: 125

• Federal, state and local government agencies that fund or are authorized to regulate a program;

• Private entities that fund or provide third-party payments to a program; and

• Peer review entities that are performing utilization or quality control review in order to conduct an audit or evaluation.

Any person or entity reviewing patient records to perform an audit or conduct an evaluation must agree in writing that the information will be used only to carry out the audit or evaluation and that patient information will be disclosed only 1) back to the program, 2) in accordance with a court order to investigate or prosecute the program (§§2.66), or 3) to a government agency overseeing a Medicare or Medicaid audit or evaluation (§§2.53(a), (c), (d)). Any other person or entity that is determined by the program director to be qualified to conduct an audit or evaluation and that agrees in writing to abide by the

National Conference of State Legislatures 64 Treatment of Alcohol and Other Substance Use Disorders

restrictions on redisclosure also can review patient records. Again, the prohibition on redisclosure is particularly important when research designs include follow-up. 126

When a researcher who seeks to interview patients or former patients meets the requirements of §§2.52 or 2.53, the federal confidentiality regulations do not require that a program obtain a patient’s consent under §§2.31 to release his or her name to the researcher. However, it is always better practice to obtain patients’ consent to the release of their names to researchers, auditors, or evaluators who are seeking to approach them for interviews. 127

Researchers also can obtain patient identifying information if the patient has agreed to the release of the information by signing a valid consent form that has not expired or been revoked (§§2.31). The regulations’ requirements regarding consent are somewhat unusual and strict and must be carefully followed. 128

A proper consent form must be in writing and must contain each of the items contained in §2.31:129

• The name or general description of the program or person making the disclosure;

• The name or title of the individual or organization that will receive the disclosure;

• The name of the patient who is the subject of the disclosure;

• The purpose or need for the disclosure;

• How much and what kind of information will be disclosed;

• A statement that the patient may revoke the consent at any time, except to the extent that the program or person authorized to make a disclosure has already acted in reliance on it;

• The date, event, or condition upon which the consent expires, if not previously revoked;

• The signature of the patient (and, in some states, his or her parent); and

• The date on which the consent is signed.

A general medical release form or any consent form that does not contain all the elements listed above is not acceptable. 130

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 65

5. WHAT FUNDING IS AVAILABLE FOR STATES TO PROVIDE SERVICES TO PEOPLE AFFECTED BY ALCOHOL AND OTHER SUBSTANCE USE DISORDERS?

The Substance Abuse Prevention and Treatment Block Grant provides approximately 40 percent of the public funds spent • The Substance Abuse Prevention and Treatment Block Grant on treatment and prevention in the states. Entitlement provides approximately 40 percent of the public funds spent programs, such as Medicaid, are another important source on treatment and prevention in the states. of funding. Funding of alcohol and other substance use prevention and treatment services for alcohol and other sub- • In FY 1996, $12.6 billion was spent on treatment for alco- stance use disorders is provided by federal, state and local hol and other substance use disorders. governments. State and federal governments share financial responsibility in the area of Medicaid, where states are • Between 1987 and 1997, the average annual growth rate of increasingly using managed care systems to administer ben- expenditures for alcohol and other substance use disorders efits. Coverage of alcohol and other substance use treat- was 2.5 percent. ment varies widely among private insurers. However, many states have laws that mandate coverage of some level of benefits for the treatment of alcohol and other substance use disorders. A small number of states require at least an offering of benefits, while still others do not address the issue at all. Federally funded programs primarily operate as block grants, entitlements or categorical grants, and research grants. Overview of State and Federal Funding

In FY 1997, $11.9 billion was spent on treatment for alcohol and other substance use disorders. Between 1987 and 1997, the average annual growth rate of expenditures for alcohol and other substance use disorders was 2.5 percent.1

The Substance Abuse and Mental Health Administration (SAMSHA) data for FY 1997 shows that the majority of funding for alcohol and other substance use treatment expenditures was from public sector funding (64 percent).2 Table 6 shows national averages of federal block grant allocations and state appropriations for mental health and substance abuse.

National Conference of State Legislatures 65 66 Treatment of Alcohol and Other Substance Use Disorders

Table 6. National Averages of Federal Block Grant Allocations and State Appropriations for Mental Health and Substance Abuse

FY 02/03 Mental Health FY 02/03 Substance FY 01 State FY 98 State Block Grant Allocation Abuse Block Grant Appropriation for Appropriation for Allocation Mental Health Substance Abuse $8,162,127 $32,684,766 $448,518,107 $24,080,673

Sources: “SAMHSA Grant Awards FY 2002/FY 2003,” http://www.samhsa.gov/funding/funding.html. “Table 1: SMHA Mental Health Actual Dollar and Per Capita Expenditures by State, Fiscal Year 2001,” http://www.nri-inc.org/RevExp01/Table1.htm. “Table 1: Expenditures Reported for State Supported Alcohol and Other Drug Services By State and Funding Source, For Fiscal Year 1998,” State Alcohol and Drug Abuse Profile (SADAP), FY 1998; data included for ONLY THOSE PROGRAMS that received at least some funds administered by the State Alcohol and Other Drug Abuse Agency during the State’s FY 1998. The State Role in Financing

Each state has designated a single state agency (see appendix E for state contacts) to be responsible for effective allocation and utilization of federal and state sources that are specifically targeted for alcohol and other substance use treatment services. Funding from state government sources include, but are not limited to:

• State general fund revenues; • Medicaid funds that are used for drug and alcohol treatment; • Earmarked taxes; • Seized assets, money or property that is derived from drug crimes and specifically appropriated for support of drug and alcohol treatment programs; and • Fines, fees and/or assessments earmarked for drug and alcohol treatment. State Funds for Treatment

Each state appropriates money to its substance abuse agency for the prevention and treatment of alcohol and other substance use disorders. States also appropriate money to other agencies for purposes related to al- Table 7. Per Capita State Spending on Alcohol and Other Substance Use Prevention, Treatment and Research cohol and other substance use disorders, such as Medicaid for treatment, children and families for screening and treatment, State Per Capita State Per Capita Spending Spending education for prevention, housing for screening and referral, jus- Alabama $7.40 Montana $8.21 tice for treatment and drug courts, and so forth. Table 7 shows Alaska $26.51 Nebraska $5.40 Arizona $12.32 Nevada $3.61 state per capita spending on alcohol and other substance use Arkansas $1.81 New Hampshire * California $14.66 New Jersey $6.17 prevention, treatment and research. Colorado $0.14 New Mexico $6.39 Connecticut $8.34 New York $27.77 Delaware $31.34 North Carolina * Private Insurance Coverage Florida $5.28 North Dakota $15.79 Georgia NA Ohio $3.74 Hawaii $7.31 Oklahoma $10.37 Many private insurance companies are providing benefits for Idaho $5.74 Oregon $23.96 Illinois $8.17 Pennsylvania $8.50 the treatment of alcohol and other substance use disorders. These Indiana * Rhode Island $0.74 benefits can vary greatly from one insurance company to the Iowa $4.00 South Carolina $0.41 Kansas $3.20 South Dakota $5.16 next. Benefits also vary across the types of plans that are offered Kentucky $3.37 Tennessee $1.66 Louisiana $3.32 Texas * by employer/purchasers of insurance coverage and other services. Maine * Utah $4.89 Standard health maintenance organization (HMO) plans offer Maryland $6.87 Vermont $5.14 Massachusetts $15.86 Virginia $4.20 more benefits than do traditional or preferred provider organi- Michigan $0.19 Washington $10.21 zation plans (PPOs) because HMO plans are more tightly man- Minnesota $12.23 West Virginia $4.30 Mississippi $4.54 Wisconsin $1.51 aged and can control use of and access to services. Some plans Missouri $7.71 Wyoming $5.81 cover medical, inpatient detoxification only for alcohol and other Note: Indiana, Maine, New Hampshire, North Carolina and Texas did not respond to the survey. Source: “Shoveling Up: The Impact of Substance Abuse on State Budgets, State-By-State Tables,” substance use disorders. Other plans may cover outpatient ser- http://www.casacolumbia.org/usr_doc/statebystate.html. vices but not inpatient or residential care. Some plans greatly

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 67

limit the amount of visits or inpatient days for the treatment of alcohol and other substance use disorders. Plans vary widely in access and the extent of services available to the insured, and in the minimum and maximum amounts of services available to patients and insureds.

Four common treatment settings are associated with alcohol and other substance use disorders. Managed care organizations and other insurance entities define these levels of care differently, based on the level and type of benefits they offer, the utilization management guidelines they are using, and their medical necessity criteria. However, certain basic components must be available in each treatment setting.

Parity and Mandated Benefits Mandating benefits for the treatment of alcohol and other substance use disorders is con- troversial. Insurers and employers—especially small group employers—oppose mandated benefits because they believe these mandates increase costs and force employers to lower other health insurance benefits for their employees. Supporters of alcohol and other substance use treatment mandates believe that mandates are the only way people who need treatment can obtain the services they need without being discriminated against. The ultimate mandate for the equality of treatment for alcohol and other substance use services can be found in state parity laws. These laws require that the benefits for the treatment of mental health and alcohol and other substance use must be provided under the same terms and conditions as the benefits for the treatment of any other physical illness. Benefits include equality in lifetime and annual limits, deductibles and co-insurance, and visit limits for inpatient and outpatient treatment. Parity for mental health has gained momen- tum during the past 10 years, and 21 states now require full parity for the treatment of mental illness. However of those 21, only nine—Connecticut, Delaware, Maine, Minne- sota, North Carolina, South Carolina, Vermont, Virginia and West Virginia—include treatment for alcohol and other substance use disorders. Parity benefits in North Carolina and South Carolina apply only to state employee plans.3

Forty-five states require that some level of benefits be provided for the treatment of alcohol and other substance use disorders (see appendix H).

Finally, mandates—even parity mandates—do not cover all third-party payers. Medicare and Medicaid are exempt from many state mandates, unless explicitly required to provide coverage under the law. Also exempt from many mandated benefits laws are small group employers, self-insured and individual health plans, and those covered under the federal Employee Retirement Income and Security Act (ERISA).4

On June 7, 1999, the White House announced its intent to provide federal employees with parity benefit coverage in the Federal Employee Health Benefit Plan (FEHBP) for the treatment of mental illness and alcohol and other substance use disorders and other medical health problems by 2001. The largest employer-sponsored health insurance program in the country, FEHBP covers about 9 million people, including federal employees, retirees and their families. This benefit coverage program could serve as a national model.

The Office of Personnel Management (OPM) has taken the lead in making mental health coverage more affordable and accessible for all federal employees. During the past few years, OPM, working with benefit providers in the FEHBP, have:

National Conference of State Legislatures 68 Treatment of Alcohol and Other Substance Use Disorders

• Eliminated lifetime and annual maximums for mental health care.

• Moved away from contractual day and visit limitations and high out-of-pocket costs for mental health care.

• Covered medical visits and testing to monitor drug treatment for mental conditions as pharmaceutical disease management.5

Following President Clinton’s directive, OPM issued a call letter to all 285 health plans that participate in the FEHBP to enlist their support in achieving parity for mental health and substance abuse coverage.

Cost Shift to Private Sector. Parity and mandated benefits shift the cost of treatment from the public system to the private sector. Many privately insured individuals require alcohol and other substance use treatment, but their insurance does not cover such treatment. Therefore, many of those individuals receive publicly funded treatment. Parity and mandated benefit laws require private insurance to cover the cost of alcohol and other substance use treatment; therefore, privately insured individuals who require alcohol and other substance use treatment have that treatment paid for by their insurers. Alcohol Tax

An alcohol tax serves the dual purposes of primary prevention and revenue enhancement for the state. The additional cost deters some individuals from purchasing alcohol. Teen- agers are particularly sensitive to price. Everyone who uses alcohol contributes toward a tax fund used for the prevention and treatment of alcoholism and alcohol abuse. The majority of people favor the tax, particularly if it is tied to prevention and treatment. (Appendix I contains alcohol taxes by state.) Federal Role in Funding Treatment

Medicaid, Medicare, TRICARE, supplemental security income (SSI) and social security disability insurance (SSDI) are entitlement programs that enable eligible recipients or states to receive income support maintenance and health care. All these programs have services that can be used for alcohol and other substance use treatment and services. P.L. 104-121, signed by President Clinton in 1996, eliminated addictions as a qualified disability for SSI/SSDI. As a result, SSI as a mandatory Medicaid eligible was not available for those with addictions. SSDI and its link to Medicare was lost. However, those with addictions were not excluded from Medicaid and Medicare per se. The denial applied immediately to any new or preceding claim for benefits. Benefits were terminated on January 1, 1997, for individuals who were receiving benefits based on alcohol and other substance use disorders; costs were shifted to state and local programs.

Many other grants are available from the federal government through various federal agencies, including the military, the Department of Education, and the Administration for Children and Families. Some of the federal programs are discussed below.

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 69

Substance Abuse and Mental Health Services Administration (SAMHSA)

State government is the largest single purchaser of treatment services for alcohol and other substance use disorders through block grants in most states. SAMSHA is the lead agency for alcohol and other substance use treatment and prevention programs.

Substance Abuse Prevention and Treatment (SAPT) Block Grant The Center for Substance Abuse Treatment within the Substance Abuse and Mental Health Services Administration is the lead agency to administer the block grant. The grant funds represent approximately 40 percent of the funds flowing through the single state agencies. The block grant contains several mandatory distributions and set-asides:

• 20 percent must be used for prevention activities;

• 2 percent to 5 percent must be spent on AIDS-related drug use programs in states with an AIDS case rate of 10 per 100,000 population;

• States must spend from their allocation an amount “equal to fiscal year 1994 spending levels” on programs for pregnant women and women with dependent children; and

• Up to 5 percent of a state’s allocation may be used for state administration.6

Of the funds allocated to the block grant program, 95 percent are distributed to states through a formula prescribed by the authorizing legislation. Factors used to calculate the allotments include total personal income; state population data by age groups (total population data for territories); total taxable resources; and a cost of services index factor.7

Performance Partnership Grants The Substance Abuse and Mental Health Services Administration (SAMHSA) published for comments in the Federal Register on December 23, 2002, its plans to create two new Performance Partnership Grant programs with states. The new Performance Partnership Grant programs will replace the current Substance Abuse Prevention and Treatment Block Grant and the Community Mental Health Services Block Grant to states.8

The announcement was the culmination of years of discussion with the National Associa- tion of State Alcohol and Drug Abuse Directors and the National Association of State Mental Health Program Directors. The request for comments provided an opportunity for interested organizations and individuals to help ensure that the Performance Partnership Program meets its long-term goals. SAMHSA was particularly interested in learning whether the proposed performance measures are the most appropriate to help SAMHSA track program performance in relation to those goals.9

“The Performance Partnership approach builds on the principles of partnership, flexibility, and accountability based on performance,” said SAMHSA Administrator Charles G. Curie. “We expect these new proposals to bring continuous quality improvement to the provision of substance abuse treatment and prevention services; and community-based mental health services for adults with serious mental illness, and children with serious emotional distur- bance.”10

National Conference of State Legislatures 70 Treatment of Alcohol and Other Substance Use Disorders

He explained that, “We are not proposing any changes that would alter eligibility for funding under the two programs, nor are we changing the formula for distribution of those funds. We are changing the relationship between the federal and state governments to achieve our goal of improved services for those with mental health and/or substance abuse disorders.”11

The Performance Partnership Program will change the thrust of the block grants from state expenditure reports and accountability based on documentation of compliance to reliance on evidence of performance. States would gain more flexibility to use block grant funds to address their specific needs. States and the federal government would work together to identify the strengths of a state’s service system and areas where it could be improved to benefit those in need of alcohol and other substance use and mental health services. The goal of the new program is to promote an atmosphere where best practices are integrated into state programs as part of a continuing cycle of quality improvement.12

Congress ordered a plan to change block grant programs to a performance-based system in the Children’s Health Act of 2000.13

Maintenance of Effort (MOE) Funds The SAPT Block Grant has a maintenance of effort (MOE) requirement. With respect to the principal agency of a state for carrying out authorized activities, such agency will for such year maintain aggregate state expenditures for authorized activities at a level that is not less than the average level of such expenditures maintained by the state for the two-year period preceding the fiscal year for which the state is applying for the grant.14

Upon the request of a state, the secretary may waive all or part of the requirement for the agency if the secretary determines that extraordinary economic conditions in the state jus- tify the waiver. The secretary shall approve or deny a request for a waiver not later than 120 days after the date on which the request is made. Any waiver provided by the secretary shall be applicable only to the fiscal year involved.15 (See Federal Regulations, 45 CFR 96.134(b) Maintenance of Effort Regarding State Expenditures.)

In making a grant to a state for a fiscal year, the secretary shall make a determination of whether, for the previous fiscal year, the state maintained material compliance with any agreement made by the agency. If the secretary determines that a state has failed to maintain such compliance, the secretary shall reduce the amount of the allotment for the state for the fiscal year for which the grant is being made by an amount equal to the amount constituting such failure for the previous fiscal year. The secretary may make a grant for a fiscal year only if the state involved submits to the secretary information sufficient for the secretary to make the determination. 16

Discretionary Grant Programs A discretionary grant permits the federal government, according to specific authorizing legislation, to exercise judgment (discretion) in selecting the applicant/recipient organization, through a competitive grant process. Types of activities commonly supported by discretionary grants include demonstration, training, service and programs. Discretionary grants are sometimes referred to as a project grants.17

Discretionary grant funds are made available and awarded by the Center for Mental Health Services (CMHS), the Center for Substance Abuse Prevention (CSAP), and the Center for

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 71

Substance Abuse Treatment (CSAT) in accordance with the mission and purpose of SAMHSA.18

Programs of Regional and National Significance (PRNS) is a type of discretionary grant included in SAMHSA’s authorizing legislation (P.L. 102-321, as amended by P.L. 106- 310). PRNS grants complement SAMHSA’s block grants to the states in many ways. They enable SAMHSA to target funds to priority populations or health concerns, respond quickly to emerging needs, and implement and promote adoption of evidence-based practices. Evaluation of the PRNS grants further helps SAMHSA ensure that federal service funds are well spent.19 These grants are not always coordinated with state programs.

SAMHSA’s PRNS grants fall into two categories, knowledge application (KA) programs and targeted capacity expansion/response (TCE) programs. KA programs are designed to bridge the gap between scientific knowledge and community-based practice. Knowledge application grants provide support for wide-scale adoption of new research tested effective practices. TCE programs provide targeted funding to implement focused responses to emerging needs using proven practices. Projects address treatment and prevention issues unique to a population or geographic area.20 Centers for Medicare and Medicaid Services (CMS)

Medicaid Medicaid is a federal-state partnership that provides required and optional health care services to millions of low-income Americans. Funds that are given to the states using an open-ended formula, provide a minimum of 50 percent federal share in the cost of medical services covered and part of administrative costs. As a result, Medicaid provides a useful way for states to maximize funding resources.

The number of Medicaid recipients has increased from approximately 10 million in 1967 to an estimated 48.9 million in FY 2002, an increase of 389 percent. This has meant rapid growth in Medicaid expenditures, although the rate of increase has subsided recently.21 Between 1990 and 2002, Medicaid recipients as a percent of the total U.S. population increased from 10.2 percent to 16.9 percent, an increase of approximately 66 percent.22 Medicaid spending on alcohol and other substance use disorders rose rapidly at an inflation-adjusted rate of 9.8 percent yearly between 1987 and 1992, still slower than the 11.8 percent annual increase in Medicaid spending on all health care during that period. In the second five-year period, Medicaid programs slowed the rate of increase of spending on alcohol and other substance use treatment to an annual 5.7 percent increase between 1992 and 1997.23

Federal Medicaid guidelines require a core of basic services, including hospital inpatient and outpatient care; early and periodic screening, diagnosis and treatment of physical and mental illnesses for individuals under age 21; rural health clinic services; physicians’ services; and nurse-midwife services. States have discretion to cover additional services, such as alcohol and other substance use treatment programs and inpatient hospital care in mental institutions for individuals under age 21; services of state-licensed practitioners, such as psychologists, alcohol and other substance use counselors, and medical social workers; rehabilitation option to expand to 10 people; clinic services, such as those offered by outpatient alcohol and other substance use clinics; prescription drugs; and transportation and emergency hospital services.

National Conference of State Legislatures 72 Treatment of Alcohol and Other Substance Use Disorders

Medicaid does not provide coverage for individuals between the ages of 21 and 65 who receive alcohol and other substance use or mental illness treatment from an institution for mental disease (IMD). (An IMD is defined as any hospital, nursing facility or other institution with more than 16 beds whose primary business is mental health, which includes alcohol and other substance use disorders.) The IMD exclusion effectively denies Medic- aid funding to residential, community-based alcohol and other substance use treatment services, such as therapeutic communities. This policy has particularly adverse effects for substance using women who are pregnant or have dependent children and may require residential treatment services. The IMD exclusion is viewed as a barrier to appropriate alcohol and other substance use treatment for vulnerable populations and effectively shifts the cost of serving these populations to the states and to block grant funded programs.

Section 1115 of the Social Security Act allows states to apply for waivers for demonstration projects as long as the programs are “budget neutral.” Several states have used the 1115 waiver to implement projects that waive the IMD exclusion. In addition, states that are experimenting with managed care delivery systems (some no longer require a waiver, according to the Balanced Budget Act of 1997) and under 1915b waivers can circumvent the IMD exclusion. Because Medicaid pays managed care systems flat rates with an agreed upon capitation fee, CMS does not require information about the actual services provided. Therefore, Medicaid-approved managed care systems may provide alcohol and other substance use treatment services, provided the costs for these services fall within the agreed upon capitation fee.

To obtain your state’s coverage of alcohol and other substance use disorder treatment under Medicaid, contact your single state agency director or the Medicaid office. (A listing of single state agency directors is contained in appendix E.)

Mental Health vs. Alcohol and Other Substance Use Disorders Spending. States can choose, under Medicaid, to expand alcohol and other substance use disorders services and expand the list of those eligible. If a state chooses to include the medically needy population under Medicaid, the State plan must provide, as a minimum, particular services. If the state plan includes services (only two ways: 1115 IMD waiver or use DSH or cost savings fund) either in institutions for mental diseases or in intermediate care facilities for the mentally retarded (ICF/MRs), it must offer either of the following to each of the medically needy groups: the services contained in 42 CFR sections 440.10 through 440.50 and 440.165 (to the extent that nurse-midwives are authorized to practice under state law or regulations); or the services contained in any seven of the sections in 42 CFR 440.10 through 440.165. States also may receive federal funding if they elect to provide other optional services. The most commonly covered optional services under the Medicaid program include intermediate care facility/mentally retarded services.24

Sanctions. Medicaid sanctions involve cutting people off of treatment for various crimes.

Medicaid and Managed Care States increasingly rely on managed care as an alternative to traditional fee-for-service delivery systems. Under managed care systems, health maintenance organizations (HMOs), prepaid health plans (PHPs) or comparable entities provide a specific set of services to Medicaid enrollees, usually in return for a predetermined periodic payment per enrollee. Managed care programs seek to enhance access to quality care in a more cost-effective

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 73 manner.25 The percentage of Medicaid enrollees participating in a managed care plan increased from 14 percent in 1993 to 54 percent in 1998.26

States employ four approaches to providing mental health and/or alcohol and other substance use treatment in a managed care model.

• Integrated managed care programs include alcohol and other substance use treatment as a component of an overall physical health plan. Three approaches are models that are designed specifically to serve mental health and/or alcohol and other substance use needs.27

• Integrated models provide alcohol and other substance use services as part of a comprehensive physical health managed care plan. Health maintenance organizations (HMOs) and managed care organizations (MCOs) typically run these programs. The HMO or MCO may subcontract with a specialty organization to provide alcohol and other substance use treatment services. However, payment for services by state Medicaid remains integrated. Another variation of integrated programs is known as a carve-in, where states require the specialty organization that provides treatment services to have a clinical relationship with the primary managed care organization.28

• Partial carve-out programs offer a basic set of benefits under a comprehensive physical health plan, but supplement these benefits under a separate managed care program that offers services targeted toward specific populations or high users (e.g., pregnant women with alcohol and other substance use disorders).

• Full carve-out programs go a step further and separate all mental health or alcohol and other substance use services from physical health managed care programs. In stand- alone programs, alcohol and other substance use treatment services are completely independent of any other program. In other words, these programs are not carved out of a physical health program. Stand-alone programs typically are not associated with Medicaid.29

Temporary Assistance to Needy Families (TANF) The Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996 replaced the Aid to Families with Dependent Children (AFDC) program with the TANF block grant. To receive the TANF block grant, states must meet a maintenance of effort (MOE) requirement each year. The law delinked Medicaid eligibility from eligibility for TANF services. As a result, a new Medicaid eligibility category was created to cover families that would have been covered under AFDC eligibility in 1997.30

States can use welfare funds as a funding source for different approaches to alcohol and other substance use treatment and services. States can maximize the flexibility of the welfare block grant by separating the different funding streams. State MOE for TANF can be used for “medical services,” including treatment by a physician or medical professional, the cost of medication, and health insurance premiums. Federal TANF funds are restricted to “non-medical” services. The state can maximize TANF spending for alcohol and other substance use disorders by setting a narrow definition of “medical services.” Many aspects of alcohol and other substance use services and treatment are considered “non-medical.” These include screening, assessment, treatment, and residential and child care costs associated with treatment.

National Conference of State Legislatures 74 Treatment of Alcohol and Other Substance Use Disorders

At least 40 percent of the states have allocated some TANF funds for alcohol and other substance use services, including integrating alcohol and other substance use education into job readiness programs; providing screening services and treatment for welfare clients through mental health programs; providing counseling services; developing a plan to address the alcohol and other substance use needs of the entire welfare family through a comprehensive approach to treatment; and beginning pilot programs that provide financial incentives to businesses that hire welfare recipients.31

All TANF and TANF MOE spending must meet one of the four goals of the 1996 Personal Responsibility and Work Opportunity Act:

• To provide assistance to needy families so that children may be cared for in their own homes or in the homes of relatives;

• To end the dependence of needy parents on government benefits by promoting job preparation, work and marriage;

• To prevent and reduce the incidence of out-of-wedlock pregnancies and establish annual numerical goals for preventing and reducing the incidence of these pregnancies; and

• To encourage the formation and maintenance of two-parent families.

Alcohol and other substance use services and treatment can be effective in meeting each of the four goals.

Many states are using TANF funds to provide “non-medical assistance,” including:

• Screening and assessment of welfare recipients for alcohol and other substance use;

• Placing qualified alcohol and other substance use professionals in every welfare office;

• Reimbursing the room and board costs of residential care;

• Providing counseling by social workers;

• Integrating alcohol and other substance use education into job readiness programs;

• Teaching welfare recipients about alcohol and other substance use disorders and how to recognize them;

• Developing comprehensive plans to address the alcohol and other substance use treatment needs of the entire family;

• Providing screening and referring individuals to treatment services provided by mental health programs; and

• Providing child care and transportation to facilitate treatment.

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 75

States are using their TANF MOE funds to expand “medical services” for alcohol and other substance use treatment, including treatment by a physician, medication and reimbursing the cost of health insurance premiums. The 1996 federal welfare law also gives states the option of universal drug testing of welfare recipients.

State Children’s Health Insurance Program (SCHIP) Under the State Children’s Health Insurance Program (SCHIP), states can choose to expand Medicaid, establish a new separate program such as employer-sponsored health care, or create a combination program. A state’s choice of whether to expand Medicaid often affects the alcohol and other substance use benefits children will receive.

Regardless of whether states choose to expand Medicaid or establish a private/combination program, coverage of alcohol and other substance use treatment services is “optional” except for children who are to be given any Medicaid service they need even if it is not on the state’s usual benefits.32 When SCHIP is a Medicaid expansion, SCHIP children also get this entitlement. This is not true for separate SCHIP. Adolescent alcohol and other substance use treatment also raises different issues regarding confidentiality of treatment and involvement of family members. Although many programs seek to involve families in treatment, adolescents may view family involvement as a deterrent to seeking treatment.33 Also, the IMD restriction does not affect children.

Early Prevention, Screening, Detection and Treatment (EPSDT) Funds The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) service is Medicaid’s comprehensive and preventive child health program for individuals under age 21. It requires that any medically necessary health care service listed as a possible Medicaid service be provided to an EPSDT recipient even if the service is not available under the state’s Medicaid plan to the rest of the Medicaid population.34 If managed care does not cover, the state must pay for it in fee for service.

The EPSDT program consists of two mutually supportive, operational components: 1) Assuring the availability and accessibility of required health care resources; and 2) Helping Medicaid recipients and their parents or guardians effectively use these resources.

All Medicaid children are periodically screened and are screened if they need diagnosis or treatment.

Medicare Alcohol and other substance use— particularly alcohol and prescription drug abuse— among the elderly is one of the fastest growing problems in the country. The problem is expected to continue to grow as baby boomers reach retirement.35 Medicare is a public health insurance program that covers most people over age 65, people who are entitled to Social Security or Railroad Retirement disability benefits for 24 months or more, people with end-stage renal disease who require continuing dialysis or kidney transplant, and certain otherwise non-covered elderly people who elect to buy into Medicare. Like Medic- aid, Medicare includes alcohol and other substance use disorders as mental disorders.36

To qualify for Medicare under age 65, a disabled person must be over age 18 and have incurred the disability prior to age 22. Since these individuals first must qualify for Social Security Disability Insurance (SSDI) and SSDI is not awarded on the basis of alcohol and

National Conference of State Legislatures 76 Treatment of Alcohol and Other Substance Use Disorders

other substance use disorders alone, only alcohol and other substance users with physical or mental impairments are eligible for Medicare on the basis of disability. Even then, SSDI beneficiaries must receive 24 months of SSDI payments before they become eligible for Medicare.

The number of people enrolled in Medicare grew significantly, from 19.5 million in 1967 to a projected 39.2 million in 1998, an increase of 101 percent.37 In 1997, Medicare spending accounted for only 8 percent of expenditures for alcohol and other substance use treatment. The growth of Medicare alcohol and other substance use disorders expenditures more than doubled over the two five-year intervals, from a growth rate of 4.7 percent per year between 1987 and 1992 to a rate of 10.7 percent per year between 1992 and 1997, on average.38 Social Security Administration (SSA)

Supplemental Security Income (SSI) The SSI program provides monthly income to people who are age 65 or older, or are blind or disabled, and have limited income and financial resources.39 SSI does not cover alcohol and other substance use disorder treatment.

Social Security Disability Insurance (SSDI) The Social Security Disability Insurance program pays benefits to a person with a work history if he or she is disabled or blind insured under the act; the child of an insured worker; or the widow, widower, or surviving divorced spouse of an insured worker.40 SSDI does not cover alcohol and other substance use disorder treatment. Administration for Children and Families (ACF)

Title IVB and Title IVE Funds To provide states flexibility to design innovative child welfare programs, Congress enacted a provision in 1994 (Public Law 103-432) authorizing the secretary of the U.S. Depart- ment of Health and Human Services (DHHS) to approve up to 10 demonstration projects requiring waivers of provisions under titles IV-B and IV-E. This authority, established by section 1130 of the Social Security Act, was subsequently amended by the Adoption and Safe Families Act in 1997, allowing DHHS to approve an additional 10 demonstration projects in each of fiscal years 1998-2002. The secretary may waive any provision of either Title IV-B or Title IV-E if necessary to enable the state to carry out its demonstration project, with some exceptions. Demonstrations are limited to five years and must include an evaluation component and be cost-neutral to the federal government.41

As of April 2000, almost half the states had had demonstration projects approved, with some states operating more than one project. For new waivers, DHHS is especially interested in proposals that would examine the following: performance-based systems, integrated systems for behavioral health (substance abuse and mental health), effective prevention and early intervention, adoption and postadoption services, service improvements for children in the placement and care responsibility of tribes, service improvements for adolescent youth, and reunification services for adolescent youth.42

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 77

Department of Education (DOE)

The Safe and Drug-Free Schools and Communities State Grants Program Run by the Department of Education, this program provides funds primarily to the state education agencies and governors’ offices for anti-alcohol and other substance use education, prevention, early intervention and treatment referral programs. This money cannot be used for treatment services. In 1996, 97 percent of all school districts in the country participated in the program.43

The program provides support to state educational agencies (SEAs) for a variety of drug and violence prevention activities focused primarily on school-age youth. SEAs are required to distribute 91 percent of funds to local education agencies (LEAs) for drug and violence prevention activities authorized under the statute, which may include developing instruc- tional materials; providing counseling services; developing professional development programs for school personnel, students, law enforcement officials, judicial officials or community leaders; implementing conflict resolution, peer meditation and mentoring programs; implementing character education programs and community service projects; establishing safe zones of passage for students to and from school; and acquiring and installing metal detectors and hiring security personnel. Of the funds distributed to LEAs, 30 percent must be awarded to LEAs that have the greatest need for additional funds for drug and violence prevention; the remaining 70 percent of funds must be awarded to LEAs based on enrollment.44

The governor has 20 percent of the money. This program provides support to governors for a variety of drug and violence prevention activities focused primarily on school-age youth. Governors use their program funds to provide support to parent groups, community-based organizations, and other public and private nonprofit entities for drug and violence prevention activities that complement the state education agency (SEA) and local education agency (LEA) portion of the Safe and Drug-Free Schools and Communities Program.45 Department of Justice (DOJ)

The Residential Substance Abuse Treatment for State Prisoners Program Administered by the Corrections Program Office in the Office of Justice Programs, this program provides funds for individual and group alcohol and other substance use treatment activities for offenders in residential facilities operated by state and local correctional agencies. To receive funding, state and local correctional agencies must:

• Provide treatment that lasts between six and 12 months;

• Provide treatment in residential treatment facilities set apart from the general correctional population;

• Focus on the alcohol and other substance use disorders of the inmate;

• Develop the inmates’ cognitive, behavioral, social, vocational and other skills to solve the alcohol and other substance use disorders; and

• Implement or continue to require urinalysis and other reliable forms of drug and alcohol testing.

National Conference of State Legislatures 78 Treatment of Alcohol and Other Substance Use Disorders

Each state that participates in the program receives a base of 4 percent of the total funds available for the program. The remaining funds are distributed to the participating states based on their prison populations, as compared to the prison populations of all participating states.46

The Drug-Free Communities Program This program, created by the Drug-Free Communities Act of 1997, is administered for the Office of National Drug Control Policy. Under the program, agreements are entered into with national drug control agencies to delegate authority for the execution of grants. The grants are awarded to coalitions that meet specified criteria, including those that:

• Have as a principal mission the comprehensive and long-term reduction of alcohol and other substance use with a primary focus on youth in the community;

• Describe and document the nature and extent of the alcohol and other substance use problem in the community;

• Provide a description of alcohol and other substance use prevention and treatment programs and activities in the community at the time of the grant application;

• Identify alcohol and other substance use programs and service gaps in the community; and

• Develop a strategic plan for comprehensive, long-term reduction of alcohol and other substance use among youth and work to develop a consensus regarding the priorities of the community to combat alcohol and other substance use among youth.47

Byrne Formula Grant Program The Edward Byrne Memorial State and Local Law Enforcement Assistance Grant Program (Byrne Formula Grant Program) is a partnership among federal, state and local governments to create safer communities. The Bureau of Justice Assistance (BJA) is authorized to award grants to states for use by states and units of local government to improve the functioning of the criminal justice system—with emphasis on violent crime and serious offenders—and enforce state and local laws that establish offenses similar to those in the federal Controlled Substances Act (21 U.S.C. 802(6) et seq.).48

Grants may be used to provide personnel, equipment, training, technical assistance and information systems for more widespread apprehension, prosecution, adjudication, detention and rehabilitation of offenders who violate such state and local laws. Grants also may be used to provide assistance (other than compensation) to victims of these offenders. Twenty- nine legislatively authorized purpose areas were established to define the nature and scope of programs and projects that may be funded under the Byrne Formula Grant Program. 49 Chemical dependency assessments, treatment and prevention are allowable uses of the money.

Drug Court Discretionary Grant Program The Drug Court Discretionary Grant Program (DCDG) provides financial and technical assistance to states, state courts, local courts, units of local government and American In- dian tribal governments to develop and implement treatment drug courts that effectively integrate substance abuse treatment, mandatory drug testing, sanctions and incentives,

National Conference of State Legislatures What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders? 79

and transitional services in a judicially supervised court setting with jurisdiction over nonviolent, substance-abusing offenders. Programs funded by DCDG are required by law to target nonviolent offenders and must implement a drug court based on 10 key components. This program supports the following drug court activity:50

• Adult drug court implementation, • Juvenile drug court implementation, • Family drug court implementation, • Single jurisdiction drug court enhancement, and • Statewide drug court enhancement.

Training and Technical Assistance. The National Drug Court Training and Technical Assis- tance Program (NDCTTAP) supports DCDG by increasing the knowledge and skills of drug court practitioners to plan, implement and sustain effective drug court programs. It also builds capacity at the state and local levels to provide comprehensive practitioner-based training and technical assistance. Following are the three components of NDCTTAP. 51

• The goal of the Drug Court Planning Initiative (DCPI) is to provide communities with the knowledge, skills and tools necessary to implement a drug court. Particular emphasis is placed on learning new roles, cross training, and developing both a team and a coordinated strategy across justice and treatment systems.

• The goal of the Drug Court Training Initiative (DCTI) is to provide state-of-the-art training on a variety of subjects to operational adult, juvenile or tribal drug courts and state agencies.

• The goal of the Drug Court Technical Assistance Initiative (DCTAI) is to provide technical assistance on a variety of subjects to operational adult, juvenile or tribal drug courts and state agencies.

Reentry: Serious and Violent Offender Reentry Initiative The Serious and Violent Offender Reentry Initiative is supported by the Department of Justice’s Office of Justice Programs (OJP) and its federal partners, the U.S. departments of Education, Health and Human Services, Housing and Urban Development, and Labor. This initiative is a comprehensive effort that addresses both juvenile and adult populations of serious, high-risk offenders. It provides funding to develop, implement, enhance and evaluate reentry strategies that will ensure the safety of the community and the reduction of serious, violent crime. This is accomplished by preparing targeted offenders to successfully return to their communities after having served a significant period of secure confine- ment in a state training school, juvenile or adult correctional facility, or other secure institution.52

The Reentry Initiative envisions the development of model reentry programs that begin in correctional institutions and continue throughout an offender’s transition to and stabilization in the community. These programs will provide for individual reentry plans that address issues confronting offenders as they return to the community. The initiative will encompass three phases and be implemented through appropriate programs:53

Phase 1—Protect and Prepare: Institution-Based Programs. These programs are designed to prepare offenders to reenter society. Services provided in this phase will in-

National Conference of State Legislatures 80 Treatment of Alcohol and Other Substance Use Disorders

clude education, mental health and alcohol and other substance use treatment, job training, mentoring, and full diagnostic and risk assessment.

Phase 2—Control and Restore: Community-Based Transition Programs. These programs will work with offenders prior to and immediately following their release from correctional institutions. Services provided in this phase will include, as appropriate, education, monitoring, mentoring, life-skills training, assessment, job-skills development, and mental health and alcohol and other substance use treatment.

Phase 3—Sustain and Support: Community-Based Long-Term Support Programs. These programs will connect individuals who have left the supervision of the justice system with a network of social services agencies and community-based organizations to provide ongoing services and mentoring relationships. Department of Veterans Affairs (VA)

Veterans Health Administration (VHA) People who receive treatment from the Veterans Health Administration (VHA) are not captured in the single state agency’s data because they are considered to receive treatment directly from the federal government. It is important for states to determine how many veterans they are treating who are eligible for VHA so they can shift them to VHA and have more money to treat other people. Housing and Urban Development (HUD)

The Public Housing Drug Elimination Grants Program This program, run through the Department of Housing and Urban Development and created through the 1988 Anti-Drug Abuse Act, provides grants to public and Indian housing authorities to eliminate drug-related crime in public housing projects. The funds may be used for a variety of actions, including enhancing security; making physical improvements to improve security; or developing and implementing prevention, intervention and treatment programs to help curtail the use of drugs in public and Indian housing projects.54 Department of Defense (DOD)

TRICARE TRICARE is a medical program that provides coverage for active duty military personnel and their dependents, non-Medicare eligible retirees and their family members, and survi- vors of all uniformed services. The program offers eligible enrollees a choice between managed health care programs. TRICARE Standard is the new name for the traditional standard CHAMPUS (Civilian Health and Medical Program of the Uniformed Services), which is perhaps the largest federal program outside the block grants and entitlement programs.55

National Conference of State Legislatures Appendices 81

APPENDIX A. LEGISLATORS’ CHECKLIST

What strategies are available for the treatment of alcohol and other substance use disorders IN MY STATE? Does MY STATE: YES NO Have a comprehensive continuum of treatment? Have the infrastructure for identification? Use the screening, brief intervention, and referral model for identification? Have the Uniform Accident and Sickness Policy Provision Law? Have the infrastructure to conduct assessment? Use the American Society of Addiction Medicine (ASAM) patient placement criteria? Have the infrastructure to provide comprehensive treatment? Use medications in treatment? Use coerced treatment in the criminal justice system? Have a spectrum of treatment intensities and modalities? Have inpatient and outpatient detoxification? Have inpatient/residential treatment facilities? Have therapeutic communities? Have outpatient treatment facilities? Have intensive outpatient treatment facilities? Have the infrastructure for ongoing recovery management? Have the infrastructure for relapse prevention? Have a spectrum of self-help groups? Have special living arrangements for people in recovery? Have sober living environments? Have targeted treatment for specific populations? Have treatment programs for adolescents? Have treatment programs for women? Have treatment programs for older adults? Provide culturally competent treatment? Meet the needs of Native Americans in treatment? Meet the needs of Asian and Pacific Islander Americans in treatment? Meet the needs of Hispanic/Latino populations in treatment? Meet the needs of African Americans in treatment? Meet the needs of rural populations in treatment? Have a spectrum of treatment in the criminal justice system? Address the treatment of co-occurring mental illness and alcohol and other substance use disorders? Use the quadrant system model for co-occurring disorders? Have barriers to recovery, such as sanctions for various crimes?

National Conference of State Legislatures 81 82 Treatment of Alcohol and Other Substance Use Disorders

Appendix A. Legislators’ Checklist (continued) YES NO Have standards for the licensing of providers? Have standards for regulating treatment? Have standards to protect the confidentiality of people in treatment? Have the infrastructure to make the transition from the SAPT Block Grant to Performance Partnership Grants?

What Funding is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders IN MY STATE?

What is MY STATE’S role in financing treatment? What is MY STATE’S appropriation of state funds for treatment? What is MY STATE’S per capita spending for treatment? What does MY STATE mandate in private insurance coverage for treatment? What are MY STATE’S parity and mandated benefits laws? What are MY STATE’S alcohol taxes? What is the federal role in funding treatment in MY STATE? What funding does MY STATE receive from the Substance Abuse and Mental Health Services Agency? What is the amount of MY STATE’S Substance Abuse Prevention and Treatment Block Grant? What are the amounts of MY STATE’S discretionary grants? What funding does MY STATE receive from the Centers for Medicare and Medicaid Services? What treatment services does MY STATE cover under Medicaid? What treatment services do MY STATE’S Medicaid Managed Care plans cover? What treatment services does MY STATE cover under Temporary Assistance to Needy Families? What treatment services does MY STATE cover under the State Children’s Health Insurance Program? What treatment services does MY STATE cover with Early Prevention, Screening, Detection, and Treatment Funds? What funding does MY STATE receive from the Administration for Children and Families? What treatment services does MY STATE provide under a demonstration program with Title IVB and Title IVE funds? What funding does MY STATE receive from the Department of Education? What is the amount of MY STATE’S Safe and Drug-Free Schools and Communities State Grant? What funding does MY STATE receive from the Department of Justice? What is the amount of MY STATE’S Residential Substance Abuse Treatment for State Prisoners Grant? What is the amount of MY STATE’S Drug-Free Communities Grant? What is the amount of MY STATE’S Byrne Formula Grant? What is the amount of MY STATE’S Drug Court Discretionary Grant? What is the amount of MY STATE’S Reentry: Serious and Violent Offender Reentry Initiative Grant? What funding does MY STATE receive from Housing and Urban Development? What is the amount of MY STATE’S Public Housing Drug Elimination Grant?

National Conference of State Legislatures Appendices 83

APPENDIX B. NATIONAL RESOURCES

American Council for Drug Education National Institute of Mental Health 164 West 74th Street NIMH Public Inquiries New York, N.Y. 10023 6001 Executive Boulevard, Room 8184 (800) 488-DRUG MSC 9663 http://www.acde.org/ Bethesda, Md. 20892-9663 (301) 443-4513 The White House Office of National Drug http://www.nimh.nih.gov/ Control Policy, Drug Policy Information Clearinghouse National Council on Alcoholism and Drug 2277 Research Boulevard Dependence Inc. Rockville, Md. 20849 20 Exchange Place, Suite 2902 (800) 666-3332 New York, N.Y. 10005 http://www.whitehousedrugpolicy.gov/about/ (212) 269-7797 clearinghouse.html http://www.ncadd.org/

Justice Information Center National Highway Traffic Safety National Criminal Justice Reference Service Administration P.O. Box 6000 400 Seventh Street, S.W. Rockville, Md. 20849-6000 Washington, D.C. 20590 (800) 851-3420 (800) 424-9393 http://www.ncjrs.org/ http://www.nhtsa.dot.gov/

National Association of State Alcohol and National Institute on Alcohol Abuse and Drug Abuse Directors Alcoholism 808 17th Street N.W., Suite 410 6000 Executive Boulevard, Willco Building Washington, D.C. 20006 Bethesda, Md. 20892-7003 http://www.nasadad.org/ (301) 443-6371 http://www.niaaa.nih.gov/ National Clearinghouse for Alcohol and Drug Information National Institute on Drug Abuse P.O. Box 2345 6001 Executive Boulevard, Room 5213 Rockville, Md. 20847-2345 Bethesda, Md. 20892 (800) 729-6686 (301) 443-1124 http://www.health.org/ http://www.nida.nih.gov/NIDAHome1.html

National Conference of State Legislatures 83 84 Treatment of Alcohol and Other Substance Use Disorders

Appendix B. National Resources (continued)

Center for Substance Abuse Treatment The Robert Wood Johnson Foundation Substance Abuse and Mental Health College Road East and Route 1 Services Administration P.O. Box 2316 Room 12-105, Parklawn Building Princeton, N.J. 08543 5600 Fishers Lane (888) 631-9989 Rockville, Md. 20857 http://www.rwjf.org/ (301) 443-4795 http://www.samhsa.gov/index.htm NIAAA Alcohol Policy Information Service http://alcoholpolicy.niaaa.nih.gov/ American Society of Addiction Medicine 4601 North Park Avenue, Arcade Suite 101 National Association of Drug Court Chevy Chase, Md. 20815 Professionals (301) 656-3920 National Drug Court Institute http://www.asam.org/ 4900 Seminary Road, Suite 320 Alexandria, Va. 22311 Alcoholics Anonymous (703) 575-9400 A.A. World Services Inc. http://www.nadcp.org P.O. Box 459 http://www.ndci.org New York, N.Y. 10163 (212) 870-3400 National Treatment Accountability for Safer http://www.aa.org/ Communities (TASC) 2204 Mt. Vernon Avenue, Suite 200 Narcotics Anonymous Alexandria, Va. 22301 World Service Office (703) 836-8272 P.O. Box 9999 http://www.nationaltasc.org Van Nuys, Calif. 91409 (818) 773-9999 Parents Corps http://www.na.org/ c/o National Families in Action http://www.nationalfamilies.org Join Together One Appleton Street, 4th Floor Center for Substance Abuse Prevention Boston, Mass. 02116-5223 Substance Abuse and Mental Health (617) 437-1500 Services Administration http://www.jointogether.org/ Room 12-105, Parklawn Building 5600 Fishers Lane Community Anti-Drug Coalitions of America Rockville, Md. 20857 901 North Pitt Street, Suite 300 (301) 443-4795 Alexandria, Va. 22314 http://www.samhsa.gov/index.htm (800) 54-CADCA http://www.cadca.org/ Center for Mental Health Services Substance Abuse and Mental Health Faces and Voices of Recovery Services Administration 901 North Washington Street, Suite 601 Room 12-105, Parklawn Building Alexandria, Va. 22314 5600 Fishers Lane (703) 299-6760 Rockville, Md. 20857 http://www.facesandvoicesofrecovery.org/ (301) 443-4795 http://www.samhsa.gov/index.htm Drug Strategies 1150 Connecticut Avenue, N.W., Suite 800 Washington, D.C. 20036 (202) 289-9070 http://www.drugstrategies.org/

National Conference of State Legislatures Appendices 85

Appendix B. National Resources (continued)

National Center on Addiction and Substance Adult Children of Alcoholics Abuse at Columbia University ASA WSO 633 Third Avenue, 19th Floor P.O. Box 3216 New York, N.Y. 10017-6706 Torrance, Calif. 90510 (212) 841-5200 (310) 534-1815 http://www.casacolumbia.org http://www.adultchildren.org

National Conference of State Legislatures 86 Treatment of Alcohol and Other Substance Use Disorders

National Conference of State Legislatures 86 Appendices 87

APPENDIX C. “HOT TOPIC” DRUGS

Substance Other Names Route of Medical Uses Possible Effects Administration Alcohol Alcohol Booze, Sauce, Juice Oral None Marijuana Marijuana Pot, Weed, Dope Smoked Glaucoma, pain Methamphetamine Methamphetamine Crank, Crystal, Glass, Ice, Injected, oral, smoked, ADHD, obesity, narcolepsy Speed sniffed Inhalants Volatile Solvents Adhesives Model airplane glue, Sniffed None Rubber cement, Household glue Aerosols Spray paint, hairspray, air Sniffed None freshener, deodorant, fabric protector Solvents and gases Nail polish remover, paint Sniffed None thinner, type correction fluid and thinner, toxic markers, pure toluene, cigar lighter fluid, gasoline, carburetor cleaner, octane booster Cleaning agents Dry cleaning fluid, spot Sniffed None remover, degreaser Food products Vegetable cooking spray, Sniffed None dessert topping spray (whipped cream, whippets Gases Nitrous oxide, butane, Sniffed None propane, helium Anesthetics Anesthetic Nitrous oxide, ether, Sniffed None chloroform Nitrites (Nitrite room deodorizers) Amyl “Poppers,” “Snappers” Sniffed None Butyl “Rush,” “Locker room,” Sniffed None “Bolt,” “Climax,” also marketed in head shops as “Video head cleaner” Ecstacy Amphetamine Adam, Ecstasy, STP, XTC Oral None variants Prescription Narcotics/Opiates/Barbituates Codeine Tylenol w/codeine, Injected, oral Analgesic, antitussive (relieves or Opiods and morphine Robitussin A-C prevents cough) derivatives are used Methadone Amidone, Dolophine, Injected, oral Analgesic, treatment for opiate medicinally to relieve Methadose dependence pain. Users experience Morphine Roxanol, Duramorph Oral, smoked Analgesic relaxation with an Opium Laudanum, Paregoric, Oral, smoked Analgesic, immediate rush or Dover’s Powder Antidiarrheal euphoria. Illegal Narcotics/Opiates Heroin Horse, Smack Injected, smoked, sniffed None

Sources: National Institute on Drug Abuse, Drug Abuse and Addiction: The Sixth Triennial Report; The National Clearinghouse for Alcohol and Drug Information, Web page: www.health.org, September 1999; “Products Abused as Inhalants,” http://www.inhalants.org/.

National Conference of State Legislatures 87 88 Treatment of Alcohol and Other Substance Use Disorders

National Conference of State Legislatures Appendices 89

APPENDIX D. PET SCANS OF LONG-TERM BRAIN CHANGES IN ABSTINENCE AND BRAINS ON DRUGS

The following text and pictures are taken from the National Institute on Drug Abuse (NIDA) Slide Teaching Packet, “Understanding Drug Abuse and Addiction: What Science Says,” slides 9-11.1

Measuring Brain Activity in Response to Drug Use Position Emission Tomography (PET) measures emissions from ra- dioactively-labeled chemicals that have been injected into the blood- stream and uses the data to produce images of the distribution of the chemicals in the body.2

In alcohol and other substance use disorders research, PET is being used for a variety of reasons including: to identify the brain sites where drugs and naturally occurring neurotransmitters act; to show how quickly drugs reach and activate receptors; to determine how long drugs occupy these receptors; and to find out how long they take to leave the brain. PET is also being used to show brain changes following chronic drug use, during withdrawal from drug use, and during the experience of drug craving. In addition, PET can be used to assess the effects of pharmacological and behavioral therapies for drug addiction on the brain.3

Positron Emission Tomography (PET) Scan of a Person Using Cocaine Cocaine has other actions in the brain in addition to activating the brain’s reward circuitry. Using brain imaging technologies, such as PET scans, scientists can see how cocaine actually affects brain function in people. PET allows scientists to see which areas of the brain are more or less active by measuring the amount of glucose that is used by different brain regions. Glucose is the main energy source for the brain. When brain regions are more active, they will use more glucose and when they are less active they will use less. The amount of glucose that is used by the brain can be measured with PET scans. The left scan is taken from a normal, awake person. The red color shows the highest level of glucose utilization (yellow rep-

National Conference of State Legislatures 89 90 Treatment of Alcohol and Other Substance Use Disorders

resents less utilization and blue indicated the least). The right scan is taken from someone who is on cocaine. The loss of red areas in the right scan compared to the left (normal) scan indicates that the brain is using less glucose and therefore is less active. This reduction in activity results in disruption of many brain functions. 4

MDMA (Ecstasy) and Brain Changes This slide shows brain PET scans of an individual who has never used MDMA (seen at the top of slide marked “control”) and those of an individual who used MDMA for an extended period of time up until 3 weeks prior to the images being taken. Specifically, the PET scans show the brain’s ability to transport a neurotransmitter called “serotonin” from the synapse back into the releasing neuron. Serotonin is fundamental to the brain’s integration of information and emotion.5

Brighter colors in the PET scans indicate that more serotonin is being transported than do duller colors. As seen in the slide, the brain of the MDMA user shows duller colors compared to the control, indicating a decrease in the MDMA abuser’s ability to remove serotonin from the synapse. Such findings are leading researchers to conclude that MDMA may increase the risk of long-term, perhaps permanent, problems with learning and memory.6

The following text and picture are taken from the National Institute on Drug Abuse (NIDA) Slide Teaching Packet, “Bringing the Power of Science to Bear on Drug Abuse and Addic- tion,” slide 6.7

A positron emission tomography (PET) scanner. One of the tools that scientists use to see the effects of drugs on the brain is called positron emission tomography or a PET scan. Simi- lar to an x-ray, but much more sophisticated, a PET scan is used to examine many different organs including the heart, liver, lungs, and bones, as well as the brain. A PET scan shows much more than the physical structure of bone and tissue. A PET scan shows how well (or how little) an organ is functioning. 8

Using a PET scan, a doctor or a scientist can see what is actually happening in a person’s brain and see the effects of drugs. The PET scan shows areas of the brain that are active and also areas that are inactive or not functioning at all. Typically, a PET scan takes 1 to 2 hours with the person lying completely still so that the PET images will be clear.9

Notes 1. “Understanding Drug Abuse and Addiction: What Science Says,” http://www.drugabuse.gov/pubs/teaching/Teaching3/Teaching.html, Dec. 18, 2003. 2. “Understanding Drug Abuse and Addiction: What Science Says, Slide 9: Measuring Brain Activity in Response to Drug Use,” http://www.drugabuse.gov/pubs/teachingTeaching3/ Teaching3.html, Dec. 18, 2003. 3. Ibid. 4. “Understanding Drug Abuse and Addiction: What Science Says, Slide 10: Positron Emission Tomography (PET) Scan of a Person Using Cocaine,” http://www.drugabuse.gov/ pubs/teaching/Teaching3/Teaching3.html, Dec. 18, 2003. 5. “Understanding Drug Abuse and Addiction: What Science Says, Slide 11: MDMA (Ecstasy) and Brain Changes,” http://www.drugabuse.gov/pubs/teaching/Teaching3/ Teaching3.html, Dec. 18, 2003. 6. Ibid. 7. “Bringing the Power of Science to Bear on Drug Abuse and Addiction,” http://www.drugabuse.gov/pubs/teaching/Teaching5/Teaching.html, Dec. 18, 2003. 8. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 6: A positron emission tomography (PET) scanner,” http://www.drugabuse.gov/pubs/teaching/ Teaching5/Teaching3.html, Dec. 18, 2003. 9. Ibid.

National Conference of State Legislatures Appendices 91

APPENDIX E. STATE AND JURISDICTIONAL RESOURCES

This directory is taken from the Treatment Improvement Exchange, a resource sponsored by the Division of State and Community Assistance of the Center for Substance Abuse Treatment (CSAT) to provide information exchange between CSAT staff and state and local single state agencies. This list is subject to change. It is current as of Nov. 9, 2003.

Alabama Arkansas J. Kent Hunt, Associate Commissioner for Joe M. Hill, Director Substance Abuse Alcohol and Drug Abuse Prevention Alabama Department of Mental Health and Division of Behavioral Health Services Mental Retardation Arkansas Department of Human Services RSA Union Building 4313 West Markham, Third Floor 100 North Union Street Administration Montgomery, Ala. 36130-1410 Little Rock, Ark. 72205 Phone: (334) 242-3953 Phone: (501) 686-9871 Fax: (334) 242-0759 Fax: (501) 686-9035 http://www.healthyarkansas.com Alaska Karen Pearson, Director California Division of Alcoholism and Drug Abuse Kathryn Jett, Director Alaska Department of Health and Social Department of Alcohol and Drug Programs Services 1700 K Street, Fifth Floor P.O. Box 110607 Executive Office Juneau, Alaska 99811-0607 Sacramento, Calif. 95814-4037 Phone: (907) 465-5808 Phone: (916) 445-1943 Fax: (907) 465-2185 Fax: (916) 323-5873 http://www.hss.state.ak.us/dada/ http://www.adp.cahwnet.gov/

Arizona Colorado Christy Dye, Program Manager Janet Wood, Director Bureau of Substance Abuse Treatment and Alcohol and Drug Abuse Division Prevention Colorado Department of Human Services Division of Behavioral Health Services 4055 South Lowell Boulevard, Building K-8 Arizona Department of Health Services Denver, Colo. 80236-3120 150 North 18th Avenue, Suite 220 Phone: (303) 866-7480 Phoenix, Ariz. 85007 Fax: (303) 866-7481 Phone: (602) 364-4558 http://www.cdhs.state.co.us/ohr/adad/index.html Fax: (602) 364-4763 http://www.hs.state.az.us/bhs/

National Conference of State Legislatures 91 92 Treatment of Alcohol and Other Substance Use Disorders

Appendix E. State and Jurisdictional Resources (continued)

Connecticut Hawaii Thomas Kirk, Commissioner Elaine Wilson, Chief Department of Mental Health and Addiction Alcohol and Drug Abuse Division Services Hawaii Department of Health P.O. Box 341431 Kakuhihewa Building Hartford, Conn. 06134 601 Kamokila Boulevard, Room 360 Phone: (860) 418-6969 Kabolei, Hawaii 96707 Fax: (860) 418-6691 Phone: (808) 692-7507 http://www.dmhas.state.ct.us/ Fax: (808) 692-7521

Delaware Idaho Renata Henry, Director Pharis Stanger, Substance Abuse Project Division of Alcoholism, Drug Abuse and Manager Mental Health Bureau of Mental Health and Substance Delaware Health and Social Services Abuse DHH Campus, Room 192 Division of Family and Community Services 1901 North DuPont Highway, Administration Idaho Department of Health and Welfare Building 450 West State Street, Fifth Floor Newcastle, Del. 19720 Boise, Idaho 83720-0036 Phone: (302) 255-9426 Phone: (208) 334-4944 Fax: (302) 255-4428 Fax: (208) 332-7305 http://www.state.de.us/ http://www2.state.id.us/dhw/mentalhealth/ index.htm Florida Ken DeCherchio, Director Illinois Substance Abuse Program Office Theodora Binion-Taylor, Associate Director Department of Children and Families Office of Alcoholism and Substance Abuse Building 6, Third Floor Illinois Department of Human Services 1317 Winewood Boulevard James R. Thompson Center Tallahassee, Fla. 32399-0700 100 West Randolph, Suite 5-600 Phone: (850) 921-2495 Chicago, Ill. 60601 Fax: (850) 487-2627 Phone: (312) 814-2300 http://www.state.fl.us/cf_web/topics/substance/ Fax: (312) 814-2419 http://www.state.il.us/agency/dhs/ Georgia Bruce Hoopes, Chief Indiana Substance Abuse Program John Viernes, Director Division of Mental Health, Developmental Division of Mental Health Disabilities and Addictive Disease Indiana Family and Social Services Georgia Department of Human Resources Administration 2 Peachtree Street, N.W., Fourth Floor Indiana Government Building, Room W353 Atlanta, Ga. 30303-3171 402 West Washington Street Phone: (404) 657-2135 Indianapolis, Ind. 46204 Fax: (404) 657-2160 Phone: (317) 232-7844 http://www2.state.ga.us/Departments/DHR/ Fax: (317) 233-3472 mhmrsa.html http://www.ai.org/fssa/HTML/PROGRAMS/ 2c.html

National Conference of State Legislatures Appendices 93

Appendix E. State and Jurisdictional Resources (continued)

Iowa Maine Janet Zwick, Director Kimberly Johnson, Director Division of Health Promotion, Prevention Maine Office of Substance Abuse and Addictive Behaviors Augusta Mental Health Complex Iowa Department of Public Health Marquardt Building, Third Floor Lucas State Office Building, Fourth Floor 159 State House Station 321 East 12th Street Augusta, Maine 04333-0519 Des Moines, Ia. 50319-0075 Phone: (207) 287-6330 Phone: (515) 281-4417 Fax: (207) 287-4334 Fax: (515) 281-4535 http://www.state.me.us/dmhmrsa/osa/ http://idph.state.ia.us/sa.htm Maryland Kansas Peter Luongo, Director Donna Doolin, Acting Director Alcohol and Drug Abuse Administration Division of Health Care Policy, Addiction and Maryland Department of Health and Mental Prevention Services Hygiene Kansas Department of Social and 55 Wade Avenue Rehabilitation Services Catonsville, Md. 21228 Docking State Office Building, Tenth Floor, Phone: (410) 402-8600 North Fax: (410) 402-8601 915 S.W. Harrison Street maryland-adaa.org/ Topeka, Kan. 66612 Phone: (785) 296-7272 Massachusetts Fax: (785) 296-5507 Michael Botticelli, Associate Commissioner http://www.srskansas.org Bureau of Substance Abuse Services Massachusetts Department of Public Health Kentucky 250 Washington Street, Third Floor Michael Townsend, Director Boston, Mass. 02108 Division of Substance Abuse Phone: (617) 624-5111 Kentucky Department of Mental Health and Fax: (617) 624-5185 Mental Retardation Services http://www.state.ma.us/dph/bsas/bsas.htm 100 Fair Oaks Lane Frankfort, Ky. 40621-0001 Michigan Phone: (502) 564-2880 Yvonne Blackmond, Director Fax: (502) 564-7152 Bureau of Mental Health and Substance http://dmhmrs.chr.state.ky.us/ Abuse Michigan Department of Community Health Louisiana Lewis Cass Building Michael Duffy, Assistant Secretary 320 South Walnut Street, Sixth Floor Office for Addictive Disorders Lansing, Mich. 48909 Louisiana Department of Health and Phone: (517) 373-4726 Hospitals Fax: (517) 373-4288 P.O. Box 2790, BIN #18 http://www.mdch.state.mi.us/mdch2/mhsub.htm Baton Rouge, La. 70821-2790 Phone: (225) 342-6717 Fax: (225) 342-3875 http://www.dhh.state.la.us/OADA/Index.htm

National Conference of State Legislatures 94 Treatment of Alcohol and Other Substance Use Disorders

Appendix E. State and Jurisdictional Resources (continued)

Minnesota Nebraska Donald R. Eubanks, Director Ron Sorensen, Director Chemical Health Division Division of Mental Health, Substance Abuse Minnesota Department of Human Services and Addictions Services 444 Lafayette Road North Nebraska Department of Health and Human St. Paul, Minn. 55155-3823 Services Systems Phone: (651) 582-1856 Folsom Street and West Prospector Place, Fax: (651) 582-1865 Building 14, West Campus http://www.dhs.state.mn.us/ P.O. Box 98925 Lincoln, Neb. 68509-8925 Mississippi Phone: (402) 479-5583 Herbert L. Loving, Director Fax: (402) 479-5162 Division of Alcohol and Drug Abuse http://www.hhs.state.ne.us/beh/dadaas.htm Mississippi Department of Mental Health 1101 Robert E. Lee State Building Nevada 239 North Lamar Street Maria Canfield, Chief Jackson, Miss. 39201 Bureau of Alcohol and Drug Abuse, Health Phone: (601) 359-6220 Division Fax: (601) 359-6295 Department of Human Resources http://www.dmh.state.ms.us/ 505 East King Street, Room 500 Carson City, Nev. 89701-3703 Missouri Phone: (775) 684-4190 Michael Couty, Director Fax: (775) 684-4185 Division of Alcohol and Drug Abuse http://www.health2k.state.nv.us/bada/ Missouri Department of Mental Health 1706 East Elm Street New Hampshire Jefferson City, Mo. 65102-0687 Riley Regan, Director Phone: (573) 751-4942 Division of Alcohol and Drug Abuse Fax: (573) 751-7814 Prevention and Recovery http://www.modmh.state.mo.us/ada/ada.html New Hampshire Department of Health and Human Services Montana State Office Park South Roland Mena, Bureau Chief 105 Pleasant Street Addictive and Mental Disorders Division Concord, N.H. 03301 Chemical Dependency Bureau Phone: (603) 271-6100 P.O. Box 202905 Fax: (603) 271-6116 Helena, Mont. 59620-2905 http://www.dhhs.state.nh.us/Index.nsf?Open Phone: (406) 444-3964 Fax: (406) 444-9389 New Jersey http://www.dphhs.state.mt.us/divisions/ Carolann Kane-Cavaiola, Assistant Commissioner Division of Addiction Services New Jersey Department of Health and Senior Services 120 South Stockton Street, Third Floor P.O. Box 362 Trenton, N.J. 08625 Phone: (609) 292-5760 Fax: (609) 292-3816 http://www.state.nj.us/health/as/addsrvs.htm

National Conference of State Legislatures Appendices 95

Appendix E. State and Jurisdictional Resources (continued)

New Mexico Ohio Pamela Martin, Director Gary Q. Tester, Director Behavioral Health Services Division Ohio Department of Alcohol and Drug New Mexico Department of Health Addiction Services Harold Runnels Building, Room 3200 North Two Nationwide Plaza, 12th Floor 1190 St. Francis Street 280 North High Street Santa Fe, N.M. 87502-6110 Columbus, Ohio 43215-2537 Phone: (505) 827-2658 Phone: (614) 466-3445 Fax: (505) 827-0097 Fax: (614) 752-8645 http://www.state.oh.us/ada/main.html New York William Gorman, Commissioner Oklahoma New York State Office of Alcoholism and Ben Brown, Deputy Commissioner Substance Abuse Services Substance Abuse Services 1450 Western Avenue Oklahoma Department of Mental Health and Albany, N.Y. 12203-3526 Substance Abuse Services Phone: (518) 457-2061 P.O. Box 53277 Fax: (518) 457-5474 Oklahoma City, Okla. 73152-3277 http://www.oasas.state.ny.us/ Phone: (405) 522-3877 Fax: (405) 522-0637 North Carolina http://www.state.ok.us/~dmhsas/ Flo Stein, Chief Community Policy Management Oregon Division of Mental Health, Developmental Bob Nikkel, Administrator Disabilities and Substance Abuse Services Office of Mental Health and Addiction North Carolina Department of Health and Services Human Services Department of Human Services 3007 Mail Service Center Health Services Building Raleigh, N.C. 27603-3007 2575 Bittern Street, N.E. Phone: (919) 733-4670 P.O. Box 14250 Fax: (919) 733-9455 Salem, Ore. 97309-0740 http://www.state.nc.us/DHR/docs/divinfo/ Phone: (503) 945-9700 dmh.htm Fax: (503) 373-7327 http://www.oadap.hr.state.or.us North Dakota Don Wright, Unit Manager Pennsylvania Substance Abuse Services Gene Boyle, Director Division of Mental Health and Substance Bureau of Drug and Alcohol Programs Abuse Services Pennsylvania Department of Health North Dakota Department of HumanServices 02 Klein Plaza, Suite B Professional Building Harrisburg, Pa. 17014 600 South 2nd Street, Suite 1E Phone: (717) 783-8200 Bismarck, N.D. 58504-5729 Fax: (717) 787-6285 Phone: (701) 328-8922 http://www.health.state.pa.us/php/SCA/ Fax: (701) 328-8969 default.htm http://207.108.104.74/dhs/dhsweb.nsf/ ServicePages/MentalHealthandSubstanceAbuse Services

National Conference of State Legislatures 96 Treatment of Alcohol and Other Substance Use Disorders

Appendix E. State and Jurisdictional Resources (continued)

Rhode Island Texas Craig Stenning, Executive Director Dave Wanser, Executive Director Behavioral Health Care Services Texas Commission on Alcohol and Drug Department of Mental Health, Retardation Abuse and Hospitals P.O. Box 80529 14 Harrington Road-Barry Hall Austin, Texas 78708-0529 Cranston, R.I. 02920 Phone: (512) 349-6602 Phone: (401) 462-2339 Fax: (512) 837-4123 Fax: (401) 462-3204 http://www.tcada.state.tx.us http://www.mhrh.state.ri.us/ Utah South Carolina Randall Bachman, Director W. Lee Catoe, Director Division of Substance Abuse and Mental South Carolina Department of Alcohol and Health Other Drug Abuse Services Utah Department of Human Services 101 Business Park Boulevard 120 North 200 West, Room 201 Columbia, S.C. 29203-9498 Salt Lake City, Utah 84103 Phone: (803) 896-5551 Phone: (801) 538-3939 Fax: (803) 896-5557 Fax: (801) 538-4696 http://www.daodas.state.sc.us http://www.hsdsa.state.ut.us/ http://www.scprevents.org Vermont South Dakota Linda Piasecki and Peter Lee, Interim Gilbert Sudbeck, Director Directors Division of Alcohol and Drug Abuse Office of Alcohol and Drug Abuse Programs South Dakota Department of Human Vermont Department of Health Services 108 Cherry Street East Highway 34, Hillsview Plaza Burlington, Vt. 05402 c/o 500 East Capitol Phone: (802) 651-1550 Pierre, S.D. 57501-5070 Fax: (802) 651-1573 Phone: (605) 773-3123/5990 http://www.state.vt.us/adap Fax: (605) 773-5483 http://www.state.sd.us/dhs/ada Virginia Robert Johnson, Director Tennessee Substance Abuse Specialty Services Stephanie W. Perry, Assistant Virginia Department of Mental Health, Commissioner Mental Retardation and Substance Abuse Bureau of Alcohol and Drug Abuse Services Services Tennessee Department of Health 1220 Bank Street, Eighth Floor Cordell Hull Building, Third Floor Richmond, Va. 23218 425 Fifth Avenue, North Phone: (804) 786-3906 Nashville, Tenn. 37247-4401 Fax: (804) 786-4320 Phone: (615) 741-1921 http://www.dmhmrsas.state.va.us/ Fax: (615) 532-2419 http://www.state.tn.us/health/badas/

National Conference of State Legislatures Appendices 97

Appendix E. State and Jurisdictional Resources (continued)

Washington American Samoa Kenneth D. Stark, Director Uiagalelei Lealofi, Director Division of Alcohol and Substance Abuse Department of Human and Social Services Washington Department of Social and P.O. Box 997534 Health Services 997534 Utulei Street P.O. Box 45330 Pago Pago, A.S. 96799 Olympia, Wash. 98504-5330 Phone: (011-684) 633-2696 Phone: (360) 438-8200 Fax: (011-684) 699-7449 Fax: (360) 438-8078 http://www.wa.gov/dshs/hrsa/hrsa3ov.html# District of Columbia DASA William Steward, Acting Administrator Senior Deputy Director for Substance Abuse West Virginia Services Steve Mason, Director Department of Operations Division of Alcohol and Drug Abuse Addiction Prevention and Recovery Office of Behavioral Health Services Administration West Virginia Department of Health and 825 North Capitol Street, N.E., Suite 3125 Human Services Washington, D.C. 20002 Building 6, Room 738 Phone: (202) 442-9155 1900 Kanawha Boulevard, Capitol Complex Fax: (202) 442-9427 Charleston, W.V. 25305 Phone: (304) 558-2276 Guam Fax: (304) 558-1008 Peter Roberto, Director http://www.wvdhhr.org/bhhf/ Department of Mental Health and Substance Abuse Wisconsin Government of Guam Keith Lang, Director 790 Governor Carlos G. Camacho Road Bureau of Substance Abuse Services Tamuning, Guam 96911 Division of Supportive Living Phone: (011-671) 647-5445 Department of Health and Family Services Fax: (011-671) 649-6948 P.O. Box 7851 Madison, Wis. 53707-7851 Marshall Islands Phone: (608) 266-2717 Saeko Shoniber Fax: (608) 266-1533 Ministry of Finance http://www.dhfs.state.wi.us/SubstAbuse/ Office of the SSA Director index.htm P.O. Box D Majuro, MH 96960 Wyoming Phone: (011-692) 625-8311/8320 Diane Galloway, Administrator Fax: (011-692) 625-3607 Substance Abuse Division Department of Health Micronesia 2424 Pioneer Avenue, Suite 306 Eliuel K. Pretrick, Secretary Cheyenne, Wyo. 82002 Department of Health, Education and Social Phone: (307) 777-6494 Affairs Fax: (307) 777-7006 Federated States of Micronesia http://wbdh.state.wy.us/services/psa/index.htm P.O. Box PS 70 http://www.wyowins.net Palikir, Pohnpei FM 96941 Phone: (691) 320-2619 Fax: (691) 320-5263

National Conference of State Legislatures 98 Treatment of Alcohol and Other Substance Use Disorders

Appendix E. State and Jurisdictional Resources (continued)

Northern Mariana Islands Red Lake James Hofschneider, Secretary of Health Judy Roy, Acting Chairman Department of Public Health Tribal Council Commonwealth of the Northern Mariana Islands RedLake Band of the Chippewa Indian Tribe P.O. Box 409 CK P.O. Box 574 Saipan, MP 96950 RedLake, MN 56671 Phone: (011-670) 234-8950 ext. 2001 Phone: (218) 679-3341 Fax: (011-670) 234-8930 Fax: (218) 679-3378 Palau Virgin Islands Sandra S. Pierantozzi, Minister of Health Jaslene Williams, Acting Director Ministry of Human Services Division of Mental Health Palau National Hospital Department of Health P.O. Box 6027 3500 Richmond, Christiansted Koro, Republic of Palau 96940-0504 St. Croix, U.S. VI 00802-4370 Phone: (011-680) 488-2813 Phone: (340) 773-1311, ext. 3011 or 3012 Fax: (011-680) 488-1211 Fax: (340) 773-7900

Puerto Rico Johnny Rullan, Acting Administrator Puerto Rico Mental Health and Anti-Addiction Services Administration G.P.O. Box 70184 San Juan, PR 00928-1414 Phone: (787) 274-7676 Fax: (787) 274-7604

National Conference of State Legislatures Appendices 99

APPENDIX F. C ENTER FOR SUBSTANCE ABUSE TREATMENT (CSAT) TREATMENT IMPROVEMENT PROTOCOLS

The TIPs Editorial Advisory Board, a distinguished group of substance use disorders experts and professionals in such related fields as primary care, mental health, and social services, and the state alcohol and other drug abuse directors generate topics for the TIPs based on the field’s current needs for information and guidance.2

After selecting a topic, CSAT invites staff from pertinent federal agencies and national organizations to a resource panel that recommends specific areas of focus as well as resources that should be considered in developing the content for the TIP. Soon after that, a consensus panel is held: non-federal experts who are familiar with the topic and are nomi- nated by their peers participate in panel discussions over five days. The information and recommendations on which they reach consensus form the foundation of the TIP. The members of each consensus panel represent substance use treatment programs, hospitals, community health centers, counseling programs, criminal justice and child welfare agencies, and private practitioners. A panel chair ensures that the guidelines mirror the results of the group’s collaboration.3

A large and diverse group of experts closely reviews the draft document. Once the changes recommended by the field reviewers have been incorporated, the TIP is prepared for publication. Although each TIP strives to include an evidence base for the practices it recommends, CSAT recognizes that the field of substance abuse treatment is evolving, and research frequently lags behind the innovations pioneered in the field. A major goal of each TIP is to convey “front-line” information quickly but responsibly. For this reason, recommendations proffered in the TIP are attributed to either panelists’ clinical experience or the literature. If there is research to suggest a particular approach, citations are provided.4

Notes 1. “Treatment Improvement Protocol Series, CSAT TIPs,” http://www.treatment.org/Externals/tips.html, Dec. 18, 2003. 2. Ibid. 3. Ibid. 4. Ibid.

National Conference of State Legislatures 99 100 Treatment of Alcohol and Other Substance Use Disorders

TIP 1: State Methadone Treatment Guidelines TIP 2: Pregnant, Substance-Using Women TIP 3: Screening and Assessment of Alcohol- and Other Drug-Abusing Adolescents TIP 4: Guidelines for the Treatment of Alcohol and Other Drug-Abusing Adolescents TIP 5: Improving Treatment for Drug-Exposed Infants TIP 6: Screening for Infectious Diseases Among Substance Abusers TIP 7: Screening and Assessment for Alcohol and Other Drug Abuse Among Adults in the Criminal Justice System TIP 8: Intensive Outpatient Treatment for Alcohol and Other Drug Abuse TIP 9: Assessment and Treatment of Patients with Coexisting Mental Illness and Alcohol and Other Drug TIP 10: Assessment and Treatment of Cocaine-Abusing, Methadone-Maintained Patients TIP 11: Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases TIP 12: Combining Substance Abuse Treatment With Intermediate Sanctions for Adults in the Criminal Justice System TIP 13: The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders TIP 14: Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment TIP 15: Treatment for HIV-Infected Alcohol and Other Drug Abusers TIP 16: Alcohol and Other Drug Screening of Hospitalized Trauma Patients TIP 17: Planning for Alcohol and Other Drug Abuse Treatment for Adults in the Criminal Justice System TIP 18: The Tuberculosis Epidemic: Legal and Ethical Issues for Alcohol and Other Drug Abuse Treatment Providers TIP 19: Detoxification From Alcohol and Other Drugs TIP 20: Matching Treatment to Patient Needs in Opioid Substitution Therapy TIP 21: Combining Alcohol and Other Drug Abuse Treatment With Diversion for Juveniles in the Justice System TIP 22: LAAM in the Treatment of Opiate Addiction TIP 23: Treatment Drug Courts: Integrating Substance Abuse Treatment With Legal Case Processing TIP 24: A Guide to Substance Abuse Services for Primary Care Physicians TIP 25: Substance Abuse Treatment and Domestic Violence TIP 26: Substance Abuse Among Older Adults TIP 27: Comprehensive Case Management for Substance Abuse Treatment TIP 28: Naltrexone and Alcoholism Treatment TIP 29: Substance Use Disorder Treatment for People With Physical and Cognitive Disabilities TIP 30: Continuity of Offender Treatment for Substance Use Disorders From Institution to Community TIP 31: Screening and Assessing Adolescents For Substance Use Disorders TIP 32: Treatment of Adolescents With Substance Use Disorders TIP 33: Treatment for Stimulant Use Disorders TIP 34: Brief Interventions And Brief Therapies for Substance Abuse Treatment TIP 35: Enhancing Motivation for Change in Substance Abuse Treatment TIP 36: Substance Abuse Treatment Responding to Child Abuse and Neglect Issues TIP 37: Substance Abuse Treatment for Persons With HIV/AIDS TIP 38: Integrating Substance Abuse Treatment and Vocational Services

National Conference of State Legislatures Appendices 101

APPENDIX G. QUADRANT SYSTEM

A conceptual framework for treatment that is flexible, cost-effective, client-centered and evidence-driven was developed by the NASMHPD-NASADAD Task Force on Co-occurring Mental Health and Substance Use Disorders. Use of the framework helps key stakeholders speak the same language about symptom severity, locus of care, and the level of service coordination needed to address co-occurring disorders. The vast majority of the research literature and the bulk of the money invested tend to focus on people with serious mental illnesses who also have alcohol and other substance use disorders. This framework, which takes a much broader approach, is designed to ensure enough flexibility to address the needs of all individuals with co-occurring disorders; to fit into any service setting; and to allow policymakers, providers and funders to plan and fund services for individuals regardless of the current structure of a state’s or community’s health care delivery system.1

Finally, the framework points to the need for special attention to three groups of individuals: 1) individuals, especially children and adolescents, who are at risk of developing serious disease; 2) individuals engaged in one of the two treatment systems where the other, less severe, aspect of the co-occurring disorder remains a lower priority for treatment; and 3) individuals with more severe mental and alcohol and other substance use disorders, who are found in inappropriate settings—including jails, emergency rooms, or living on the streets—who use the most resources and have the worst outcomes.2 Figure 5. Co-occurring Disorders by Severity Levels of Illness Severity

The underlying assumption of the model is that the severity of an individual’s mental illness and/or alcohol and other substance use disorder may vary from high severity to low severity at any given time. The model uses four major categories of illness severity (see figure 5):

• Category I. Less severe mental disorder/less severe substance disorder.

• Category II. More severe mental disorder/less severe substance disorder.

• Category III. Less severe mental disorder/more severe substance disorder. Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.: NASMHPD and • Category IV. More severe mental disorder/more severe substance NASADAD, March 1999). disorder.3

National Conference of State Legislatures 101 102 Treatment of Alcohol and Other Substance Use Disorders

Because of the opportunity for prevention, Category I, which includes many children and adolescents, is arguably one of the most important categories of individuals upon which states should focus their treatment resources and funding. It is believed that early intervention can prevent the development of more serious disorders that if left inadequately treated, will result in much greater financial and human costs to society. At the other end of the scale, Category IV represents the group of individuals who currently use a dispropor- tionate share of service funding because their illnesses are the most severe and because they are found in the most expensive treatment and institutional settings, including inpatient hospital settings, emergency rooms and jails. This group also represents a priority population upon which states should arguably focus treatment resources and funding because they exact the greatest human and financial tolls on society.4 Levels of Service Coordination by Illness Severity

Based on the severity of their disorders and the location of their care, the following levels of coordination among the substance abuse, mental health and primary health care systems are recommended to address the needs of individuals with co-occurring mental health and substance abuse disorders (see figure 6):

Figure 6. Service Coordination by Severity • Level I. Consultation. Those informal relationships among providers that ensure both mental illness and alcohol and other substance use disorders are addressed, especially with regard to identification, engagement, prevention and early intervention. An example of such consultation might include a telephone request for information or advice regarding the etiology and clinical course of depression in a person using alcohol or other drugs. 5

• Levels II/III. Collaboration. Those more formal relationships among providers that ensure both mental illness and alcohol and other substance use disorders are included in the treatment regimen. An example of such collaboration might include interagency staffing conferences where representatives of both substance abuse and mental health agencies specifically contribute to the design of a treatment program for individuals with co-occurring disorders and contribute to service delivery. 6

• Level IV. Integrated Services. Those relationships among mental health and alcohol and other substance use providers in which the contributions of professionals in both fields are merged into Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health 7 and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.: NASMHPD and a single treatment setting and treatment regimen. NASADAD, March 1999). Locus of Care by Illness Severity

Based on the severity of their disorders, people with co-occurring mental health and alcohol and other substance use disorders currently tend to receive their care in the following settings (see figure 7):

• Setting I. Primary health care settings, school-based clinics, community programs; no care.

National Conference of State Legislatures Appendices 103

• Setting II. Mental health system. Figure 7. Primary Locus of Care by Severity • Setting III. Substance abuse system.

• Setting IV. State hospitals, jails, prisons, forensic units, emergency rooms, homeless service programs, mental health and/or substance abuse system; no care.8

As with categories of illness, the use of such clearly delineated settings is for ease of discussion. In reality, there is a great deal of over- lap between and among these settings; individuals with different combinations of severity are served in all of the systems highlighted above. In addition, individuals may move back and forth throughout the system of care based on their level of recovery at any given time. 9 Financing of Services by Illness Severity Source: NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Alexandria, Va. and Washington, D.C.: Creating coordinated funding streams at the state, federal and local NASMHPD and NASADAD, March 1999). program levels for a comprehensive system of care is also a challenge. Numerous barriers to funding the treatment of co-occurring disorders exist. One such barrier is the absence of shared systems for co-occurring disorders that would be driven by shared funding. There is also institutional resistance to merging funding streams. Further- more, statutes and regulations frequently create barriers to the development of creative and effective treatment models by limiting program flexibility (e.g., in most states, a co-occurring treatment program must choose to be licensed either as a substance abuse treatment provider or a mental health treatment provider, but not as both). Coordination of funding streams at the local or county level is essential to providing the most effective treatment, but often is lacking. In light of current budgetary restraints, obtaining significant levels of new funding dedicated to the treatment of co-occurring disorders is unlikely. States and communities may need to consider a mixed model that combines different streams of existing funds and also leverages some new resources.10 Block Grant Funds

State and local mental health and substance abuse agencies currently depend on similar sources of revenue, including CMHS and SAPT block grant funds, Medicaid, state general revenue and local taxes, among others; the proportion of funds available for both systems varies widely, however. For example, many state substance abuse agencies depend almost completely on SAPT funds, while CMHS Block Grant funds make up a very small percentage of most state mental health budgets. Medicaid generally is used more often to fund mental health services. In addition, the total state budget for mental health services is usually much larger than for substance abuse services. In Massachusetts, for example, Med- icaid funding makes available $1 for substance abuse treatment for every $9 allocated for mental health services.11

The specific form that a state’s participation in Medicaid managed care takes, as well as any consent decrees or lawsuits that determine which populations can be served, also will affect the type and amount of funding available to serve people with co-occurring disorders. All

National Conference of State Legislatures 104 Treatment of Alcohol and Other Substance Use Disorders

state substance abuse agencies devote significant resources to the areas of prevention and early intervention.12

To insist that new resources must be available to serve people with co-occurring disorders is likely to be unrealistic. States and communities may need to consider a mixed model that combines different streams of existing funds while leveraging some new resources. Task force members described joint projects for people with co-occurring disorders that use SAPT Block Grant and state mental health general revenue funds, block grant funds from both mental health and substance abuse agencies, and block grant funds and resources from the Temporary Assistance to Needy Families (TANF) program. It was noted that SAMHSA had recently issued a position statement acknowledging that SAPT and Mental Health Block Grant funds can be used to provide services for individuals with co-occurring substance abuse disorders and mental illnesses in a variety of treatment settings, including settings where integrated services are delivered. Although each of these programs specifies a certain set of services that can and cannot be funded, together they can be used to support a wide range of needs.13

Notes 1. NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Alexandria, Va., and Washington, D.C.: NASMHPD and NASADAD, March 1999). 2. Ibid. 3. Ibid. 4. Ibid. 5. Ibid. 6. Ibid. 7. Ibid. 8. Ibid. 9. Ibid. 10. NASMHPD and NASADAD, Financing and Marketing the New Conceptual Framework for Co-Occurring Mental Health and Substance Abuse Disorders: A Blueprint for Systems Change (Alexandria, Va., and Washington, D.C.: NASMHPD and NASADAD, April 2000). 11. Ibid. 12. Ibid. 13. Ibid.

National Conference of State Legislatures Appendices 105

Dollar Limits Lifetime/Annual $6,000 every two every $6,000 years; $12,000 lifetime As of 1/02, at least As of 1/02, $12,715 over two consecutive benefit years and $25,425 lifetime Not specified Co-insurance Copayments and Not less favorable generally other illnesses Not specified Not specified 50% of the payment; deductible shall not differ Residential Scope of Partial/ Not less favorable generally One day of inpatient converts to two days of partial/ residential Outpatient Not less favorable generally inpatient converts to three sessions of outpatient Not specified Not specified specified Not Must be equal to generally Type of Benefit Scope of Inpatient Scope of Parity equal Must be equal Must be equal Must be equal Must be equal Must be Minimum mandated benefits or mandated offering for small group Mandated offering Must be equal Must be equal Must be equal Must be equal Must be equal Parity equal Must be equal Must be equal Must be equal Must be equal Must be Mandated offering Not less favorable Mandated offering Not specified Not specified Not specified Not specified Not specified Illnesses Covered (1) Covered Drug and alcohol dependencies Alcoholism and Alcoholism drug abuse Chemical (2) dependency Mental or nervous condi-tions, including alcoholism and drug addiction (3) drug dependency Alcoholism Mandated offering 45 days $500 annually Not specified Shall not exceed Affected by Law Insurance Policies individual and state employee plans employees or less exempt; or less20 must offer coverage employer or 50 exemption less; cost increase 1.5% or more individual amendment: Provides an option for small employers of 50 or less to purchase plans w/o mandate Federal Adopted Parity? Year Date 1987 1987 No and HMO Group and Alcoholism State Effective Del. July 2001 (1997) Yes Group, HMO, Ala. 1979 N/A N/A N/A N/A N/A Alaska No N/A 1997 Yes (1997) Group and HMO Ariz. Alcoholism Ark. Group- five small Mandated offering 1997 No days 30 Group: Calif. 1990 One day of Colo. 1994 No No 2003 Group Group No 2000 Conn. January Alcoholism and Group

Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State Treatment

National Conference of State Legislatures 105 106 Treatment of Alcohol and Other Substance Use Disorders

Dollar Limits Lifetime/Annual Must be comparable Annual benefit may be limited to the lesser of $10,000 or 25% of lifetime policy limit benefit of $2,000; of $2,000; benefit annual limits not specified Co-insurance Copayments and Must be comparable required to pay up required to 50% of the expenses incurred Residential Scope of Partial/ No less than two treatment episodes per lifetime Not specified Not specified Minimum lifetime Outpatient No less than two treatment episodes per lifetime $35 maximum maximum $35 reimbursement per visit treatment episodes per lifetime 45 days 35 days equal Must be equal Must be Not specified equal Must be Insured may be equal Must be equal Must be equal Must be equal Must be equal Must be equal Must be equal Must be Type of Benefit Scope of Inpatient Scope of Mandated offering 30 days Mandated benefits No less than two 48 visits Mandated offering Not specified for mental illnesses other than serious mental illnesses Must be equal Must be equal Mandate for plans that offer benefits, when the services are required in the treatment of a mental illness Mandate for plans that offer benefits, when the services are required in the treatment of a mental illness abuse Mandated offering Not specified 44 visit maximum; Illnesses Covered (1) Covered Mental disorders, including substance abuse (4) and drug Alcohol dependence Mental illnesses other than serious mental illnesses Substance abuse and chemical dependency Substance abuse and chemical dependency Affected by Law Insurance Policies individual and HMO small employer of 50 exemption or less with an exemption for a cost increase or more of 4% individuals and HMOs Federal Adopted Parity? Year Date State Effective Fla. 1993 N/A N/A N/A N/A Ga. 1998 N/A Yes (1998) No and N/A Group and HMO Group Hawaii 1988 Substance No Idaho Ill. group 1995 Individual, January 2002 No No Ind. January 2001 Group with a Yes (1997) Group State employees Alcoholism June 2003 (1997) Yes Mandated benefits Not specified (12) Groups, Not specified Not specified Not specified Not specified Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures Appendices 107

Dollar Limits Lifetime/Annual outpatient treatment outpatient treatment Co-insurance Copayments and Not specified Not specified Residential Scope of Partial/ Not specified Not specified Specified only for Not specified Not specified Specified only for 10 days at $50 reimbursed per day Outpatient 100% of the first 100% of the 80% $100, and $100 next 50% of the next year per $1,640 and not less than per $7,500 lifetime 100% of the first 100% of the 80% $100, and $100 next 50% of the next year per $1,640 and not less than per $7,500 lifetime 10 visits at $10 reimbursed per visit Equal if offered Equal if offered Equal if offered Equal if offered Equal if offered detoxification- 3 days reimbursed at $40day per Type of Benefit Scope of Inpatient Scope of Mandated benefits 30 days Not less than Mandated benefits 30 days Not less than Mandate for plans that offer benefits Mandated offering Not specified Not specified Not specified Not specified Not specified Illnesses Covered (1) Covered Alcoholism or drug abuse or mental conditions (5) Alcoholism, drug abuse, or nervous or mental condition Mental illness and alcohol and other drug abuse (6) drug abuse Affected by Law Insurance Policies HMO and state employee plans individual employer of 50 exemption or less group exempt health benefit plans covering 51 fewer than (previously 50), employees Federal Adopted Parity? Year Yes (1997) Group, individual, Date The section of law that requires group plans offer that mental health benefits to comply with the federal Mental Health Parity Act sunsets December 31, 2003 State Effective Kan. 1998 Kan. 1998 January 2002 Yes (1997) Group and Ky. 1980 No Group Emergency offering Alcoholism July 2000 Mandated No April 2002 Group with small La. 1982 Amends the law to Yes (1997) Group and Alcoholism Ia. N/A N/A N/A N/A N/A N/A Ia. Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures 108 Treatment of Alcohol and Other Substance Use Disorders

Dollar Limits Lifetime/Annual Lifetime not specified $2,968 annual limit for outpatient and intermediate care for substance treatment abuse $1,500 per year per $1,500 for outpatient and intermediate treatment Must be equal Must be May place a May place maximum limit on benefits as long they are consistent with the law Co-insurance Copayments and Charges, terms, and conditions for the services shall not be less favorable than the for any maximum other comparable service Charges terms and conditions shall not be less favorable except outpatient 80% -visits 1-5, 65% - visits 6-30, 50% visits 31 and above maximum limit on benefits as long they are consistent with the law Not specified Not specified Residential Scope of Partial/ $2,968 for $2,968 substance abuse $1,500 per year per $1,500 for outpatient and intermediate treatment days of partial/ residential to one day of inpatient Outpatient visits per year for mental illness and for $2,968 substance abuse $1,500 per year per $1,500 for outpatient and intermediate treatment None. Not fewer than 20 Must be equal Unlimited visits 60 days Must be equal, To the extent agreed upon Type of Benefit Scope of Inpatient Scope of Parity equal Must be equal Must be equal Must be equal Must be equal Must be Minimum mandated benefits Mandated benefit Not specified Not specified Minimum mandated benefit Not specified May place a Mandated benefits 60 days 24 visits of inpatient and mandated benefits for other levels Illnesses Covered (1) Covered Mental illness; (7) expands coverage under 1996 law to 11 categories of mental illness, including substance abuse- related disorders Mental health and substance abuse Alcoholism and drug dependency Mental illness, emotional disorder, drug abuse or alcohol abuse disorder Alcoholism Mandated benefits All DSM 30 days diagnoses not covered under the parity provision (mental illness and $500 per year substance abuse) Substance abuse May convert two Mandated offering Affected by Law Insurance Policies with a small employer exemption for 20 or less group and individual contracts, with a for cost exemption substance abuse services, if the fees increase by 3% or more small employer exemption for 20 or less group and HMO HMO and state employee plans; small employer of 50 exemption or less that expired 1/1/2001 inpatient; group and individual for other levels; exemption for cost increase of 3% or more Federal Adopted Parity? Year Date State Effective Maine 2003 Yes Group and HMO only, No HMOs 2001 January 1984 Md. 1994 No No group, and Individual No Individual, a with Group Mass. 1991 2001 No January group Individual, 1988 Mich. No for Group Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures Appendices 109

Dollar Limits Lifetime/Annual A lifetime limit equal to four times the annual limit may be imposed for alcohol and drug abuse Must be equal Must be equal Must be mental illness; chemical dependency may not be limited to less than 10 episodes of treatment $1,000 per year, $1,000 per lifetime limit not specified Co-insurance Copayments and unreasonable in relation to the cost of services provided for mental illness Must be equal Must be equal Must be Not specified Not specified Not specified Not specified Must be equal Must be equal for Residential Scope of Partial/ Not specified Shall not be Must be equal Must be equal Must be At least 20% of the inpatient days not allowed but less than 28 days yearly 30 days for all levels of care total, not for each level Must be equal for mental disorders, 21 days for chemical dependency Outpatient Equal for mental illness, at least 20 visits for alcohol and drug abuse if offered Must be equal Must be equal Must be At least 130 hours of treatment per year 30 days for all levels of care total, not for each level Two visits for mental disorders, 26 visits for chemical dependency ecified Not specified Not specified Not specified Annual limit of Equal for mental illness, at least 30 days for alcohol and drug abuse if offered Must be equal Must be equal Must be the total days not allowed but less than 28 days yearly 30 days for alcoholism; 80% of reasonable $2,000 charges, maximum disorders and six days for detoxification Type of Benefit Scope of Inpatient Scope of Mandate for plans that offer benefits Parity Mandated offering Mandated benefit At least 20% of Mandated benefit for alcoholism; mandated offering for others Mandated offering 90 days for mental Illnesses Covered (1) Mental illness including alcohol and drug abuse (10) Mental health and chemical dependency Mental health and chemical dependency Alcoholism, chemical dependency or drug addiction Alcoholism, chemical dependency or drug addiction Mental (8) disorders and chemical (9) dependency Affected by Law Insurance Policies individual Group and individual individual individual and HMO Federal Adopted Parity? Year Date State Effective January 2000 No Group and No Group 2000 January Minn. 1995 No HMOs 1986 Miss. 1975 No Mo. No 1995 and Group individual Group 1997 No No Group, and Group Alcoholism Mandated benefit Not sp

Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures 110 Treatment of Alcohol and Other Substance Use Disorders

Dollar Limits Lifetime/Annual See specified under maximums inpatient and outpatient benefits; aggregate limits may not be imposed more restrictively Not specified Must be paid in Must be paid same manner to maximum benefit; lifetime maximum not specified No less favorable generally than for physical illness Co-insurance Copayments and No less favorable up to maximums No less favorable up to maximums same manner generally than for physical illness Residential Scope of Partial/ Not specified Not specified May be limited One day of inpatient treatment for mental illness may be traded for two days of partial One day of inpatient treatment for mental illness may be traded for two days of partial Not specified No less favorable Outpatient May be limited; May be must include benefits for detoxification and rehabilitation No less than for mental $2,000 illness and $1,000 for alcohol and drug addiction per year $2,500 per year $2,500 per specified Not in Must be paid No less than for mental $2,000 illness 60 visits during lifetime of the the policy May be limited; May be must include benefits for detoxification and rehabilitation a $4,000 a $4,000 maximum every two years and a maximum $8,000 lifetime for alcohol and drug addiction only and $1,500 for and $1,500 detoxification per year illness only. maximum $6,000 months every 12 and until $12,000 maximum lifetime is met, then annual benefit may be reduced to for alcohol $2,000 and drug addiction only with at least two treatment periods in a lifetime Type of Benefit Scope of Inpatient Scope of Minimum mandated benefits Mandated benefits 21 days each, with Mandated benefits $9,000 inpatient Mandated benefits 21 days for mental Illnesses Covered (1) Covered Chemical Chemical dependency, including alcoholism Mental illness, alcoholism and drug addiction Abuse of alcohol or drugs alcoholism and drug addiction Alcoholism Mandated offering 30 days per year Affected by Law Insurance Policies blanket accident blanket or health insurers, HMOs (unless the HMO elects to provide coverage under the federal "HMO Act"), state employee plans and, with respect to coverage of biologically mental based illnesses, nonprofit health service corporations small group exemption (number not specified) or a cost increase of 1% or more and HMO Federal Adopted Parity? Year Yes (1997) Group with a Yes (1997) Group Mental illness Date law terminated 9/30/01, then law below became effective 2001; 2001; replaces July law 1997 that sunset Sept. 30, see 2001, supra. State Effective Mont. July 1997 1997 Mont. July N.H. 2003 No and Group October 1, October Neb. 1989 Nev. No 1997 Yes (1997) Group and HMO Group, individual Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures Appendices 111

Dollar Limits Lifetime/Annual $8,000 per year per $8,000 and $16,000 per lifetime Consistent with imposed on those other benefits Not specified As deemed the appropriate by superinten-dent and consistent with those for other benefits Benefits shall be provided to the as same extent benefits for any other sickness Co-insurance Copayments and $8000 per year year per $8000 and $16,000 per lifetime those imposed on those other benefits mental illnesses: no coinsurance, co- $500 but payment per inpatient stay; 30 % coinsurance for outpatient stay; Alcohol and abuse: substance 30% coinsurance the appropriate by superintend-ent and consistent with those for other benefits provided to the as same extent benefits for any other sickness Residential Scope of Partial/ $8,000 per year per $8,000 and $16,000 per lifetime Not specified Consistent with Not specified. Biologically based Not specified As deemed Outpatient $8,000 per year per $8,000 and $16,000 per lifetime 30 visits per year, 30 limited to no less than two episodes per lifetime 30 days for based biologically mental illnesses 30 days for alcohol and substance treatment abuse days total for (30 inpatient and/or outpatient treatment) $700-mental illness and 60 visits for alcoholism or substance abuse and $16,000 per per and $16,000 lifetime Must be equal Must be equal Must be equal Benefits shall be limited to no less than two episodes per lifetime 90 days for based biologically mental illnesses 30 days for alcohol and substance treatment abuse days total for (30 inpatient and/or outpatient treatment) illness, 30 days- alcoholism or abuse, substance seven days- detoxification Type of Benefit Scope of Inpatient Scope of Mandated offering per year $8,000 for care prescribed by a doctor Parity equal Must be equal Must be equal Must be equal Must be equal Must be Mandated offering (Does not replace laws that mandate greater coverage; provides a less expensive alternative to these policies, for individual plans) Mandated offering 30 days-mental Illnesses Covered (1) dependency (11) dependency (11) Alcoholism Mandated benefits Alcoholism Mandated Mental illness and chemical dependency (11) mental illness and alcohol and substance abuse or emotional disorders and alcoholism and substance abuse Alcoholism Mandated offering 30 days per year, Affected by Law Insurance Policies Individual plans Federal Adopted Parity? Year No Individual Biologically based Biologically No Individual Date 2002 2002 State Effective N.C. 1985 Yes (1997) Group Chemical N.J. 1985 No and Group October N.M. 1987 (1998) Group Yes N.Y. 1998 No Group 1997 Mental, nervous, Yes (1997) State employee Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures 112 Treatment of Alcohol and Other Substance Use Disorders

Dollar Limits Lifetime/Annual Dual diagnosis mental health/ substance abuse = $13,125 for adults and $15,625 for children; substance abuse for only = $8,125 adults and $13,125 for children per 24 months Lifetime dollar limits are not specified Lifetime and annual dollar limits not specified Dollar limits not specified; day and visit limits as specified for each level of care Lifetime not specified Co-insurance Copayments and Shall be no greater than those for other illnesses Benefits are subject to reasonable deductibles and co-insurance No deductible or copayment for first five hours not to for 20% exceed remaining hours For the first course of treatment shall be no greater than those for other illnesses No change No change must Coverage be no less than 80% of total Residential Scope of Partial/ Substance abuse = for adults $4,375 for and $3,750 mental children; health = $1,250 for adults and for $3,125 children per 24 months At least $550 for mental illness and for $550 alcoholism per year 120 days for mental illness and 120 days for substance abuse 30 days per year, 30 90 days per lifetime If more than 60 days of residential treatment is required, up to 23 days of unused inpatient treatment may be traded at a rate of one inpatient day for two residential days in a 24- $4,500 month period Outpatient Substance abuse = for adults $1,875 for and $2,500 mental children; health = $2,500 both per 24 for months At least $550 for mental illness and for $550 alcoholism per year 30 hours for mental illness and 20 visits for substance abuse 30 visits per year, 30 120lifetime per $4,500 in a 24- $4,500 month period $5,625 for adults $5,625 for and $5,000 mental children; health = $5,000 for adults and for $7,500 children per 24 months At least $550 for mental illness and for $550 alcoholism per year illness and 60 days for substance abuse 45 days No change 60 days detoxification per per year, 28 lifetime month period Type of Benefit Scope of Inpatient Scope of Mandated benefits Substance abuse = Mandate for plans that offer mental coverage; health mandated benefits for alcoholism Mandated benefits 45 days for mental Mandated benefits Amends inpatient and residential treatment limits for alcoholism and drug addiction. (see 1995 law, supra) Mandated benefits 7 days of Illnesses Covered (1) Covered conditions, including alcoholism and chemical dependency (12) Mental or nervous disorders and alcoholism alcoholism and drug addiction drug addiction drug addiction Affected by Law Insurance Policies insured Federal Adopted Parity? Year No Group and HMO and Alcoholism Date 2003 2003 State Effective July 2000 No Group and HMO Mental or nervous N.D. 1995 1, No August Group and HMO. Mental disorders, N/A N/A N/A N/A N/A Ohio N/A 1985 No Okla. Ore. 1981 and self- Group No Individual Alcoholism Pa. Mandated offering for in $4,500 a 24- 1989 No Group and HMO or Alcoholism

National Conference of State Legislatures Appendices 113

Dollar Limits Lifetime/Annual On the same basis as benefits provided for other illnesses maximum of maximum $10,000 Co-insurance Copayments and Not specified Not specified On the same basis as benefits provided for other illnesses May be different May be Lifetime Residential Scope of Partial/ 30 days per year, 30 not to exceed lifetime limit of 90 days. equal Must be equal Must be equal Must be 30 days care overall each six days months; 90 lifetime $2,000 per year per $2,000 total overall Outpatient 30 hours for each individual under treatment and 20 hours for family per year mental illness only; 30 hours for substance abuse only; five detoxification occurrences or 30 days, whichever comes first 30 days care overall each six days months; 90 lifetime $2,000 per year per $2,000 total overall detoxification or 21 days, whichever comes first, per year Must be equal 30 visits for overall each six days months; 90 lifetime total overall Type of Benefit Scope of Inpatient Scope of Mandated offering Must be equal Must be equal Must be equal Must be equal Must be equal Mandated benefits Mandated benefits episodes of Three Minimum mandated benefit Parity equal Must be equal Must be equal Must be equal Must be equal Must be Mandated offering $2,000 per year Illnesses Covered (1) Covered Alcohol and drug Alcohol dependency Substance dependency and (13) abuse Mental illness, including substance abuse Mental health condition or alcohol or substance abuse (15) Alcoholism Mandated offering 30 days care conditions, including substance abuse (14) Affected by Law Insurance Policies small employer or 50 exemption less, or cost increase of 1% or more and self-insured self-insured and HMO insurance plan increase with cost exemptions and HMO Federal Adopted Parity? Year Date State Effective Tenn. 1982 Yes (1997) Group with a January 2002 No Individual, group, No R.I. 1995 Individual, No 2002 group Individual, January S.C. 1994 (1997)Group Yes Psychiatric 1/1/2002 1979 S.D. Yes (97) No State employee individual Group,

National Conference of State Legislatures 114 Treatment of Alcohol and Other Substance Use Disorders

Dollar Limits Lifetime/Annual Must be equal to same achieve the outcome as treatment for any other illness Must be sufficientMust be to provide appropriate care Benefits shall be no more restrictive than for other illnesses except as specified lifetime limit; annual limit must be equal May include a restriction Co-insurance Copayments and Must be equal to same achieve the outcome as treatment for any other illness Must be sufficientMust be to provide appropriate care Co-insurance for outpatient can be no more than 50% visit; all after fifth others must be equal May include a restriction Must be equal Must be equal Must be Residential Scope of Partial/ Must be equal to same achieve the outcome as treatment for any other illness. Lifetime of three maximum separate series of treatments, including all levels of medically necessary care in each episode Up to 10 days of inpatient can be converted for children to 1.5 days of partial for one day of inpatient May include a restriction Outpatient Must be equal to same achieve the outcome as treatment for any other illness Lifetime of three maximum separate series of treatments, including all levels of medically necessary care in each episode 20 visits for adults and children May include a restriction achieve the same achieve the outcome as treatment for any other illness Lifetime of three maximum separate series of treatments, including all levels of medically necessary care in each episode 45 days 60 visits Not specified Must be equal May not include a and children restriction Type of Benefit Scope of Inpatient Scope of Parity Must be equal to Mandated benefit with a mandated offering for self- insured of 250 or less Law effective Jan. allows 2004, 1, insurers and HMOs to offer policies without this mandate, in addition to at least one policy with mandate, to the provide a less expensive alternative Minimum Mandated benefit Parity equal Must be equal Must be equal Must be Mandated benefits 25 days for adults Mandated offering May include a Mandated offering Not specified Not specified Not specified Not specified Not specified Illnesses Covered (1) Covered Biologically based based Biologically mental illness, including drug and alcohol addiction (19) Chemical Chemical dependency (16) Serious mental illness (17) Mental health condition including alcohol and substance (18) abuse Mental health and substance abuse defined by the defined by Diagnostic and Statistical Manual dependency Affected by Law Insurance Policies individual with a small group or 25 exemption less insured with an exemption for self- insured plans of 250 or less plans and state employee plans and HMO Federal Adopted Parity? Year No Group and No Group Yes State employee Yes State Yes Group and HMOs Mental illness as individual Group, No Date January 1, to July 2000 2004 1, 2001 2001 HMO July 1, Group 2001- Repealed July 2001 1, until January and 2000 after July 1, 2004 State Effective Va. Effective Texas 1981 No Group and self- 1, September 2001- 1, Jan. Utah 1998 Vt. 1994 individual No Group, No Group Effective and drug Alcohol

National Conference of State Legislatures Appendices 115

Dollar Limits Lifetime/Annual Annual benefits need not exceed or the $7,000 equivalent benefits measured in services rendered; the amount may be reduced if the policy is written in combination with major medical coverage, if the combined coverage complies the mandate with Not less than $750 Not less than $750 annually and not less than an amount equal to the lesser of $10,000 or 25% lifetime of the limit Co-insurance Copayments and May apply same deductible and/or copayment to mental health and alcohol and other drug abuse services that apply to all benefits; may deductibles, apply copayments, or co-insurance to inpatient, outpatient and transitional services to 30 days; cannot to 30 for 50% exceed outpatient Residential Scope of Partial/ Transitional treatment: Not less than $3,000 minus any applicable cost sharing at the level charged under the policy for the equivalent benefits measured in services rendered or, if the policy does not use cost in $2,700 sharing, equivalent benefits measured in services rendered Not specified Not specified Not specified ecified Not specified Must be equal up Outpatient Not less than $2,000 minus any cost sharing or the equivalent benefits measured in services rendered or, if the policy does not use cost in $1,800 sharing, equivalent benefits measured in services rendered lesser of 30 days or $7,000 minus any cost sharing or the equivalent benefits measured in services rendered or, if the policy does not use cost in $6,300 sharing, equivalent benefits measured in services rendered Type of Benefit Scope of Inpatient Scope of Mandated offering Not less than the Parity equal Must be equal Must be equal Must be equal Must be equal Must be Mandated benefit Not specified Not specified (20) Mandated offering 30 days Not sp Illnesses Covered (1) Covered Nervous and mental disorders, alcoholism, and drug abuse other Serious mental illness, including substance-related disorders (21) dependency Affected by Law Insurance Policies disability insurance policies with 2% cost with 2% increase Group exemption/ accident and sick insurance plans cost with 1% increase exemption for plans of 25 or less and 2% for larger plans/ HMOs Federal Adopted Parity? Year Date State Effective Wis. 1985 Wis. 1985 blanket No or Group Wash. 1990 1990 Wash. W.V. 1998 No (1997) Group Yes Group Alcoholism Chemical 2002 Yes (1997) State employees N/A N/A N/A N/A No N/A Wyo. Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Use Substance of Alcohol and Other Coverage Laws Requiring H. OverviewAppendix of State (continued) Treatment

National Conference of State Legislatures 116 Treatment of Alcohol and Other Substance Use Disorders

Appendix H. Overview of State Laws Requiring Coverage of Alcohol and Other Substance Use Disorder Treatment (continued)

Notes 1. Thirteen Diagnostic and Statistical Manual diagnoses are commonly referred to as biologically based mental illnesses by mental health providers and consumer organizations. Between three and 13 of these diagnoses are referred to in various state parity laws. 2. Mental illnesses and developmental disorders are defined in Arizona as disorders listed in the Internal Classification of Disease Manual and the Diagnostic and Statistics Manual of the American Psychiatric Association (DSM) 3. Connecticut defines mental or nervous condition as mental disorders, as defined in the most recent edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders and includes alcoholism and drug addiction as defined by the DSM. 4. In Georgia, mental disorders are defined by the Internal Classification of Disease Manual or the Diagnostic and Statistics Manual of the American Psychiatric Association (DSM). 5. Kansas defines nervous or mental conditions to mean disorders specified in the Diagnostic and Statistics Manual of mental disorders, fourth edition (DSM-IV), but shall not include conditions not attributable to a mental disorder that are a focus of attention or treatment. 6. Kentucky defines mental health condition to mean any condition or disorder that involves mental illness or alcohol and other drug abuse that falls under any of the diagnostic categories listed in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) or that is listed in the mental disorders section of the international classification of disease, or the most recent subsequent editions. 7. Expands coverage to the following 11 categories of mental illness in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, except for those that are designated as “V” codes: substance abuse-related disorder; psychotic disorders such as schizophrenia; dissociative disorders; mood disorders; anxiety disorders; personality disorders; paraphilias; attention deficit and disruptive behavior disorders; pervasive developmental disorders; tic disorders; eating disorders, including bulimia and anorexia; and substance abuse-related disorders. 8. Missouri defines recognized mental illness as those conditions classified as “mental disorders” in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, but shall not include mental retardation. 9. Missouri defines chemical dependency as the psychological or physiological dependence upon and abuse of drugs, including alcohol, characterized by drug tolerance or withdrawal and impairment of social or occupational role functioning or both. 10. Missouri defines mental illness as the following disorders contained in the International Classification of Diseases (ICD-9-CM): 1) schizophrenic disorders and paranoid states (295 and 297, except 297.3); 2) major depression, bipolar disorder and other affective psychoses (296); 3) obsessive compulsive disorder, post-traumatic stress disorder and other major anxiety disorders (300.0, 300.21, 300.22, 300.23, 300.3 and 309.81); 4) early childhood psychoses and other disorders first diagnosed in childhood or adolescence (299.8, 312.8, 313.81 and 314); 5) alcohol and drug abuse (291, 292, 303, 304, and 305, except 305.1); 6) anorexia nervosa, bulimia and other severe eating disorders (307.1, 307.51, 307.52 and 307.53); and 7) senile organic psychotic conditions (290). 11. North Carolina defines “mental illness” to mean: “(i) when applied to an adult, an illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance, or control; and (ii) when applied to a minor, a mental condition, other than mental retardation alone, that so impairs the youth’s capacity to exercise age adequate self-control or judgment in the conduct of his activities and social relationships so that he is in need of treatment. NC defines chemical dependency to mean the pathological use or abuse of alcohol or other drugs in a manner or to a degree that produces an impairment in personal, social or occupational functioning and which may, but need not, include a pattern of tolerance and withdrawal.” 12. Oregon defines chemical dependency to mean the addictive relationship with any drug or alcohol characterized by either a physical or psychological relationship, or both, that interferes with the individual’s social, psychological or physical adjustment to common problems on a recurring basis. For purposes of this section, chemical dependency does not include addiction to, or dependency on, tobacco, tobacco products or foods. It does not provide a specific definition for mental or nervous conditions. 13. Rhode Island defines substance dependency and substance abuse as the pattern of pathological use of alcohol or other psychoactive drugs characterized by impairments in social and/or occupational functioning, debilitating physical condition, inability to abstain from or reduce consumption of the substance, or the need for daily substance use for adequate functioning. 14. South Carolina defines psychiatric conditions to mean those mental and nervous conditions, drug and substance addiction or abuse, alcoholism, or other conditions that are defined, described, or classified as psychiatric disorders or conditions in the most current publication of the American Psychiatric Association entitled The Diagnostic and Statistical Manual of Mental Disorders. 15. South Carolina defines mental health condition to mean; schizophrenia, schizoaffective disorder, major depressive disorder, bipolar disorder, pervasive developmental disorder or autism, panic disorder, obsessive-compulsive disorder, social anxiety disorder, anorexia, bulimia, asperger’s disorder, intermittent explosive disorder, post-traumatic stress disorder, psychosis not otherwise specified when diagnosed in a child under age 17, Rett’s disorder, or Tourette’s disorder. 16. Texas defines chemical dependency to mean the abuse of or psychological or physical dependence on or addiction to alcohol or a controlled substance. 17. Texas defines serious mental illness to mean the following psychiatric illnesses as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM): 1) schizophrenia, 2) paranoid and other psychotic disorders, 3) bipolar disorders (hypomanic, manic, depressive, and mixed), 4) major depressive disorders (single episode or recurrent), 5) schizoaffective disorders (bipolar or depressive), 6) pervasive developmental disorders, 7) obsessive-compulsive disorder, and 8) depression in childhood and adolescence. 18. Vermont defines mental health condition as any condition or disorder involving mental illness or alcohol or substance abuse that falls under any of the diagnostic categories listed in the mental disorders section of the International Classification of Diseases, as periodically revised. 19. Virginia defines biologically based mental illness as any mental or nervous condition caused by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person’s functioning; specifically, the following diagnoses are defined as biologically based mental illness as they apply to adults and children: 1) schizophrenia, 2) schizoaffective disorder, 3) bipolar disorder, 4) major depressive disorder, 5) panic disorder, 6) obsessive-compulsive disorder, 7) attention deficit hyperactivity disorder, 8) autism, and 9) drug and alcoholism addiction. 20. West Virginia defines alcoholism as a chronic disorder or illness in which the individual is unable, for psychological or physical reasons, or both, to refrain from the frequent consumption of alcohol in quantities sufficient to produce intoxication and, ultimately, injury to health and effective functioning. 21. West Virginia Defines serious mental illness as (i) schizophrenia and other psychotic disorders; (ii) bipolar disorders; (iii) depressive disorders; (iv) substance-related disorders with the exception of caffeine-related disorders and nicotine-related disorders; (v) anxiety disorders; and (vi) anorexia and bulimia, as defined in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, as periodically revised. For employee plans, also includes attention deficit hyperactivity disorder, separation anxiety disorder, and conduct disorder, for individuals under age 19.

Source: National Conference of State Legislatures, Health Policy Tracking Service, October 2003.

National Conference of State Legislatures Appendices 117

APPENDIX I. ALCOHOL TAX, BY STATE State Liquor Excise Tax Rates (as of Jan. 1, 2003)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied Alabama (1) Yes Alaska $12.80 N/A under 21% - $2.50/gallon Arizona 3.00 Yes under 5% - $0.50/gallon, under 21% - $1.00/gallon; $0.20/case and 3% off- Arkansas 2.50 Yes premise 14% on-premise retail taxes California 3.30 Yes over 50% - $6.60/gallon Colorado 2.28 Yes Connecticut 4.50 Yes under 7% - $2.05/gallon Delaware 3.75 N/A under 25% - $2.50/gallon under 17.259% - $2.25/gallon, over 55.780% - $9.53/gallon 6.67¢/ounce on- Florida 6.50 Yes premise retail tax Georgia 3.79 Yes $0.83/gallon local tax Hawaii 5.92 Yes Idaho (1) Yes under 20% - $0.73/gallon; $0.50/gallon in Chicago and $1.00/gallon in Cook Illinois 4.50 Yes County Indiana 2.68 Yes under 15% - $0.47/gallon Iowa (1) Yes Kansas 2.50 No 8% off-premise and 10% on-premise retail tax Kentucky 1.92 Yes (2) under 6% - $0.25/gallon; $0.05/case and 9% wholesale tax Louisiana 2.50 Yes under 6% - $0.32/gallon Maine (1) Yes Maryland 1.50 Yes under 15% - $1.10/gallon, over 50% alcohol - $4.05/proof gallon; 0.57% on Massachusetts 4.05 Yes (2) private club sales Michigan (1) Yes Minnesota 5.03 -- $0.01/bottle (except miniatures) and 9.0% sales tax Mississippi (1) Yes Missouri 2.00 Yes Montana (1) N/A Nebraska 3.00 Yes Nevada 2.05 Yes under 14% - $0.40/gallon and under 21% - $0.75/gallon. New Hampshire (1) N/A New Jersey 4.40 Yes New Mexico 6.06 Yes New York 6.44 Yes under 24% - $2.54/gallon; $1.00/gallon New York City

National Conference of State Legislatures 117 118 Treatment of Alcohol and Other Substance Use Disorders

Appendix I. State Liquor Excise Tax Rates (as of Jan. 1, 2003)— (continued)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied North Carolina (1) Yes (2) North Dakota 2.50 -- 7% state sales tax Ohio (1) Yes Oklahoma 5.56 Yes $1.00/bottle on-premise and 12% on-premise Oregon (1) N/A Pennsylvania (1) Yes Rhode Island 3.75 Yes South Carolina 2.72 Yes $5.36/case and 9% surtax South Dakota 3.93 Yes under 14% - $0.93/gallon, 2% wholesale tax Tennessee 4.40 Yes $0.15/case and 15% on-premise; under 7% - $1.21/gallon. Texas 2.40 Yes 14% on-premise and $0.05/drink on airline sales Utah (1) Yes Vermont (1) No 10% on-premise sales tax Virginia (1) Yes Washington (1) Yes (2) West Virginia (1) Yes Wisconsin 3.25 Yes Wyoming (1) Yes Dist. of Columbia 1.50 Yes 8% off- and 10% on-premise sales tax U.S. Median 3.30

Notes: 1. In 18 states, the government directly controls the sales of distilled spirits. Revenue in these states is generated from various taxes, fees and net liquor profits. 2. Sales tax is applied to on-premise sales only.

Source: Compiled by FTA from various sources.

National Conference of State Legislatures Appendices 119

Appendix I. State Wine Excise Tax Rates (as of Jan. 1, 2003)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied Alabama $1.70 Yes over 14% - sold through state store Alaska 2.50 N/A Arizona 0.84 Yes under 5% - $0.25/gallon; $0.05/case; and 3% off-premise and 10% on- Arkansas 0.75 Yes premise California 0.20 Yes sparkling wine - $0.30/gallon Colorado 0.32 Yes Connecticut 0.60 Yes over 21% and sparkling wine - $1.50/gallon Delaware 0.97 N/A over 17.259% - $3.00/gallon, sparkling wine $3.50/gallon 6.67¢/4 ounces on- Florida 2.25 Yes premise retail tax Georgia 1.51 Yes over 14% - $2.54/gallon; $0.83/gallon local tax Hawaii 1.36 Yes sparkling wine - $2.09/gallon and wine coolers - $0.84/gallon Idaho 0.45 Yes over 20% - $4.50/gallon; $0.30/gallon in Chicago and ($0.16-$0.30)/gallon Illinois 0.73 Yes in Cook County Indiana 0.47 Yes over 21% - $2.68/gallon Iowa 1.75 Yes under 5% - $0.19/gallon Kansas 0.30 No over 14% - $0.75/gallon; 8% off-premise and 10% on-premise Kentucky 0.50 Yes (1) 9% wholesale Louisiana 0.11 Yes 14% to 24% - $0.23/gallon, over 24% and sparkling wine - $1.59/gallon over 15.5% - sold through state stores, sparkling wine - $1.25/gallon; Maine 0.60 Yes additional 5% on-premise sales tax Maryland 0.40 Yes Massachusetts 0.55 Yes (1) sparkling wine - $0.70/gallon; Michigan 0.51 Yes over 16% - $0.76/gallon 14% to 21% - $0.95/gallon, under 24% and sparkling wine - $1.82/gallon; Minnesota 0.30 -- $0.01/bottle (except miniatures) and 9.0% sales tax Mississippi 0.35 Yes over 14% and sparkling wine - sold through the state Missouri 0.36 Yes Montana 1.06 N/A over 16% - sold through state stores Nebraska 0.75 Yes over 14% - $1.35/gallon Nevada 0.40 Yes 14% to 22% - $0.75/gallon, over 22% - $2.05/gallon New Hampshire (2) N/A New Jersey 0.70 Yes New Mexico 1.70 Yes over 14% - $6.06/gallon New York 0.19 Yes North Carolina 0.79 Yes over 17% - $0.91/gallon

National Conference of State Legislatures 120 Treatment of Alcohol and Other Substance Use Disorders

Appendix I. State Wine Excise Tax Rates (as of Jan. 1, 2003)— (continued)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied North Dakota $0.50 -- over 17% - $0.60/gallon, Sparkling wine - $1.00/gallon; 7% state sales tax over 14% - $1.00/gallon, vermouth - $1.10/gallon and sparkling wine - Ohio 0.32 Yes $1.50/gallon over 14% - $1.44/gallon, sparkling wine - $2.08/gallon; $1.00/bottle on- Oklahoma 0.72 Yes premise and 12% on-premise Oregon 0.67 N/A over 14% - $0.77/gallon Pennsylvania (2) Yes Rhode Island 0.60 Yes sparkling wine - $0.75/gallon South Carolina 0.90 Yes $0.18/gallon additional tax 14% to 20% - $1.45/gallon, over 21% and sparkling wine - $2.07/gallon; 2% South Dakota 0.93 Yes wholesale tax Tennessee 1.21 Yes $0.15/case and 15% on-premise. over 14% - $0.408/gallon and sparkling wine - $0.516/gallon; 14% on- Texas 0.20 Yes premise and $0.05/drink on airline sales Utah (2) Yes Vermont 0.55 Yes over 16% - sold through state store, 10% on-premise sales tax Virginia 1.51 Yes under 4% - $0.2565/gallon and over 14% - sold through state store Washington 0.87 Yes over 14% - $1.72/gallon West Virginia 1.00 Yes 5% local tax Wisconsin 0.25 Yes over 14% - $0.45/gallon Wyoming (2) Yes 8% off-premise and 10% on-premise sales tax, over 14% - $0.40/gallon and Dist. of Columbia 0.30 Yes Sparkling - $0.45/gallon. U.S. Median 0.60

Notes:

1. Sales tax is applied to on-premise sales only. 2. All wine sales are through state stores. Revenue in these states is generated from various taxes, fees and net profits.

Source: Compiled by FTA from various sources.

National Conference of State Legislatures Appendices 121

Appendix I. State Beer Excise Tax Rates (as of Jan. 1, 2003)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied Alabama $0.53 Yes $0.52/gallon local tax Alaska 1.07 N/A $0.35/gallon small breweries Arizona 0.16 Yes under 3.2% - $0.16/gallon; $0.008/gallon and 3% off-premise 10% on- Arkansas 0.23 Yes premise tax California 0.20 Yes Colorado 0.08 Yes Connecticut 0.19 Yes Delaware 0.16 N/A Florida 0.48 Yes $.0267/12 ounces on-premise retail tax Georgia 0.48 Yes $0.53/gallon local tax Hawaii 0.92 Yes $0.53/gallon draft beer Idaho 0.15 Yes over 4% - $0.45/gallon Illinois 0.185 Yes $0.16/gallon in Chicago and $0.06/gallon in Cook County Indiana 0.12 Yes Iowa 0.19 Yes over 3.2% - {8% off-premise and 10% on-premise}, under 3.2% - 4.25% sales Kansas 0.18 -- tax. Kentucky 0.08 Yes (1) 9% wholesale tax Louisiana 0.32 Yes $0.048/gallon local tax Maine 0.35 Yes additional 5% on-premise tax Maryland 0.09 Yes $0.2333/gallon in Garrett County Massachusetts 0.11 Yes (1) 0.57% on private club sales Michigan 0.20 Yes Minnesota 0.15 -- under 3.2% - $0.077/gallon, 9.0% sales tax Mississippi 0.43 Yes Missouri 0.06 Yes Montana 0.14 N/A Nebraska 0.23 Yes Nevada 0.09 Yes New Hampshire 0.30 N/A New Jersey 0.12 Yes New Mexico 0.41 Yes New York (2) 0.125 Yes $0.12/gallon in New York City North Carolina 0.53 Yes $0.48/gallon bulk beer North Dakota 0.16 -- 7% state sales tax, bulk beer $0.08/gal. Ohio 0.18 Yes

National Conference of State Legislatures 122 Treatment of Alcohol and Other Substance Use Disorders

Appendix I. State Beer Excise Tax Rates (as of Jan. 1, 2003)— (continued)

State/ Excise Tax Rates Sales Taxes Other Taxes Jurisdiction ($ Per Gallon) Applied Oklahoma $0.40 Yes under 3.2% - $0.36/gallon; $1.00/case on-premise and 12% on-premise Oregon 0.08 N/A Pennsylvania 0.08 Yes Rhode Island 0.10 Yes $0.04/case wholesale tax South Carolina 0.77 Yes South Dakota 0.27 Yes Tennessee 0.14 Yes 17% wholesale tax Texas 0.19 Yes over 4% - $0.198/gallon, 14% on-premise and $0.05/drink on airline sales Utah 0.35 Yes over 3.2% - sold through state store Vermont 0.265 No 6% to 8% alcohol - $0.55; 10% on-premise sales tax Virginia 0.26 Yes Washington 0.261 Yes West Virginia 0.18 Yes Wisconsin 0.06 Yes Wyoming 0.02 Yes Dist. of Columbia 0.09 Yes 8% off-premise and 10% on-premise sales tax U.S. Median 0.185

Notes: 1. Sales tax is applied to on-premise sales only. 2. Tax rate scheduled to decrease to 11.5 cents per gallon on Sept. 1, 2003.

Source: Compiled by FTA from various sources.

National Conference of State Legislatures Notes 123

NOTES

Chapter 1. What Are Alcohol and Other Substance Abuse Disorders?

1. News Advisory: Surgeon General Helps to Launch First Ever National Alcohol Screen- ing Day (Washington D.C.: National Institutes of Health, April 3, 1999).

2. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis- orders, Fourth Edition Text Revision (Washington, D.C.: APA, 2000).

3. U.S. Department of Health and Human Services, Alcohol and Health: Ninth Special Report to the U.S. Congress (Washington, D.C.: DHHS, June 1997), 337.

4. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis- orders, Fourth Edition Text Revision.

5. Dean R. Gerstein and Henrick J. Harwood, eds., Treating Drug Problems, vol. 1 (Washington, D.C.: National Academy Press, 1990), 59.

6. Ibid.

7. Ibid.

8. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Dis- orders, Fourth Edition Text Revision.

9. National Institutes of Health, National Institute on Drug Abuse, 25 Years of Dis- covery to Advance the Health of the Public (Bethesda, Md.: NIH, 1999).

10. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Summary of Findings from the 1998 National Household Survey on Drug Abuse (Washington, D.C.: DHHS, August 1999).

11. “NIDA InfoFacts: Science-Based Facts on Drug Abuse and Addiction, Understanding Drug Abuse and Addiction,” http://www.drugabuse.gov/Infofax/understand.html, Dec. 18, 2003.

12. Ibid.

National Conference of State Legislatures 123 124 Treatment of Alcohol and Other Substance Use Disorders

13. Ibid.

14. Ibid.

15. Ibid.

16. Ibid.

17. Ibid.

18. “Bringing the Power of Science to Bear on Drug Abuse and Addiction,” http:// www.drugabuse.gov/pubs/teaching/Teaching5/Teaching.html, Dec. 18, 2003.

19. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 7: This is Literally the Brain on Drugs,” http://www.drugabuse.gov/pubs/teaching/Teach- ing5/Teaching3.html, Dec. 18, 2003.

20. Ibid.

21. Ibid.

22. Ibid.

23. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 8: Long-term Effects of Drug Abuse,” http://www.drugabuse.gov/pubs/teaching/Teaching5/ Teaching3.html, Dec. 18, 2003.

24. Ibid.

25. Ibid.

26. Ibid.

27. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 9: Drugs Have Long-term Consequences,” http://www.drugabuse.gov/pubs/teaching/Teach- ing5/Teaching4.html, Dec. 18, 2003.

28. Ibid.

29. Ibid.

30. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 10: The Memory of Drugs,” http://www.drugabuse.gov/pubs/teaching/Teaching5/ Teaching4.html, Dec. 18, 2003.

31. Ibid.

32. Ibid.

National Conference of State Legislatures Notes 125

33. Ibid.

34. “Bringing the Power of Science to Bear on Drug Abuse and Addiction, Slide 14: Have You Changed Your Mind?,” http://www.drugabuse.gov/pubs/teaching/Teaching5/ Teaching5.html, Dec. 18, 2003.

35. Ibid.

36. Ibid.

37. A.D. Dager, et al., “Effects of Alcohol and Marijuana Use on fMRI Response in Adolescents,” Alcoholism: Clinical and Experimental Research 26, no. 5 (May 2002): 36A.

S.F. Tapert, et al., “fMRI BOLD response to alcohol stimuli in alcohol dependent young women,” Addictive Behaviors (in press).

S.F. Tapert, et al, “Neural response to alcohol stimuli in alcohol use disordered adolescents,” Archives of General Psychology 60 (2003): 727-735.

Chapter 2. What Are the Effects of Alcohol and Other Substance Use Disorders?

1. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap3, Dec. 18, 2003.

2. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, Dec. 18, 2003.

3. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap3, Dec. 18, 2003.

4. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, Dec. 18, 2003.

5. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap3, Dec. 18, 2003.

6. Ibid.

7. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, Dec. 18, 2003.

National Conference of State Legislatures 126 Treatment of Alcohol and Other Substance Use Disorders

8. Ibid.

9. “State Estimates of Substance Use from the 2000 National Household Survey on Drug Abuse: Volume I. Findings, 1.3. Format of Report and Presentation of Data,” http:/ /www.samhsa.gov/oas/2kState/PDF/Vol1/2kSAEv1W.pdf, Dec. 18, 2003.

10. Ibid.

11. “What Is Healthy People?,” http://www.healthypeople.gov/About/whatis.htm, Dec. 18, 2003.

12. Ibid.

13. “What Are Its Goals?,” http://www.healthypeople.gov/About/whatis.htm, Dec. 18, 2003.

14. “Fact Sheet,” http://www.healthypeople.gov/About/hpfact.htm, Dec. 18, 2003.

15. Healthy People 2010: Understanding and Improving Health (second edition, four- color version), “Substance Abuse: Leading Health Indicator,” http://www.healthypeople.gov/ Document/html/uih/uih_4.htm#subsabuse, Dec. 18, 2003.

16. Ibid.

17. Ibid.

18. “DATA2010 ... the Healthy People 2010 Database—October 2003 Edition— 10/20/03—10:16:57AM Focus area: 26-Substance Abuse,” http://wonder.cdc.gov/scripts/ broker.exe, Dec. 18, 2003.

19. Healthy People 2010: Understanding and Improving Health (second edition, four- color version), “Substance Abuse: Leading Health Indicator,” http://www.healthypeople.gov/ Document/html/uih/uih_4.htm#subsabuse, Dec. 18, 2003.

20. Ibid.

21. Ibid.

22. “National and State Estimates of Drug Abuse Treatment Gap, Chapter 3. Esti- mates of the Treatment Gap, by State,” http://www.samhsa.gov/oas/TXgap/chapter3.htm, Dec. 18, 2003.

23. Ibid.

24. Ibid.

25. Ibid.

26. “My Name is Jim, and I’m an Alcoholic,” http://www.alcoholics-anonymous.org/ default/en_about_aa_sub.cfm?subpageid=73&pageid=12, Dec. 18, 2003.

National Conference of State Legislatures Notes 127

27. Ibid.

28. Ibid.

29. Ibid.

30. Ibid.

31. Ibid.

32. Ibid.

33. Ibid.

34. Ibid.

35. Ibid.

36. Ibid., 20.

37. Ibid., 11.

38. “Children of Addicted Parents: Important Facts,” http://www.nacoa.net/pdfs/ addicted.pdf, Dec. 18, 2003.

Chapter 3. Why Should State Legislators Be Concerned About Alcohol and Other Substance Use Disorders?

1. Substance Abuse and Mental Health Services Administration, National Expendi- tures for Mental Health Alcohol and Other Drug Treatment (Washington, D.C.: SAMSHA, September 1998).

2. Center for Substance Abuse Treatment, Although the Costs of Increased Substance Abuse Benefits Are Low, the Advantages Are Significant (Washington D.C.: Office of Man- aged Care, Center for Substance Abuse Treatment, February 1999).

3. The National Institute on Drug Abuse and The National Institute on Alcohol Abuse and Alcoholism, The Economic Costs of Alcohol and Drug Abuse in the United States- 1992 (Washington D.C.: NIDA, NIAAA, 1992).

4. “Shoveling Up: The Impact of Substance Abuse on State Budgets,” http:// www.casacolumbia.org/publications1456/publications_show.htm?doc_id=47299, Dec. 18, 2003.

5. “Shoveling Up: The Impact of Substance Abuse on State Budgets,” http:// www.casacolumbia.org/usr_doc/47299a.pdf, Dec. 18, 2003.

6. Ibid.

National Conference of State Legislatures 128 Treatment of Alcohol and Other Substance Use Disorders

7. “Substance Abuse, Workplace Concerns,” http://www.drugfreeworkplace.gov/ SubstanceAbuse/SADefined/SBDefined.htm#Concerns, Dec. 18, 2003.

8. “Substance Abuse Prevention in Workplaces is Good Business,” http:// www.drugfreeworkplace.gov/WPResearch/CollaborativeResearch/GoodBusiness.pdf, Dec. 18, 2003.

9. Ibid.

10. Ibid.

11. Ibid.

12. Ibid.

13. Ibid.

14. Ibid.

15. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 8. Substance Dependence, Abuse, and Treatment,” http://www.samhsa.gov/oas/ nhsda/2k2nsduh/Results/2k2Results.htm#chap8, Dec. 18, 2003.

16. Ibid.

17. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, Dec. 18, 2003.

18. J.W. Langenbucher, B.S. McCrady, J. Brick, and R. Esterly, Socioeconomic Evalua- tions of Addictions Treatment (Piscataway, N.J.: Center of Alcohol Studies, Rutgers Univer- sity, 1994).

19. The National Organization on Fetal Alcohol Syndrome, NO FAS (Washington, D.C.: NOFAS, 1998).

20. Ibid.

21. Substance Abuse and Mental Health Services Administration, New National Study on Substance Use Among Women in the United States (Washington D.C.: SAMHSA, Septem- ber 22, 1997); http://www.samhsa.gov/press/97.

22. Substance Abuse Policy Research Program, Backgrounder on Substance Abuse Dur- ing Pregnancy (Winston-Salem, N.C.: SAPRP, August, 1998).

23. “Hepatitis C: What Clinicians and Other Health Professionals Need To Know, Transmission Modes, Injection and Other Illegal Drug Use,” http://www.cdc.gov/ncidod/ diseases/hepatitis/c_training/edu/1/epidem-trans-3.htm, Dec. 18, 2003.

National Conference of State Legislatures Notes 129

24. Ibid.

25. Ibid.

26. Ibid.

27. U.S. Centers For Disease Control and Prevention, Division of HIV/AIDS Preven- tion, Drug Associated HIV Transmission Continues in the United States (Atlanta: Ga.: CDCP, 1999).

28. National Association of State Alcohol and Drug Abuse Directors, National Dia- logue on Co-Occurring Mental Health and Substance Abuse Disorders (Washington, D.C.: NASADAD, 1998).

29. R.C. Kessler et al., “Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey,” Archives of General Psychiatry 51 (January 1994): 8-19.

30. “Alcohol: What You Don’t Know Can Harm You,” http://www.niaaa.nih.gov/publications/harm-al.htm, Dec. 18, 2003.

31. Ibid.

32. Ibid.

33. Ibid.

34. Ibid.

35. Ibid.

36. Ibid.

37. “NIDA InfoFacts: Crack and Cocaine,” http://www.drugabuse.gov/Infofax/ cocaine.html, Dec. 18, 2003.

38. “NIDA InfoFacts: Marijuana,” http://www.drugabuse.gov/Infofax/marijuana.html, Dec. 18, 2003.

39. Ibid.

40. Ibid.

41. “Alcohol: What You Don’t Know Can Harm You,” http://www.niaaa.nih.gov/publications/harm-al.htm, Dec. 18, 2003.

42. “NIDA InfoFacts: Crack and Cocaine,” http://www.drugabuse.gov/Infofax/ cocaine.html, Dec. 18, 2003.

National Conference of State Legislatures 130 Treatment of Alcohol and Other Substance Use Disorders

43. “NIDA InfoFacts: Marijuana,” http://www.drugabuse.gov/Infofax/marijuana.htm, Dec. 18, 2003.

44. “Detailed Emergency Department Tables from the Drug Abuse Warning Network 2001, Table 2.2—ED Drug Abuse Episodes: Episode Characteristics by Demographic Characteristics: Estimates, 2001,” http://dawninfo.samhsa.gov/pubs_94_02/edpubs/ 2001detailed/Tables/DT2001_2.2.xls, Dec. 18, 2003.

45. Ibid.

46. National Institute of Justice, ADAM 1999: Annual Report on Drug Use Among Adult and Juvenile Arrestees (Washington, D.C.: U.S. Department of Justice, 2000). De- scriptions of the ADAM program and links to the latest publications and data, are at http: //www.adam-nj.net.

47. M. Mauer and M. Chesney-Lind, eds., “Introduction,” (In M. Mauer & M. Chesney-Lind (Eds.), Invisible Punishment: The Collateral Consequences of Mass Imprison- ment (pp. 1-12). New York: The New Press, 2001).

48. Bureau of Justice Statistics, Number of Persons in Custody of State Correctional Au- thorities by Most Serious Offense, 1980-1999 (Washington, DC: U.S. Department of Justice, 2002).

49. M. Mauer, Americans Behind Bars: U.S. and International Use of Incarceration, 1995 (Washington, D.C.: The Sentencing Project, 1997).

50. R.J. MacCoun and P. Reuter, Drug War Heresies (New York: Cambridge University Press, 2001).

51. M. Tonry, Malign Neglect: Race, Crime, and Punishment in America (New York: Oxford University Press, 1995).

52. Bureau of Justice Statistics, Number of Persons in Custody of State Correctional Au- thorities by Most Serious Offense, 1980-1999 (Washington, D.C.: U.S. Department of Jus- tice, 2002).

53. J.P. Lynch and W.J. Sabol. “Prison use and social control,” In J. Horney (ed.), Criminal Justice 2000: Policies, Processes, and Decisions of the Criminal Justice System (Wash- ington, D.C.: U.S. Department of Justice, National Institute of Justice, 2000), 7-44.

54. Bureau of Justice Statistics, Prisoners in 2002 (Washington, D.C.: U.S. Depart- ment of Justice, 2003).

55. C. Haney and P. Zimbardo. “The Past and Future of U.S. Prison Policy: Twenty- Five Years After the Stanford Prison Experiment” American Psychologist 53 (1999): 711- 720.

56. T.P. Bonczar and A.J. Beck, Lifetime Likelihood of Going to State or Federal Prison (Washington, D.C.: U.S. Department of Justice, Bureau of Justice Statistics, 1997).

National Conference of State Legislatures Notes 131

57. Mauer, 1999.

58. Human Rights Watch, Punishment and Prejudice: Racial Disparities in the War on Drugs (New York: Human Rights Watch, 2000).

59. T. Clear, “The Problem with ‘Addition by Subtraction:’ The Prison-Crime Rela- tionship in Low-Income Communities,” In M. Mauer and M. Chesney-Lind (eds.), Invis- ible Punishment: The Collateral Consequences of Mass Imprisonment (New York: The New Press, 2001): 181-194.

60. D.T. Courtwright, “The Drug War’s Hidden Toll,” Issues in Science and Technology 14 (1996): 69-78.

61. B. Bloom and D. Steinhart, Why Punish the Children? (San Francisco, Calif.: Na- tional Council on Crime and Delinquency, 1993).

62. J. Fellner and M. Mauer, Losing the Vote: The Impact of Felony Disenfranchisement Laws in the United States (New York: The Sentencing Project and Human Rights Watch, 1998).

63. Clear, 2001; Mauer, 1999.

64. J. Travis, “Invisible Punishment: An Instrument of Social Exclusion,” in M. Mauer and M. Chesney-Lind (eds.), Invisible Punishment: The Collateral Consequences of Mass Im- prisonment (New York: The New Press, 2001): 15-36.

65. “CASAWORKS for Families: A Promising Approach to Welfare Reform and Sub- stance-Abusing Women,” http://www.casacolumbia.org/usr_doc/68773.pdf, Dec. 18, 2003.

66. S.P. Baker, B. O’Neill, and R.S. Karpf, The Injury Fact Book, 2nd edition (New York, N.Y..: Oxford University Press, 1992), as referenced in DHHS, Alcohol and Health, 254.

67. R. Hingson and J. Howland, “Alcohol and Non-traffic Unintended Injuries,” Ad- diction 88, no. 7 (1993): 877-883, as referenced in DHHS, Alcohol and Health, 254.

68. S. P. Baker, et al., Injury Fact Book, 254.

69. Hingson and Howard, “Unintended Injuries,” 254.

70. U.S. Department of Transportation, National Highway Traffic Safety Administra- tion, Traffic Safety Facts 1998: Alcohol (Washington, D.C.: NHTSA, 1998).

71. Ibid.

72. L. Hayward, S.R. Zubrick and S. Silburn, “Blood Alcohol Levels in Suicide Cases“ Journal of Epidemiol Community Health 46, no. 3 (1992): 256-260, as referenced in DHHS, Alcohol and Health, 259.

73. Martha R. Burt et al., Homelessness: Programs and the People They Serve, 24.

National Conference of State Legislatures 132 Treatment of Alcohol and Other Substance Use Disorders

74. Ibid., 48.

75. National Coalition for the Homeless, Addiction Disorders and Homelessness, Fact Sheet 6 (Washington, D.C.: NCH, 1999).

76. U.S. Department of Justice. Alcohol and Crime: An Analysis of National Data on the Prevalence of Alcohol Involvement in Crime (Washington, D.C.: DOJ, 1998).

77. “Substance Abuse Treatment and Domestic Violence: Treatment Improvement Protocol (TIP) Series 25, Executive Summary and Recommendations,” http:// ncadi.samhsa.gov/govpubs/BKD239/25c.aspx, Dec. 18, 2003.

78. Nancy K. Young; Sidney L. Gardner, and Kimberly Dennis, Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Washington, D.C.: Child Welfare League of America, 1998).

79. National Association for Children of Alcoholics, Children of Alcoholics: Important Facts (Rockville, Md.: NACOA, 1999).

80. Ibid.

81. National Center on Addiction and Substance Abuse at Columbia University, Sur- vey of Child Welfare Professionals (New York, N.Y.: CASA, 1997).

82. Ibid.

83. Department of Justice, Alcohol and Crime.

84. M. Mauer, Race to Incarcerate (New York: The New Press, 1999).

85. J.J. Donohue and P. Siegelman, “Allocating Resources Among Prisons and Social Programs in the Battle Against Crime,” Journal of Legal Studies 27 (1998): 30-43.

Chapter 4. What Strategies Are Available for the Treatment of Alcohol and Other Substance Use Disorders?

1. National Institutes of Health, National Institute on Drug Abuse, 25 Years of Dis- covery to Advance the Health of the Public (Bethesda, Md.: NIH, 1999), vii.

2. DHHS, Alcohol and Health, chapter 2.

3. National Institutes of Health, 25 Years of Discovery, 13.

4. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 4-Screening and Assessment,” http:// www.treatment.org/Taps/Tap11/tap11chap4.html, Dec. 18, 2003.

5. “Principles of Drug Addiction Treatment, Principles of Effective Treatment,” http://www.nida.nih.gov/PODAT/PODAT1.html, Dec. 18, 2003.

National Conference of State Legislatures Notes 133

6. “Principles of Drug Addiction Treatment: A Research Based Guide,” http:// www.nida.nih.gov/PODAT/PODAT2.html, Dec. 18, 2003.

7. “Treatment Improvement Protocol Series, CSAT TIPs,” http://www.treatment.org/ Externals/tips.html, Dec. 18, 2003.

8. Ibid.

9. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 5-The Importance of Patient-Treat- ment Matching,” http://www.treatment.org/Taps/Tap11/tap11chap5.html, Dec. 18, 2003.

10. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 1-Who Needs Treatment: An Over- view of Addiction and Its Treatment, Recovery,” http://www.treatment.org/Taps/Tap11/ tap11chap1.html#recovery, Dec. 18, 2003.

11. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 4-Screening and Assessment,” http:// www.treatment.org/Taps/Tap11/tap11chap4.html, Dec. 18, 2003.

12. Ibid.

13. Ibid.

14. States and jurisdictions with laws that give insurers the option to deny medical reimbursements to patients under the influence of alcohol are Alabama, Alaska, Arizona, Arkansas, California, Delaware, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Mississippi, Missouri, Montana, Nebraska, Nevada, New Jersey, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Virginia, Washington, West Virginia, Wyoming and the District of Co- lumbia; states with laws that give insurers the option to deny medical reimbursements to patients under the influence of narcotics are Minnesota, New York, Oklahoma and South Dakota; states that have repealed laws are Maryland, North Carolina and Vermont.

15. Ibid.

16. “Patient Placement Criteria, Second Edition Revised,” http://www.asam.org/ppc/ ppc2.htm, Dec. 18, 2003.

17. Ibid.

18. Ibid.

19. Ibid.

20. National Institutes of Health, National Institute on Drug Abuse, Principles of Drug Addiction Treatment (Rockville, Md.: NIH, October 1999), FAQ section.

21. Ibid.

National Conference of State Legislatures 134 Treatment of Alcohol and Other Substance Use Disorders

22. DHHS, Alcohol and Health, 348–350.

23. Office of the National Drug Control Policy, The National Drug Control Strategy, 1999 (Washington D.C.: ONDCP, 1999) 61.

24. Ibid., 61.

25. U.S. Department of Health and Human Services, The National Institutes on Drug Abuse, Infofax Treatment Methods (Washington, D.C.: DHHS, 1999).

26. Department of Health and Human Services, Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination (Washington, D.C.: DHHS, 1994).

27. Institutes of Medicine, Treating Drug Problems, Volume 1-A Study of the Evolution, Effectiveness, and Financing of Public and Private Drug Treatment Systems (PLACE, PUB- LISHER, 1990), 10-11.

28. “Compulsory Treatment of Drug Abuse: Research and Clinical Practice, NIDA Research Monograph Series 86,” http://165.112.78.61/pdf/monographs/86.pdf, Dec. 18, 2003.

29. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Detoxification From Alcohol and Other Drugs Treatment Improve- ment Protocol (TIP) Series 19 (Rockville, Md.: SAMHSA, 1995), chapters 1 and 3.

30. Margaret A.E. Jarvis, Michael F. Weaver, and Sidney H. Schnoll, Role of the Primary Care Physician in Problems of Substance Abuse (vol. 159, no. 9) (Chicago, Ill.: American Medical Association, May 1999).

31. Therapeutic Communities of America, TCA News, Therapeutic Communities of America, About TCA (Washington, D.C.: TCA, 1999).

32. Ibid., 2.

33. R.L. Hubbard et al., “Overview of 1-year Follow-up Outcomes in the Drug Abuse Treatment Outcome Study (DATOS),” Psychology of Addictive Behaviors 11, no. 4 (1997): 261-278.

34. Margaret A.E. Jarvis, Michael F. Weaver, and Sidney H. Schnoll, Role of the Primary Care Physician in Problems of Substance Abuse.

35. Ibid.

36. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 9-Relapse Prevention,” http:// www.treatment.org/Taps/Tap11/tap11chap9.html, Dec. 18, 2003.

37. Ibid.

National Conference of State Legislatures Notes 135

38. Ibid.

39. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 3-Causes of Addiction and Modalities for Treatment, Treatment Components,” http://www.treatment.org/Taps/Tap11/ tap11chap3.html#components, Dec. 18, 2003.

40. Ibid.

41. Ibid.

42. Ibid.

43. Ibid.

44. Ibid.

45. Ibid.

46. Ibid.

47. Ibid.

48. Ibid.

49. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 6-Special Populations, Juveniles,” http://www.treatment.org/Taps/Tap11/tap11chap6.html#juveniles, Dec. 18, 2003.

50. Ibid.

51. Ibid.

52. Ibid.

53. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 3. Alcohol Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap3, Dec. 18, 2003.

54. DHHS, Alcohol and Health, 251-253.

55. The National Center on Addiction and Substance Abuse at Columbia University, Substance Abuse and The American Woman (New York, N.Y.: CASA, June 1996), vi.

56. DHHS, Alcohol and Health, 137.

57. Ibid., 22.

National Conference of State Legislatures 136 Treatment of Alcohol and Other Substance Use Disorders

58. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, Dec. 18, 2003.

59. Dan Steinberg and Shelly Gehshan, State Responses to Maternal Drug and Alcohol Use: An Update (Washington D.C.: National Conference of State Legislatures, 2000).

60. Ibid.

61. State of Wisconsin, Office of the Governor, New Law Protects Unborn Babies From Alcohol and Cocaine Abuse (June 16, 1998).

62. Wisconsin Legislative Reference Bureau, Unborn Children in Need of Protection (Brief 98-9) (Madison: Wisconsin Legislative Reference Bureau, June 1998).

63. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Substance Abuse Among Older Adults (Washington, D.C.: DHHS, 1998), executive summary and chapter 1.

64. DHHS, Alcohol and Health, 24.

65. “Results from the 2002 National Survey on Drug Use and Health (NSDUH), Chapter 2. Illicit Drug Use,” http://www.samhsa.gov/oas/nhsda/2k2nsduh/Results/ 2k2Results.htm#chap2, December 18, 2003.

66. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Substance Abuse Among Older Adults (Washington, D.C.: DHHS, 1998), chapter 1.

67. The National Center on Addiction and Substance Abuse at Columbia University, Under the Rug: Substance Abuse and The Mature Woman (New York, N.Y.: CASA, June 1998), 3-5.

68. “Treatment for Alcohol and Other Drug Abuse: Opportunities for Coordination, Technical Assistance Publication Series 11, Chapter 6-Special Populations, Ethnic and Racial Minority Populations,” http://www.treatment.org/Taps/Tap11/tap11chap6.html#ethnic, Dec. 18, 2003.

69. Ibid.

70. Ibid.

71. Ibid.

72. Ibid.

73. Ibid.

74. Ibid.

National Conference of State Legislatures Notes 137

75. Ibid.

76. Ibid.

77. Ibid.

78. Ibid.

79. Ibid.

80. Ibid.

81. Ibid.

82. Ibid.

83. Ibid.

84. Ibid.

85. Ibid.

86. Ibid.

87. Ibid.

88. North Central Regional Educational Laboratory, Human Services Coordination: Who Cares? (Policy Briefs, Report No. 1) (Oak Brook, Ill.: Evaluation and Policy Information Center of NCREL, 1996).

89. D.C. McBride, Curtis J. VanderWaal, Yvonne M. Terry, and Holly VanBuren, Breaking the Cycle of Drug Abuse Among Juvenile Offenders, Office of Juvenile Justice and Delin- quency Prevention (November 1999).

90. NCREL, 1996.

91. D. Bailey and K. Koney, “Interorganizational Community-Based Collaboratives: A Strategic Response to Shape the Social Work Agenda,” Social Work 41 (1996): 602-611.

92. See National Institute on Drug Abuse, Principles of Drug Addiction Treatment: A Research-Based Guide (Washington, D.C.: National Institutes of Health, 1999); (see also National Institute of Justice, Case Management in the Criminal Justice System: Research in Action (Washington, D.C.: NIJ, 1999); see also A.H. Crowe and R. Reeves, 1994.

93. Office of Juvenile Justice and Delinquency Prevention, 1999. Citing others.

94. Office of Juvenile Justice and Delinquency Prevention, Duane C. McBride, Curtis J. VanderWaal, Yvonne M. Terry, and Holly VanBuren, November 1999.

National Conference of State Legislatures 138 Treatment of Alcohol and Other Substance Use Disorders

95. NIJ, 1999.

96. A.T. McLellan and James R. McKay, “Components of Successful Treatment Pro- grams: Lessons from the Research Literature,” in Allen W. Graham and Terry K. Schultz (eds.), (1998) Principles of Addiction Medicine (Chevy Chase, Md.: American Society of Addiction Medicine Inc., 1998).

97. See NIDA, 1999.

98. Also known as the Drug Medicalization, Prevention and Control Act of 1996; see Arizona Revised Statutes section 13-901.01 et. seq.

99. Known as the Substance Abuse Crime and Prevention Act of 2000; see www.adp.ca.gov for additional information.

100. See Illinois Compiled Statutes, Chapter 20, section 301/40-5 et. seq.

101. For more information about drug courts and related materials, see the National Association of Drug Court Professional/National Drug Court Institute, at www.ndci.org.

102. For more information about the TASC model and TASC programs around the country, see the National Association of TASC Programs, at www.nationaltasc.org.

103. A. Harrell, O. Mitchel, A. Hirst, D. Marlowe and J. Merrill, “Breaking the Cycle of Drugs and Crime: Findings from the Birmingham BTC Demonstration” Crimi- nology & Public Policy 1, no. 2 (2002): 189-216.

104. For general information on therapeutic communities, see Therapeutic Commu- nities of America, Therapeutic Communities in Correctional Settings: The Prison Based TC Standards Development Project, Final Report of Phase II (Washington D.C.: The White House Office of National Drug Control Policy, 1999).

105. G. Melnick, G. De Leon, G. Thomas, D. Kressel and H.K. Wexler, “Treatment Process in Prison Therapeutic Communities: Motivation, Participation and Outcome,” American Journal of Drug and Alcohol Abuse 27, no. 4 (2001): 633-50.

106. H.K. Wexler, G. Melnick, L. Lowe and J. Peters, “Three-Year Reincarceration Outcomes for Amity In-Prison Therapeutic Community and Aftercare in California,” The Prison Journal 79, no. 3 (1999).

107. California. A National Institute of Drug Abuse (NIDA)-funded study evaluated outcomes for inmates who participated in nine to 12 months of TC programming operated by a private agency in a 200-bed unit at the R. J. Donovan Correctional Facility in San Diego. Upon completion of the TC in the prison, graduates could participate in a TC treatment program for up to one year in a community-based facility that included services for the residents’ wives and children. The recidivism rate at 36 months for those who completed the aftercare component was 27 percent versus 75 percent for other groups. Texas. In the Texas model, inmates participated in a 500-bed, nine-month modified TC in Kyle, Texas. Following in-prison TC treatment (ITC), offenders are paroled and transferred to a community-based residential facility near to their home city where they

National Conference of State Legislatures Notes 139

continue to participate in TC programming for three months. The transitional centers use a work-release model and are designed to reintegrate the offender into the community, while providing ongoing treatment support. Following their stay in the transitional center, the men are required to participate in up to one year of outpatient counseling. The study found that “return rates for ITC treated and untreated offenders were not significantly different (41 percent vs. 42 percent, respectively). However, it was found that 25 percent of the aftercare completers were returned to custody, significantly less than the rate for the comparison group” Delaware. This 1997 study showed that offenders who received TC treatment both in prison and in the work release center did “by far the best in terms of avoiding relapse and recidivism” in a one-year follow-up. The NIDA and NIJ-funded three-year follow-up study showed that clients who also participated in the community aftercare outpatient program did even better in remaining arrest- and drug-free. After three years, the non-treatment group had re-arrest rates of 71 percent, those who completed the prison and work release programs had a re-arrest rate of 45 percent, and those who completed all three steps, including the community aftercare, had a re-arrest rate of only 31 percent.

108. National Institute of Justice, Breaking the Cycle of Drug Use Among Juvenile Of- fenders (Washington, D.C.: NIJ, November 1999), 46.

109. Ibid., 50.

110. Ibid., 56.

111. U.S. Department of Justice, Juvenile Offenders and Victims: 1999 National Report (Washington D.C.: DOJ, 1999), 152.

112. NIJ, Breaking the Cycle of Drug Use Among Juvenile Offenders, 35.

113. Ibid., 47-48.

114. Ibid., 49.

115. Ibid.

116. National Association of State Alcohol and Drug Abuse Directors, National Dia- logue on Co-Occurring Mental Health and Substance Abuse Disorders (Washington, D.C.: NASADAD, 1998).

117. NASMHPD and NASADAD, National Dialogue on Co-Occurring Mental Health and Substance Abuse Disorders (Alexandria, Va., and Washington, D.C.: NASMHPD and NASADAD, March 1999).

118. “Developing State Outcomes Monitoring Systems for Alcohol and Other Drug Abuse Treatment: Treatment Improvement Protocol (TIP) Series 14, Chapter 6-Legal Is- sues in Outcomes Monitoring, Overview of the Federal Confidentiality Laws,” http:// www.treatment.org/Externals/Tip-14/tip-14ch6.htm#_ch6a, Dec. 18, 2003.

119. Ibid.

National Conference of State Legislatures 140 Treatment of Alcohol and Other Substance Use Disorders

120. Ibid.

121. Ibid.

122. Ibid.

123. Ibid.

124. Ibid.

125. Ibid.

126. Ibid.

127. Ibid.

128. Ibid.

129. Ibid.

130. Ibid.

Chapter 5. What Funding Is Available for States to Provide Services to People Affected by Alcohol and Other Substance Use Disorders?

1. “National Estimates of Expenditures for Substance Abuse Treatment,” http:// www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.

2. Ibid.

3. National Conference of State Legislatures, Health Policy Tracking Service, Issue Brief: Parity and Other Insurance Mandates for the Treatment of Mental Illness and Substance Abuse (Washington, D.C.: NCSL, 2003), v.

4. Ibid.

5. “Parity in Mental Health and Substance Abuse Coverage: Expanding Health Ben- efit Opportunities for Federal Employees,” http://www.opm.gov/insure/mental/html/ parity.htm, Dec. 18, 2003.

6. U.S. Department of Health and Human Services, Blending Perspectives and Build- ing Common Ground: A Report to Congress on Substance Abuse and Child Protection (Wash- ington, D.C.: DHHS, April 1999), appendix C.

7. “Substance Abuse Prevention and Treatment Block Grant,” http://www.samhsa.gov/ budget/content/2004/2004budget-14a.htm, Dec. 18, 2003.

National Conference of State Legislatures Notes 141

8. “SAMHSA Proposes Change in Block Grants: Comments Sought on Performance Partnership Plans,” http://www.samhsa.gov/news/newsreleases/021219nr_perfpartners.htm, Dec. 18, 2003.

9. Ibid.

10. Ibid.

11. Ibid.

12. Ibid.

13. Ibid.

14. “PUBLIC LAW 102–321, Subpart II, Block Grants for Prevention and Treatment of Substance Abuse, Sec. 1930. Maintenance of Effort Regarding State Expenditures, Sec. 1930. Maintenance of Effort Regarding State Expenditures,” http://www.treatment.org/ legis/pl102sc1.html#Sec1930, Dec. 18, 2003.

15. Ibid.

16. Ibid.

17. “Developing Competitive SAMHSA Grant Applications, Participant Manual, April 2003, Glossary of Terms,” http://www.samhsa.gov/grants/TAManual/TAmanual_frame. html, Dec. 18, 2003.

18. “Developing Competitive SAMHSA Grant Applications, Participant Manual, April 2003, Module 1: Know SAMHSA and Its Centers, SAMHSA Organization Chart,” http:/ /www.samhsa.gov/grants/TAManual/TAmanual_frame.htm, Dec. 18, 2003.

19. “SAMHSA Grants Snapshot, A Word From The Administrator,” http:// www.samhsa.gov/grants/content/snapshot/intro.html, Dec. 18, 2003.

20. Ibid.

21. ”Medicaid Enrollment and Beneficiaries: Selected Fiscal Years,” http:// www.cms.hhs.gov/researchers/pubs/datacompendium/2002/02pg34.pdf, Dec. 18, 2003.

22. “U.S. Census Bureau: Population Estimates,” http://eire.census.gov/popest/data/ states/ST-EST2002-ASRO-01.php, Dec. 18, 2003.

23. “National Estimates of Expenditures for Substance Abuse Treatment,” http:// www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.

24. “Medicaid Services,” http://www.cms.gov/medicaid/mservice.asp, December 18, 2003.

National Conference of State Legislatures 142 Treatment of Alcohol and Other Substance Use Disorders

25. U.S. Department of Health and Human Services, Health Care Financing Admin- istration, Brief Summaries of Medicare and Medicaid, July 31, 1997, www.hcfa.gov/pubforms/ mmsum1.htm, Dec. 18, 2003.

26. U.S. Department of Health and Human Services, Health Care Financing Adminis- tration, National Summary of Medicaid Managed Care Programs and Enrollment (Washing- ton, D.C.: DHHS, June 30, 1998), http://www.hcfa.gov/medicaid/trends98.htm.

27. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Managed Care Tracking System (Washington D.C.: DHHS, July 1998), section V.

28. Ibid.

29. Ibid.

30. U.S. Department of Health and Human Services, Health Care Financing Admin- istration and Administration for Children and Families, Supporting Families in Transition: A Guide to Expanding Health Coverage in the Post-Welfare Reform World (Washington, D.C.: DHHS, 1999).

31. “Window of Opportunity for Welfare Reform,” State Legislatures (National Confer- ence of State Legislatures) (April 1999).

32. H. Westley Clark, The Children’s Health Insurance Program: Are Substance Abuse Treatment Services For Youth Really Optional? (Washington D.C.: Center for Substance Abuse Treatment, 1999).

33. Shelly Geshan, Substance Abuse Treatment in State Children’s Health Insurance Pro- grams.

34. “Medicaid and EPSDT,” http://cms.hhs.gov/medicaid/epsdt/default.asp, Dec. 18, 2003.

35. DHHS, Substance Abuse Among Older Adults, chapter 1.

36. DHHS, Brief Summaries of Medicare and Medicaid.

37. U.S. Department of Health and Human Services Health Care Financing Adminis- tration, HCFA Statistics: Highlights, www.hcfa.gov/stats/hstats98/highli98.htm, Dec. 18, 2003.

38. “National Estimates of Expenditures for Substance Abuse Treatment,” http:// www.samhsa.gov/centers/csat/content/idbse.htm, Dec. 18, 2003.

39. “Answers to Your Questions, What is Supplemental Security Income (SSI)?” http://ssa-custhelp.ssa.gov/cgi-bin/ssa.cfg/php/enduser/std_adp.php?p_sid=z-U- *NOg&p_lva=&p_faqid=93&p_created=955552221&p_sp=cF9zcmNoPTEmcF9ncmlkc29ydD0mc F9yb3dfY250PTM1JnBfY2F0X2x2bDE9NDgmcF9jYXRfbHZsMj1_YW55fiZwX3BhZ2U 9MQ**&p_li=, Dec. 18, 2003.

National Conference of State Legislatures Notes 143

40. “Answers to Your Questions, What kind of disability benefits does Social Security pay?”http://ssa-custhelp.ssa.gov/cgi-bin/ssa.cfg/php/enduser/ std_adp.php?p_sid=g2Bi2OOg&p_lva=&p_faqid=153&p_created=955633203&p_sp=cF9zcm NoPTEmcF9ncmlkc29ydD0mcF9yb3dfY250PTI4JnBfc2VhcmNoX3RleHQ9JnBfc2Vhcm NoX3R5cGU9MyZwX2NhdF9sdmwxPTEwNSZwX2NhdF9sdmwyPTg4JnBfcGFnZT0x&p_li=, Dec. 18, 2003.

41. “Green Book—Section 11. Child Protection, Foster Care, and Adoption Assis- tance, Federal Waivers of Title IV-B and IV-E Provisions,” http://www.acf.hhs.gov/programs/cb/dis/tables/sec11gb/waivers.htm, Dec. 18, 2003.

42. Ibid.

43. Executive Office of the President, Responding to Drug Use and Violence: A Directory and Resource Guide of Public- and Private-Sector Drug Control Grants, The Safe and Drug-Free Schools and Communities State Grants Program (Washington D.C.: EOP, 1997).

44. “Safe and Drug-Free Schools State Formula Grants,” http://www.ed.gov/programs/ dvpformula/index.html, Dec. 18, 2003.

45. “Safe and Drug-Free Schools Governors’ Grants,” http://www.ed.gov/programs/ dvpgovgrants/index.html, Dec. 18, 2003.

46. U.S. Department of Justice, Office of Justice Programs/Corrections Program Of- fice, Residential Substance Abuse Treatment for State Prisoners FY 1999 Program Guidance and Application Kit (Washington D.C.: DOJ, 1999).

47. Office of National Drug Control Policy, Drug Free Communities Grant Program, November 1998, http://www.whitehousedrugpolicy.gov/prevent/support.html, Dec. 18, 2003.

48. “Programs, Edward Byrne Memorial State and Local Law Enforcement Assistance (Byrne Formula Grant Program),” http://www.ojp.usdoj.gov/BJA/grant/byrne.html, Dec. 18, 2003.

49. Ibid.

50. “Programs, Drug Court Discretionary Grant Program,” http://www.ojp.usdoj.gov/ BJA/grant/drugcourts.html, Dec. 18, 2003.

51. Ibid.

52. “Reentry: Serious and Violent Offender Reentry Initiative,” http:// www.ojp.usdoj.gov/BJA/grant/reentry.html, Dec. 18, 2003.

53. Ibid.

National Conference of State Legislatures 144 Treatment of Alcohol and Other Substance Use Disorders

54. U.S. Department of Housing and Urban Development, Funding Availability for the Public Housing Drug Elimination Program, www.hud.gov/nofa/suprnofa/supnofa1/ 4340sec10.html, Dec. 18, 2003.

55. U.S. Navy, TRICARE, www.ndw.navy.mil/html/tricare.html, Dec. 18, 2003.

National Conference of State Legislatures