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

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director

Center for Substance Abuse TreatmentSubstance Abuse Mental Health Services

AdministrationU.S. Department of Health & Human Services

““The Ripple Effect of Substance The Ripple Effect of Substance Abuse on Family and Community”Abuse on Family and Community”

October 29, 2008Mandan, ND

North Dakota Conference on Injury Prevention & Control

North Dakota Conference on Injury Prevention & Control

2

President George W. BushSeptember 2003

“Alcohol addiction and drug addiction continue to challenge our Nation. Addiction to alcohol or

drugs destroys family ties, friendship, ambition, and

moral conviction, and reduces the richness of

life to a single destructive desire.”

Substance Abuse and Mental Health Substance Abuse and Mental Health Services Administration/CSATServices Administration/CSAT

Substance Abuse and Mental Health Substance Abuse and Mental Health Services Administration/CSATServices Administration/CSAT

SAMHSA’s Mission: • To build resilience and facilitate recovery for

people with or at risk for substance abuse and mental illness.

Center for Substance Abuse Treatment (CSAT) Mission:

• To improve the health of the nation by bringing effective alcohol and drug treatment to every community.

4

The Impact of AddictionThe Impact of AddictionThe Impact of AddictionThe Impact of Addiction

• Addiction impacts an individual’s behavior, health, thinking process, quality of life, and overall functioning.

• Alcohol & other drugs are powerful reinforcing psychoactive substances that take on a life of their own.

5

SAMHSA’s Role in Supporting Recovery SAMHSA’s Role in Supporting Recovery from Substance Use Problems & from Substance Use Problems &

DisordersDisorders

SAMHSA’s Role in Supporting Recovery SAMHSA’s Role in Supporting Recovery from Substance Use Problems & from Substance Use Problems &

DisordersDisorders• SAMHSA works to ensure that science, rather

than ideology or anecdote, forms the foundation for the Nation’s addiction treatment system.

• SAMHSA serves health professionals and the public by disseminating scientifically sound, clinically relevant information on best practices in the treatment of addictive disorders and by working to enhance public acceptance of that treatment.

SAMHSA/CSAT’s Public Health SAMHSA/CSAT’s Public Health ApproachApproach

SAMHSA/CSAT’s Public Health SAMHSA/CSAT’s Public Health ApproachApproach

• Population-based

• Comprehensive and holistic

• Incorporates early intervention, treatment, recovery support, and health promotion

• Works across systems and professions

• Involves people in recovery, the community, the public and private sectors

• Evidence-based

7

We Face Multiple ChallengesWe Face Multiple ChallengesWe Face Multiple ChallengesWe Face Multiple Challenges

• Reaching those in need of services

• Providing adequate resources

• Developing culturally-appropriate, evidence-based interventions

• Building and sustaining a qualified workforce

• Integrating substance use disorder services into the public health paradigm

8

Greater Burden on Public SectorGreater Burden on Public SectorGreater Burden on Public SectorGreater Burden on Public Sector

50%

50%

Source: Health Affairs, July-August 2007

77%

23%

1986 All SA = $9.3BPublic = $4.6 BPrivate = $4.6 B

2003 All SA = $20.7 BPublic = $16.0 BPrivate = $4.7 B

Private

Private

Public Public

Projections indicate that the burden on the

public sector will continue to increase

A Greater Burden & Tighter BudgetsA Greater Burden & Tighter BudgetsA Greater Burden & Tighter BudgetsA Greater Burden & Tighter Budgets

At the same time that a larger percentage of substance abuse treatment costs are being placed on the public sector, states are facing tighter budgets:

• According to the Center on Budget and Policy Priorities, 2929 states face budget shortfalls in

2009 – ranging from $59 Million to $22.2 Billion.

• Funds need to be used effectively for programs that can show evidence of their success

• All of these factors make the challenges facing treatment providers even more difficult.

The Challenges RemainThe Challenges RemainThe Challenges RemainThe Challenges Remain

• Despite tightening budgets and changing populations, the challenges of alcohol and substance abuse remain. According to the 2007 National Survey on Drug Use and Health (NSDUH):– In 2007, an estimated 19.9 million Americans

aged 12 or older were current (past month) illicit drug users.

– Slightly more than half of Americans (12 and older) reported being current drinkers of alcohol – more than a fifth of them participated in binge drinking at least once in the 30 days prior to the 2007 survey.

Drug AbuseDrug Abuse

Past Month Use of Specific Illicit Drugs Past Month Use of Specific Illicit Drugs among Persons Aged 12 or Older: among Persons Aged 12 or Older:

2002-20072002-2007

Past Month Use of Specific Illicit Drugs Past Month Use of Specific Illicit Drugs among Persons Aged 12 or Older: among Persons Aged 12 or Older:

2002-20072002-2007

8.0%

5.8%

2.8%2.1%

0.8%0.2%0%

1%

2%

3%

4%

5%

6%

7%

8%

9%

2002 2003 2004 2005 2006 2007

Pe

rce

nt

Us

ing

in

Pa

st

Mo

nth

Illicit Drugs Marijuana Psychotherapeutics

Pain Relievers Cocaine Methamphetamine

Source: NSDUH, 2007

Past Month Nonmedical Use of Prescription Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons Drugs (Psychotherapeutics) among Persons

12+: 2002-200712+: 2002-2007

Past Month Nonmedical Use of Prescription Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons Drugs (Psychotherapeutics) among Persons

12+: 2002-200712+: 2002-2007Percent Using in Past Month

+ Difference between this estimate and the 2006 estimate is statistically significant at the .05 level.

0.5

0.2

0.8

0.5

0.1

0.8

0.5

0.1

0.7

0.4

0.1

0.7

2.1

0.5

0.2

0.7

1.9+2.0

1.8+1.9

0.1

0.4

0.7

2.1

0

1

2

Pain Relievers Stimulants Sedatives Tranquilizers

2002 2003 20042005 2006 2007

Source Where Pain Relievers Were Obtained Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past for Most Recent Nonmedical Use among Past

Year Users Aged 12 or Older: 2007Year Users Aged 12 or Older: 2007

Source Where Pain Relievers Were Obtained Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past for Most Recent Nonmedical Use among Past

Year Users Aged 12 or Older: 2007Year Users Aged 12 or Older: 2007

Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown.1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s

Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.”

Bought/Took from Friend/Relative

14.1%

Drug Dealer/Stranger

4.1%

Bought on Internet

0.5% Other 1

4.2%

Free from Friend/Relative

6/6%

Bought/Took from

Friend/Relative5.9%

Drug Dealer/Stranger

1.8%

Other 1

1.8%

Source Where Respondent ObtainedSource Where Friend/Relative Obtained

One Doctor18.1%

More than One Doctor

2.6%

Free from Friend/Relative

56.5%

More than One Doctor2.9%

Bought on Internet

0.1%

OneDoctor81.0%

Estimated numbers of Estimated numbers of newnew nonmedical nonmedical users in past year by type of drug, US, users in past year by type of drug, US,

1990-20071990-2007

Estimated numbers of Estimated numbers of newnew nonmedical nonmedical users in past year by type of drug, US, users in past year by type of drug, US,

1990-20071990-2007

0

500

1000

1500

2000

2500

3000

90 91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07

Nu

mb

ers

in T

ho

us

an

ds

Pain relievers Tranquilizers Cocaine Stimulants Heroin

Source: SAMHSA NSDUH, 2006 and 2007

Mean Age at Mean Age at First UseFirst Use for Specific Drugs for Specific Drugs among Past Year Initiates Aged 12 to 49: among Past Year Initiates Aged 12 to 49:

20072007

Mean Age at Mean Age at First UseFirst Use for Specific Drugs for Specific Drugs among Past Year Initiates Aged 12 to 49: among Past Year Initiates Aged 12 to 49:

20072007

Source: SAMHSA NSDUH 2007

16.4 17.1 17.6 18.320.2 20.2 21.2 21.8 21.9

24.2 24.5

0

5

10

15

20

25

30

PC

P

Ina

ha

lan

ts

Ma

riju

an

a

LS

D

Co

ca

ine

Ec

sta

cy

Pa

inR

elie

ve

rs

He

roin

Sti

mu

lan

ts

Se

da

tiv

es

Tra

nq

uili

zers

Ag

e in

Ye

ars

Percentage of Persons

9.40 – 11.21

8.36 - 9.39

7.89 – 8.35

7.20 – 7.88

5.66 – 7.19

Illicit Drug UseIllicit Drug Use in Past Month among Persons Aged 12 or Older, by State: in Past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005-2006 NSDUHsPercentages, Annual Averages Based on 2005-2006 NSDUHs

Percentages of Persons

3.11-4.25

2.92-3.10

2.82-2.91

2.57-2.81

2.10-2.56

Illicit Drug Dependence or AbuseIllicit Drug Dependence or Abuse in Past Year among Persons Aged 12 or in Past Year among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsNSDUHs

Alcohol MisuseAlcohol Misuse

Past Month Alcohol Use - 2007Past Month Alcohol Use - 2007

• Any Use: 51% (127 million)

• Binge Use: 23% (58 million)

• Heavy Use: 7% (17 million)

(Current, Binge, and Heavy Use estimates are similar to those in 2002-2006)

Source: NSDUH 2007


57.86-63.14

54.04-57.85

51.52-54.03

44.86-51.51

32.40-44.85

AlcoholAlcohol Use Use in past Month among Persons Aged 12 or Older, by State: in past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsPercentages, Annual Averages Based on 2005 and 2006 NSDUHs


25.47-30.32

23.84-25.46

21.80-23.83

20.72-21.79

17.38-20.71

BingeBinge Alcohol Use in Past Month among Persons Aged 12 or Older, by Alcohol Use in Past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsState: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs


8.78-10.81

8.15-8.77

7.52-8.14

6.81-7.51

6.30-6.80

AlcoholAlcohol Dependence Dependence or Abuse in Past Year among Persons Aged 12 or or Abuse in Past Year among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsNSDUHs


44.24-47.63

42.06-44.23

39.10-42.05

36.97-39.09

32.86-36.96

Perceptions of Great Risk of Having Five or more Drinks of an Alcoholic Perceptions of Great Risk of Having Five or more Drinks of an Alcoholic beverage Once or Twice A Week among Persons Aged 12 or Older, by beverage Once or Twice A Week among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsState: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Alcohol Related DeathsAlcohol Related DeathsAlcohol Related DeathsAlcohol Related Deaths

• There are approximately 79,000 deaths attributable to excessive alcohol use each year in the United States

• This makes excessive alcohol use the 3rd leading lifestyle-related cause of death for the nation.

Source: Centers for Disease Control

Alcohol-Related Emergency Room VisitsAlcohol-Related Emergency Room Visits

• According to the Drug Abuse Warning Network (DAWN), in 2005 approximately 492,655 Emergency Department (ED) visits involved alcohol alone or in combination with another drug – 34% of all drug misuse/abuse ED visits.

– Approximately 145,759 of these were alcohol-related ED visits for patients under the age of 21.

– Two-thirds of the alcohol-related ED visits for minors involved alcohol alone.

Immediate Health Risks from Immediate Health Risks from Inappropriate DrinkingInappropriate Drinking

Immediate Health Risks from Immediate Health Risks from Inappropriate DrinkingInappropriate Drinking

• Unintentional injuries.

• Risky sexual behaviors.

• Miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life.

• Alcohol poisoning

• Violence, including intimate partner violence and child maltreatment.

Source CDC: Alcohol-Attributable Deaths Report, Average for United States 2001-2005

Unintentional InjuriesUnintentional InjuriesUnintentional InjuriesUnintentional Injuries

• Falls

– An average of 5,532 deaths per year are related to alcohol

• Drownings

– An average of 868 deaths per year are related to alcohol

• Traffic injuries

– An average of 13,819 deaths per year are related to alcohol-related motor vehicle traffic crashes

– An average of 183 deaths per year are related to motor-vehicle non-traffic crashes


Intimate Partner Violence & Child Intimate Partner Violence & Child MaltreatmentMaltreatment

Intimate Partner Violence & Child Intimate Partner Violence & Child MaltreatmentMaltreatment

• About 35% of victims report that offenders are under the influence of alcohol.

• Alcohol use is also associated with 2 out of 3 incidents of intimate partner violence.

• Studies have also shown that alcohol is a leading factor in child maltreatment and neglect cases, and is the most frequent substance abused among these parents.

• An average of 168 children die every year as a result of alcohol related child maltreatment


Alcohol Impaired Driving: 2004-2006Alcohol Impaired Driving: 2004-2006

• In 2006, approximately 30.5 Million persons aged 12 or older drove under the influence of alcohol at least once during the past twelve months.

• North Dakota – at 24.9% -- reported the second highest rate of drivers 18 and older who reported driving under the influence of alcohol during the past year – only Wisconsin (at 26.4%) reported more.

Source: OAS, NSDUH 2007, combined data 2004-2006

Other Unintentional InjuriesOther Unintentional InjuriesOther Unintentional InjuriesOther Unintentional Injuries

Other annual deaths related to alcohol include:

• An average of 1,158 deaths related to burns

• An average of 123 unintentional firearm deaths

• An average of 370 poisoning deaths related to alcohol poisoning

• An average of 5,416 deaths per year related to alcohol related poisoning (not alcohol)

• An average of 269 deaths per year related to hypothermia

• An average of 7,787 homicide deaths


Alcohol-related SuicideAlcohol-related Suicide

• Suicide

– Alcohol related suicide has been related to an average of 7,235 deaths per year

– Another 31 deaths per year have been attributed to suicide by and exposure to alcohol


Substance Misuse can:Substance Misuse can:

Lead to:

• Worsened medical conditions (e.g. diabetes, hypertension, dental) and

• Worsened brain disorders (e.g. depression, psychosis, anxiety & sleep disorders)

• Unintentional injuries & violenceUnintentional injuries & violence

Result in:

• Dependence, which may require multiple treatment services

• Low birth weight, premature deliveries, and developmental disorders, child abuse & neglect


Contribute to or be associated with :

• Homelessness

• Criminal justice involvementCriminal justice involvement

• The effect and abuse of prescribed medications

• Unemployment

• Gambling

• Bankruptcy

• Legal Issues (e.g. DUI, DWI, domestic violence)Legal Issues (e.g. DUI, DWI, domestic violence)

• Dropping out of school


Induce or facilitate:

• Medical diseases (e.g. Stroke, dementia, hypertension, cancers, dental)

• Acquiring Infectious diseases & infections (e.g. HIV, Hepatitis C)

• Suicide attempts or tendenciesSuicide attempts or tendencies

Impact of Addiction on the FamilyImpact of Addiction on the Family

• Addiction is a developmental and inter-generational disease– Majority of persons who abuse or are dependent on

psychoactive substances begin alcohol and drug use as teens

– Children of parents who use are more likely to use themselves

• Children of substance abusing and dependent parents are at increased risk for– Abuse and neglect– Poor academic, health and psycho-social outcomes– Genetic propensity to addiction

Drug Use and Criminal ActivitiesDrug Use and Criminal ActivitiesDrug Use and Criminal ActivitiesDrug Use and Criminal Activities

• An annual average of 1.2 Million adults (18 years & older) were arrested for serious violent or property offenses from 2002 to 2004.

• An annual average of 60.1% of adults who were arrested from 2002 to 2004 for any serious offense were more likely to have used an illicit drug in the past 12 months than those who were not arrested (13.6%).

Source: Illicit Drug use among Persons Arrested for Serious Crimes, NSDUH Report, December 16, 2005

• The rate of substance abuse or dependence among adult offenders on probation or parole supervision is more than four times that of the general population1 (38.5% vs. 9%)

• Nearly 3/4ths of state prison inmates are in need of some substance abuse intervention:

– 31.5% of male inmates and 52.3% of all female inmates require intensive services such as residential treatment programs.2

1 NSDUH Report (2006)2 Belenko and J. Peugh, Estimating drug treatment needs among state prison inmates, Drug and Alcohol Dependence (2005),

Drug Use and Criminal ActivitiesDrug Use and Criminal ActivitiesDrug Use and Criminal ActivitiesDrug Use and Criminal Activities

Criminal Justice, Substance Abuse and Mental Health: The Impact on Society

Criminal Justice, Substance Abuse and Mental Health: The Impact on Society

• 72% of persons under justice supervision - jail/prison/probation/parole have a Co-Occurring Substance Abuse Disorder

• More than 60% of male arrestees have tested positive for at least 1 illegal drug

• 670,000+ offenders return to the community from State prison each year

• Almost 70% recidivate within 3 years of release

• 69% have Substance Abuse disorder

• Less than 10% receive treatment

Source: US Department of Justice, Office of Justice Programs, The Bureau of Justice Statistics

20.8 Million Needing But Not Receiving 20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol UseTreatment for Illicit Drug or Alcohol Use

4.6%

Felt They Needed Treatment and Did

Make an Effort

Did Not Feel They Needed

Treatment

Felt They Needed Treatment and Did Not Make an Effort

1.8%93.6%

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or

Alcohol Use: 2007

Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or

Alcohol Use: 2007

(955,000)

(380,000)

(19.5 Million)

Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+

Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+

Percent Reporting Reason

Not Ready to Stop Using

No Program Having Type of Treatment

No Health Coverage and Could Not Afford Cost

No Transportation/Inconvenient

Might Cause Neighbors/Community to Have Negative Opinion

Able to Handle Problem without Treatment

7.0%

6.9%

35.9%

26.6%

12.5%

10.5%

8.9%

8.1%

0% 10% 20% 30% 40%

Those who Needed & Made the Effort to Get Treatment Those who Needed & Made the Effort to Get Treatment But Did But Did NotNot Receive Specialty Treatment Receive Specialty Treatment

Source: NSDUH, 2004-2007 combined

Might Have Negative Effect on Job

Did Not Know Where to Go for Treatment

North Dakota State IndicatorsNorth Dakota State Indicators

31.52

6.16

10.86

9.49

2.04

22.7

8.02

9.25

7.35

2.67

0 5 10 15 20 25 30 35

Binge Alcohol Use inLast Month

Any Ilicit Drug use inthe Past Month

Alcohol/DrugDependence/Abuse in

Last Year

Needing AlcoholTreatment, But Not

Receiving It

Needing Treatment forIllicit Drugs But Not

Receiving It

Percent Reporting...

North Dakota National Average

Source: NSDUH 2004-2005 average

Special Populations: Special Populations: Underage Drinkers & Underage Drinkers &

AdolescentsAdolescents

Underage DrinkingUnderage Drinking

• According to the 2007 National Survey on Drug Use and Health (NSDUH), 10.7 million persons aged 12 to 20 reported drinking alcohol in the past month.

• Approximately 18.6% of them were binge drinkers, and 6% were heavy drinkers.

• 56.3% of current underage drinkers reported that their last use of alcohol in the past month occurred in someone else’s home (vs. 29.4% who reported it occurred in their own home).

Underage DrinkingUnderage Drinking

• 30.2% of underage drinkers paid for the alcohol the last time they drank – 8.2% bought it themselves.

• Among those who had someone else pay for the alcohol, 37.2% got it from an unrelated person aged 21+, 20.7% from another person under 21, and 19.5% got it from a parent, guardian, or other adult family member.

Source: 2007 NSDUH

4.7 4.3

7.5

4.5

8.7

2.5

0

2

4

6

8

10

Average DrinkingDays/Month

Average # Drinks/Day

12 to 17 18 to 25 Adult 26 and older

Adolescents Drink Less Frequently Adolescents Drink Less Frequently than Adults But More Per Occasionthan Adults But More Per Occasion

Source: SAMHSA National Survey on Drug Use and Health 2007

Alcohol Use and Binge Drinking Rise Alcohol Use and Binge Drinking Rise Rapidly Over Ages 12 to 20Rapidly Over Ages 12 to 20

Source: SAMHSA National Survey on Drug Use and Health 2007

0

10

20

30

40

50

60

70

12 13 14 15 16 17 18 19 20

Age

Pe

rce

nt

Past Month Use Past Month Binge Past Month Heavy


32.33-38.29

30.29-32.32

27.90-30.28

25.51-27.89

21.46-25.50

Alcohol useAlcohol use in Past Month among Persons in Past Month among Persons Aged 12 to 20Aged 12 to 20, by State: , by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsPercentages, Annual Averages Based on 2005 and 2006 NSDUHs


23.43-28.46

20.33-23.42

18.62-20.32

16.97-18.61

15.23-16.96

BingeBinge Alcohol use in Past Month among Persons Alcohol use in Past Month among Persons Aged 12 to 20Aged 12 to 20, by State: , by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHsPercentages, Annual Averages Based on 2005 and 2006 NSDUHs

• 5,000 deaths among youth under 21 per year from alcohol related injuries including homicides (1,600) and suicides (300)

• Physical and sexual assaults; unwanted/unintended sexual activity

• Altered academic/vocational trajectories

• Possible adverse effects on developing brain

Direct Consequences of Underage Direct Consequences of Underage DrinkingDrinking

Direct Consequences of Underage Direct Consequences of Underage DrinkingDrinking

Underage Drinking and Driving: 2007Underage Drinking and Driving: 2007

7.8%

18.3%

25.8%

20.1%

0%

5%

10%

15%

20%

25%

30%

Pe

rce

nt

Dri

vin

g U

nd

er

the

In

flu

en

ce

in t

he

Pa

st

Ye

ar

16-17 18-20 21-25 26-29

Age in Years

Source: NSDUH, 2007

Parent Awareness of Youth Substance Use

Parent Awareness of Youth Substance Use

• According to the 2006 National Survey on Drug Use and Health (NSDUH), the percentage of 12-18 year olds using the following substances during the past year totaled:

– 17% for cigarettes

– 32.9% for alcohol

– 13.2% for marijuana

• Parent awareness is high for adolescent cigarette use, but remains low for alcohol use. Findings regarding parent awareness of adolescent marijuana use are mixed.

Source: SAMHSA, NSDUH, 2006

Parent AwarenessParent Awareness

• There appears to be a link between the level of parent’s awareness of the child’s substance use and the reported use during the past year.– This is particularly true for one-parent

households.

• Reported past-year usage of alcohol, cigarettes, and marijuana by children 12-17 in one-parent households was consistently higher for father-child pairs than for mother-child pairs.– Reported parent awareness of the child’s usage

was consistently higher in mother-child pairs.

Source: SAMHSA, NSDUH, combined data 2002-2006

One Parent Homes vs. Two-Parent Homes

One Parent Homes vs. Two-Parent Homes

20.2%

34.5%

16.4% 16.8%

31.9%

12.6%

23.3%

36.6%

18.9%

14.9%

31.2%

11.9%

0%

5%

10%

15%

20%

25%

30%

35%

40%

One-ParentHousehold

Two-ParentHousehold

One-ParentHousehold

Two-ParentHousehold

Cigarettes

Alcohol

Marijuana

Mother-Child Pairs Father-Child Pairs

Percentage of Youths aged 12-17 in Parent-Child Pairs Who Reported Past Year Substance Use: 2002-2006


Mother-Child vs. Father-Child PairsMother-Child vs. Father-Child Pairs

53.7%

47.4%

53.8%

47.0%41.1%

32.5%

0%

10%

20%

30%

40%

50%

60%

Cigarettes Alcohol Marijuana

Mother-Child Pairs

Father-Child Pairs


Percentages of Parents in Parent-Child Pairs Who Were Aware of Their Child’s Substance Use (where the child had used in the past year): 2002-2006

Special Population: Special Population: Returning VeteransReturning Veterans

57

Substance Abuse and Veterans Substance Abuse and Veterans Substance Abuse and Veterans Substance Abuse and Veterans

• The military enforces a strict schedule of drug testing – with severe consequences for those who are found abusing drugs.

• Alcohol remains the primary substance of abuse among veterans 1

• Between 2005 and 2006, the Army saw an almost three-fold increase in “alcohol-related incidents,” according to the DOD Task Force on Mental Health.

• 75% of combat veterans with lifetime PTSD also met criteria for alcohol abuse or dependence. 2

1 National Survey on Drug Use and Health, 20052 Saxon, et al., . (1998). Archives of General Psychiatry, 55:913-917

58

PTSD, Alcohol Consumption and PTSD, Alcohol Consumption and DeploymentDeployment

PTSD, Alcohol Consumption and PTSD, Alcohol Consumption and DeploymentDeployment

• In one study of a non-treatment seeking sample of 800 US Army Iraq war veterans, an increase in PTSD symptoms between pre-deployment and post-deployment was associated with increased drinking from pre- to post deployment.1

1 Vasterling, JJ et al, Journal of Rehabilitation Research & Development, vol.45(3), 2008

An estimated 30.7% of troops returning from Iraq and Afghanistan have a mental health condition or reported experiencing a traumatic brain injury (TBI).

Mental Health Needs of Returning Vets

Source: Rand Center for Military Health Policy Research, Invisible Wounds: Mental Health & Cognitive Care Needs of America’s Returning Veterans, retrieved 4/18/08 from www.rand.org

30.7%12.2%

7.3%

11.2%

69.3%

No PTSD,Depression or TBI

PTSD orDepression, NO TBI

PTSD orDepression & TBI

TBI only

Prevalence of Serious Psychological Distress Prevalence of Serious Psychological Distress (SPD), SUD, and Co-Occurring SPD and SUD (SPD), SUD, and Co-Occurring SPD and SUD in the Past Year among Veterans, by Gender: in the Past Year among Veterans, by Gender:

2004 to 20062004 to 2006

Prevalence of Serious Psychological Distress Prevalence of Serious Psychological Distress (SPD), SUD, and Co-Occurring SPD and SUD (SPD), SUD, and Co-Occurring SPD and SUD in the Past Year among Veterans, by Gender: in the Past Year among Veterans, by Gender:

2004 to 20062004 to 2006

6.5%7.2%

1.5%

14.5%

5.8%

2.0%

0%

2%

4%

6%

8%

10%

12%

14%

16%

SPD SUD Co-OccurringSPD & SUD

Males

Females

Source: The NSDUH Report, November 1, 2007

61

The Younger Veteran Population Has The Younger Veteran Population Has Specific ChallengesSpecific Challenges

The Younger Veteran Population Has The Younger Veteran Population Has Specific ChallengesSpecific Challenges

• Among depressed veterans, younger individuals (18-44 years) committed suicide at the highest rate (95 suicides per 100,000 person-years) 1

• Veterans aged 18 to 25 have the highest rate of serious psychological distress (SPD) and substance use disorder (SUD) at 8.4%, with veterans 55 or older having the lowest rate at 0.7%. 2

1 Hampton, T., PhD, Research, Law Address Veterans’ Suicide, JAMA, 12/19/072 The NSDUH Report, November 1, 2007

Mental Health and Co-Occurring Illness Among Veterans

Mental Health and Co-Occurring Illness Among Veterans

• Veterans with family incomes of less than $20,000 per year were more likely to have had co-occurring SPD & SUD in the past year than veterans with higher family incomes.1

• According to the Department of Veterans Affairs, 18% of the veterans recently back from tours of duty are unemployed. Of those employed since leaving the military, 25 percent earn less than $21,840 a year.

1 The NSDUH Report, November 1, 2007

An Holistic Approach to An Holistic Approach to Recovery: Recovery:

Integrating Resources to Integrating Resources to Create a Client-centered Create a Client-centered

Recovery ProcessRecovery Process

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The Recovery ProcessThe Recovery ProcessThe Recovery ProcessThe Recovery Process

Recovery from alcohol and drug problems is a process of change through which an

individual achieves abstinence and improved health, wellness, and quality of life.

Source: CSAT National Summit on Recovery, 2005

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Challenges for a Traditional ApproachChallenges for a Traditional ApproachChallenges for a Traditional ApproachChallenges for a Traditional Approach

• Traditional treatment approaches provide challenges that translate into less cost-effective use of funds:

• 52.3% of those admitted to U.S. public substance abuse treatment programs in 2006 were re-entering treatment:– 21.3% for the second time, 17.4% for the third or fourth

time, and 13.6% for the fifth or more time. 1

• One recent study found the that median time from first treatment to 1 alcohol- and drug-free year was 9 years – with 3 to 4 episodes of treatment.2

¹SAMHSA, Office of Applied Studies. Treatment Episode Data Set (TEDS). Highlights - 2006. National Admissions to Substance Abuse Treatment Services

2 Dennis, M.L. et al, 2005. The duration and correlates of addiction and treatment careers, Journal of Substance Abuse Treatment 28 (Suppl. 1): S51-S62

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Description of Recovery-Oriented Description of Recovery-Oriented Systems of CareSystems of Care

Description of Recovery-Oriented Description of Recovery-Oriented Systems of CareSystems of Care

A recovery-oriented systems of care approach supports person-centered and self-directed approaches to care that build on the strengths

and resilience of individuals, families, and communities to take responsibility for their

sustained health, wellness, and recovery from alcohol and drug problems.

Source: CSAT National Summit on Recovery, 2005

Recovery-Oriented Systems of Care: A Paradigm Shift

Recovery-Oriented Systems of Care: A Paradigm Shift

Recovery-Oriented Systems of Care shift the question from

“How do we get the client into treatment?”

to

““How do we support the process of How do we support the process of recovery within the person’s recovery within the person’s

environment?”environment?”

68

0

100

Time

Person’s Entry into treatment

Discharge

Severe

Remission

Resource: Tom Kirk, Ph.D

Sy

mp

tom

s

A Traditional Course of Treatment for a A Traditional Course of Treatment for a Substance Use DisorderSubstance Use Disorder

69

0

100

Symptoms

Acute symptoms

Discontinuous treatment

Crisis management

Severe

Remission

A Traditional Service ResponseA Traditional Service Response


70

Promote Self Care, Rehabilitation

A Recovery-Oriented ResponseA Recovery-Oriented Response

0

100

Sym

pto

ms

Continuous treatment response


Severe

Remission

71

Improved client outcomes

Severe

Remission

Recovery ZoneRecovery Zone

Sym

pto

ms

Time

Helping People Move Into A Recovery Helping People Move Into A Recovery ZoneZone


Recovery-Oriented Systems of Care Recovery-Oriented Systems of Care ApproachApproach

Recovery-Oriented Systems of Care Recovery-Oriented Systems of Care ApproachApproach

• In the recovery-oriented systems of care approach, the treatment agency is viewed as one of many resources needed for a client’s successful integration into the community.

• No one source of support is more dominant than another.

• Various supports need to work in harmony with the client’s direction, so that all possible supports are working for and with the person in recovery.

Source: Addiction Messenger, November 2007, Vol. 10 Issue 11, published by the Northwest Frontier ATTC.

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Benefits of Moving into a Recovery ZoneBenefits of Moving into a Recovery ZoneBenefits of Moving into a Recovery ZoneBenefits of Moving into a Recovery Zone

• Chronic care approaches, including self-management, family supports, and integrated services, improve recovery outcomes 1

• Integrated and collaborative care has been shown to optimize recovery outcomes and improve cost-effectiveness 2

1 Lorig et al, 2001; Jason, Davis, Ferrari, & Bishop; 2001; Weisner et al, 2001; Friedmann et al, 20012 Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

ROSC offer a comprehensive menu of ROSC offer a comprehensive menu of services and supportsservices and supports that can be combined and readily adjusted to meet the that can be combined and readily adjusted to meet the individual’s needs and chosen pathways to recovery.individual’s needs and chosen pathways to recovery.

ROSC offer a comprehensive menu of ROSC offer a comprehensive menu of services and supportsservices and supports that can be combined and readily adjusted to meet the that can be combined and readily adjusted to meet the individual’s needs and chosen pathways to recovery.individual’s needs and chosen pathways to recovery.

IndividualFamily

Community

Family/Child Care

Housing/Transportation

Financial

Legal Case Mgt

VSO & Peer Support

Physical Health Care

PTSD &Mental Health

Alcohol/Drug Services

VocationalEducation

Cultural & Spiritual HIV Services

Services & Supports

Recovery

Wellness Health

Adolescent Care

ROSC encompass and coordinate the ROSC encompass and coordinate the operations of multiple operations of multiple systemssystems……

ROSC encompass and coordinate the ROSC encompass and coordinate the operations of multiple operations of multiple systemssystems……

IndividualFamily

Community

Family/Child Care


Financial

Legal Case MgtVSO & Peer Support

Health Care

PTSD & Mental Health

Alcohol/Drug Treatment

VocationalEducational

Spiritual

Addiction Services System

Mental HealthSystem

Primary Care System

Child Welfareand Family Services

Housing System

Social Services

Health Insurance

DoD & Veterans Affairs

Indian Health Services

Criminal & Juvenile Justice Systems

Vocational ServicesHIV ServicesFaith Community

HealthWellness

Services & Supports

Systems of Care

Recovery

Tribal Authorities

Education System

AdolescentSvcs.

……providing responsive, providing responsive, outcomes-drivenoutcomes-driven approaches to care.approaches to care.

……providing responsive, providing responsive, outcomes-drivenoutcomes-driven approaches to care.approaches to care.

IndividualFamily

Community

Family/Child Care


Financial

Legal Case Mgt

VSO & Peer Support

Health Care

PTSD &Mental Health

Alcohol/Drug Treatment

Vocational

Educational

Spiritual

Addiction Services System

Mental HealthSystem

Primary Care System

Child Welfareand FamilyServices

Housing System

Social Services

Health Insurance

DoD & Veterans Affairs

Indian HealthServices

Criminal & Juvenile Justice System

Abstinence

Employment

Crime

Homelessness

Evidence-Based Practice

Cost Effectiveness

PerceptionOf Care

Social ConnectednessAccess/Capacity

Retention

Vocational Services

HIV ServicesFaith Community

Menu of Services

Systems of Care

Recovery

Wellness HealthTribal Authorities

Education System Organized RecoveryCommunity

AdolescentSvcs.

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Goals of a Recovery-Oriented Systems Approach

Goals of a Recovery-Oriented Systems Approach

• To support preventive strategies related to substance use problems & disorders;

• To intervene early with individuals with substance use problems;

• To support sustained recovery for those with substance use disorders; and

• To improve individual, family and community outcomes.

Benefits of a Recovery-oriented Systems Approach

Benefits of a Recovery-oriented Systems Approach

Reasons for integrating an ROSC approach into current programs:

• The ROSC approach more effectively responds to individuals, families, and communities

• It supports a framework for structuring policy development and planning

• It provides an opportunity to apply knowledge gained from recovery-oriented research

North Dakota SAPT Block Grant Outcomes

North Dakota SAPT Block Grant Outcomes

North Dakota received $5.14 Million in SAPT Block Grant funds in FY 2007/2008.

The latest available outcome data are from FY 2006:

Source: SAMHSA, SAPT BG 2006

Clients reporting… Admission Discharge Rate of Change

No alcohol use 59.6% 84.5% 41.8%41.8%

No drug use 71.3% 85.6% 20.1%20.1%

No arrests 84.6% 89.5% 5.8%5.8%

Being employed 45.4% 54.0% 19.0%19.0%

Being housed 98.0% 98.2% 0.2%0.2%

The Ripple Effect: Tsunami of Destruction and Despair

The Ripple Effect: Tsunami of Destruction and Despair

• The evidence is substantial that the impact alcohol misuse and illicit drug use ripples across the lives of individuals, their families and the community at large.

• We must remember that a ripple can become a tsunami: with neglect and denial we get a tsunami of destruction and despair.

The Ripple Effect: Tsunami of Hope & Recovery

The Ripple Effect: Tsunami of Hope & Recovery

• With Prevention & Treatment we can cast a pebble of Hope into the pool of substance misuse, abuse and dependence.

• There are many pathways to Recovery, the benefits of Recovery ripple across the lives of individuals, the community and society.

• With the commitment of the community, the ripple of that commitment will become a tsunami of Hope & Recovery for those at risk or suffering from substance use disorders..

SAMHSA Resources SAMHSA Resources • SAMHSA Website: www:samhsa.gov

• SAMHSA Substance Abuse Treatment Facility Locator at http://findtreatment.samhsa.gov

• SAMHSA Health Information Network is our new clearinghouse – 1-877-SAMHSA-7

– Monday-Friday 9 am – 4:30 p.

• www.AddictionEd.org -- An international reference for distance education opportunities

• SHIN 1-800-729-6686 for publication ordering or information on funding opportunities

– 1-800-487-4889 – TDD line

• 1-800-662-HELP – SAMHSA’s National Helpline (average # of tx calls per mo.- 24,000)

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

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