Substance abuse and dependence
are complex disorders, with associated biological, psychological, and
social causes and effects (CSAT,
2000, p. 5). Historically, this disorder has been treated as a social
problem while the psychological and biologic aspects have been ignored.
However, the deterioration of functionality within each of these aspects
of the disorder requires that treatment and intervention address the entire
biopsychosocial continuum. In addition, substance abuse / dependence is
a chronic, relapsing illness (McClellan, et.al.,
2000). Although many symptoms and associated
illnesses require that a client receive specialized or acute care, these
systems might not be prepared to treat the chronic elements of the illness.
"Treatment refers to the
broad range of primary and supportive services - including identification,
brief intervention, assessment, diagnosis, counseling, medical services,
psychiatric services, psychological services, social services, and follow-up
- provided for persons with AOD problems. The overall goal of treatment
is to reduce or eliminate the use of alcohol and/or other drugs as a contributing
factor to physical, psychological, and social dysfunction and to arrest,
retard, or reverse the progress of any associated problems" (CSAT,
2000, p. 7, citing the Institute of Medicine, Broadening
the Base of Treatment for Alcohol Problems, Washington DC: National Academy
AOD disorders, due to their
complexity and chronic nature, are sometimes viewed as overwhelming or
even hopeless, especially by family members or by those who work in systems
where these symptoms are most visible, such as criminal justice, health
care, mental health, human resources, education, and welfare services.
However, research has clearly shown that, when success is measured by
client retention and relapse, treatment for addiction, substance abuse
and dependence, is as effective as treatment for other chronic relapsing
disorders such as hypertension, asthma, or diabetes (McClellan,
et.al., 2000), and the fact of successful recovery in the lives of
thousands of individuals in our County is testament to fact that these
illnesses may be brought into successful remission and that the persons
affected can return to productive and healthy lives. Research has also
shown that treatment is cost effective in reducing not only drug consumption
but also the associated health and social consequences (CSAT,
2000, p 7, citing the Institute of Medicine, Opportunities in Drug
Abuse Research, Washington DC: National Academy Press,1996).
Societal, Organizational, and Individual barriers to Treatment
There are many reasons why
individuals who need treatment fail to get it (CSAT,
2000, p. 9), including stigma associated with the disorder; cost of
treatment; unavailability of support services such as child-care or transportation,
and failure of systems to effectively identify individuals and direct
them to treatment. These issues intensify for individuals characterized
as "special" populations. The treatment system often does not
provide well for population groups such as women, children and adolescents,
the aging and disabled, ethnic groups (including mono-lingual), and rural
populations. Location of care, type of care available, hours of operation,
and other program characteristics often limit client access to care.
In addition to these barriers,
some individuals who have access to treatment do not choose to use it.
Many people fail to accept the magnitude of their problem, or have a fear
of the public perception and stigma associated with treatment. Their "denial"
increases the importance of rigorous screening across systems and facilitating
access to treatment for "resistant" individuals (CSAT,
2000, p. 9). People who need treatment but don't get it have been
asked for the reasons why in national surveys with large population samples
(Grant, 1996). One reason given is that they say
they "wanted to keep drinking or using." But many other reasons
are also given:
- They didn't think anyone
- They didn't know anyplace
to go for help.
- They couldn't afford to
pay for help.
- They didn't have any way
to get there.
- They didn't have time.
- They thought the problem
would get better by itself.
- They were too embarrassed
to discuss it with anyone.
- They were afraid of what
their boss/friends/family would think.
- They thought it was something
they should be strong enough to handle.
- They were afraid they would
put them in the hospital.
- They were afraid of the
treatment they would get.
- They hated answering personal
- The hours were inconvenient.
- A member of their family
- Their family thought they
should go but they didn't think it was necessary.
- They couldn't speak English
- They were afraid they would
lose their job.
- They couldn't arrange for
- They had to wait too long
to get into the program.
- They didn't think the problem
was serious enough.
Access and Inter-System Linkage Barriers
Because of the nature of the
disorder and its symptoms, individuals in need of treatment might appear
in various settings, including healthcare, the justice system, mental
health, welfare and social services, and juvenile or educational systems.
Often they are not effectively screened and diagnosed to facilitate movement
into the treatment / recovery system. Different systems often function
independently, failing to use intersystem linkages and resources for treatment
that may already exist. Additionally, the lack of cohesive interaction
among systems interferes with the ability of the treatment systems to
provide a high quality continuum of care. While inadequate resources are
often blamed on deficiencies in the treatment system, the reality is that
many resources available to Santa Barbara County (e.g. Drug Medi-Cal,
CalWORKS), are under-utilized. The development of an interactive system
that matches care to need, regardless of point of entry, is crucial to
establishing inter-system linkages and improving both access to services
and successful treatment outcomes (CSAT, 2000,
The justice system poses one
of the greatest challenges for improving access (CSAT,
2000, p. 10). One study, corroborating local Probation, Police, and
County Jail prevalence data, estimates that approximately 80% of the people
who are incarcerated have a history of AOD problems (Culpepper
Foundation, 1998). A report from Join Together (1996)
indicates that only 7% - 15% of incarcerated individuals receive treatment.
According to a Bureau of Prisons study, inmates who received treatment
are 73% less likely to be re-arrested in the firs six months after release
than those who have not (Adler, 1999). This percentage
is consistent with our County "Sheriff's Treatment Program,"
where 81 of an average of 1000 persons in County Jail receive treatment.
While our local County Probation, Courts, and Sheriff have been proactive
in improving collaborative linkages and achieving supplemental treatment
resources through the state Department of Corrections and the National
Institute of Justice, of the 5500 adults on Probation ("Santa Barbara
County Probation Fact Sheet" presented to Strategic Planners), 190
are enrolled in drug court, a percentage that exceeds national estimates
that Drug Courts handle fewer than 2% of drug cases, but that still represents
far fewer than those offenders who are eligible for the services. Seven
hundred adult probationers in Santa Barbara County are estimated to be
in other outpatient treatment services, and 134 are estimated to be residing
in clean and sober or residential treatment environments, for a total
of 1084 adult probationers (20%) engaged in some type of treatment or
recovery support service. Proposition 36 may increase treatment capacity
by as many as 600 treatment "slots" County-wide. While this
potentially addresses the treatment needs of another 10% of the existing
adult probation population, the Proposition may produce a larger probation
caseload, and is also planned to target State parolees; there are approximately
600 of the latter in the County, who are significantly underserved in
that a majority are uninsured and unable to pay for treatment services.
Of the 1157 juveniles on probation
("Santa Barbara County Probation Fact Sheet" presented to Strategic
Planners), fewer than 650 receive AOD services in either Juvenile Drug
Court or in the County's "Challenge" and youth camp programs
(this far exceeds national averages for youth probationers engaged in
some type of recovery or treatment support).
Inability to effectively deal
with persons in need of treatment is not limited to the justice systems.
Studies show that primary and urgent care physicians see, but fail to
screen or refer, a substantial number of individuals in need of substance
treatment (Join Together, 1998). Our County ranks
among the top 10 in the State for deaths related to drug overdose, and
reported Hepatitis C cases are at epidemic levels (Santa
Barbara County Public Health Department, 1999). Between 40% and 60%
of all trauma beds in hospitals are occupied by patients who were injured
while under the influence of alcohol (Gentilello,
et.al, 1995). Untreated alcoholics incur general health care costs
that are at least 100% higher than those of non alcoholics. After treatment,
the number of days lost to illness, sickness claims, and hospitalization
rates drop by 50% (Langen, et al., 1994). While
there are a number of current, proactive outreach and training initiatives
within County Public Health, effective screening, assessment, intervention,
and referral mechanisms are deficient in most County clinics and other
public health services, as well as in private provider healthcare networks.
The intersystem disconnect
between the mental health and substance treatment system is also common
nationally (CSAT, 2000, p 11). A joint report
by the National Association of State Alcohol and Drug Abuse Directors
and the national Association of State Mental health Program Directors
indicates that patients with mental, drug, or alcohol disorders appear
in both systems and are often missed or misdiagnosed (NASMHPD
and NASADAD, 1999).
Additionally, differences in insurance coverage and funding mechanisms
between systems fuel the disconnect because diagnoses might not be covered
by one payer or the other (CSAT, 2000, p. 11).
While there are a great many efforts in Santa Barbara among front-line
staff in both systems to coordinate services, and while there is a level
of coordination of services in MISC and the Mental Health Treatment Court,
system-wide coordination is often lacking, and capacity for alcohol for
alcohol/drug assessment and treatment is reported as inadequate in all
areas of mental health ("ADMS Mental Health Services" report
to Strategic Planners). Of great significance as well are persons with
mental illness and substance disorders who do not benefit from County
Mental Health services either because (a) they do not have an Axis I diagnosis
or (b) they have not elected to apply for Mental Health services. Services
need to be coordinated with private sector psychiatrists and mental health
therapists, with the non-County Medi-Cal health authority, and with Veteran's
There is also a substantial
disconnect nationally between the social services system and the AOD treatment
system. In the welfare system, caseworkers often have limited clinical
training and few standards for screening and assessing individuals who
might be in need of treatment. This lack of training makes it difficult
to identify individuals who are in need of treatment, and nearly impossible
to ensure that they are referred into treatment (CSAT,
2000, p. 11, citing Institute of Medicine, Dispelling the Myths about
Addiction: Strategies to Increase Understanding and Strengthen Research,
Washington DC: National Academy Press,1997). Most welfare agencies do
not specifically screen for AOD issues. Our County DSS estimates that
50% of CalWORKS clients have AOD problems in some regions of the County
("Alcohol and Drug Issues in DSS Programs" report to Strategic
Planners). It has been estimated nationally that 15-20% of welfare recipients
are dependent on alcohol or other drugs (Legal Action
Center, 1997). Using the 20% estimate, approximately 746 of CalWORKS
recipients have AOD problems, and yet only an estimated 76 of the 3730
current CalWORKS clients have been referred for AOD services, and significant
State AOD treatment funding targeting CalWORKS is lost due to the gap
between the welfare-to-work services and the AOD treatment system.
A new John Hopkins study shows
that welfare recipients with addiction problems are among the groups most
likely to lose their benefits for not following the rules than other welfare
recipients (Join Together, 2001). And yet the
completion of AOD treatment by welfare recipients in need of addiction
services has been shown to clearly improve their employment prospects,
outcomes, and earning potential. Local DSS Child Protective Services and
General Relief clients have a higher prevalence of AOD issues, and are
more proactively identified and referred by case workers, but the former
group lose Medi-Cal benefits (and hence the ability to pay for treatment)
as a result of the typical loss of custody of their children, and the
latter group are often uninsured.
Inter-system issues that contribute
to the treatment gap are not limited to the inability of systems to identify
and move individuals toward appropriate treatment. They also include the
difficulty associated with transferring patient-specific information from
one system to another. Current systems with overlapping clients often
do not share data (CSAT, 2000, p11.).
Another challenge associated
with the effects of substance abuse is that systems must address the impact
of the problem on those not directly involved. Treatment tends to focus
on the individuals with the problem and not the family members (CSAT,
2000, p. 11). Accompanying the national decline in private insurance
coverage for chemical dependency over the past ten years has been a commensurate
decline in emphasis in treatment on the needs of family members. While
our ADP has done much to correct this through the development of Youth
and Family Centers, and while recent Probation initiatives have begun
to target family members, adequate resources to work with the children
and family members of the AOD client is critical and must be considered
by all systems interacting with persons experiencing problems.
Resource Allocation and Financing
While the barriers described
above limit access to care for those who need it, often resulting in an
underutilization of available treatment resources, financing and resource
allocation issues - including financial, infrastructure, and other resources
that support and sustain the provision of AOD treatment - directly determine
the ability of an individual or family member to access treatment (CSAT,
2000, p. 12).
The Governor's current "May
Revise" of the State allocations for AOD treatment reduces discretionary
funding and curb proposed Medi-Cal reimbursement enhancement initiatives
that were passed by the Legislature. While public expenditures for treatment
from all sources (Substance Abuse and Health Care Agencies, Criminal Justice
Agencies, Labor and Housing Authorities, etc.) has increased somewhat
over the past few years, part of the reason is a dramatic decrease in
private insurance coverage. This has caused a significant decline in private
treatment capacity. Although "70% of drug users are employed and
most have private health insurance, 20% of public treatment funds were
spent on people with private health insurance in 1993, due to limitations
on their policy" (ONDCP, 1996). The emergence
of a significant uninsured and under-insured population on "waiting
lists" for publicly funded "slots" has put additional pressure
on the County for its publicly funded "safety net" services.
Several issues have had an
impact on the effective allocation of resources (CSAT,
2000, p. 12). Because financing is not based on program effectiveness,
inefficient allocation and use of resources is common. Clients often enter
treatment based on the geographic and financial factors that affect their
ability to access care. An individual's course of treatment is decided
based on the program to which he or she has access (and on the restrictions
imposed by bureaucratic funding systems, such as Drug Medi-Cal) rather
than on his or her specific needs. Often a patient's culture, gender,
culture, or other individual factors are not considered in the treatment
plan. Thus the needs of special populations such as women, children, and
minorities who require additional or different services might not be addressed.
"Other issues related
to resources that are affecting the treatment system - such as low resources
relative to the number of clients treated, low wages, erosion of dollars
per client, staff burnout, and other provider issues - make it difficult
to provide a full continuum of appropriate care. Further exacerbating
the gap is the poor condition of many structural facilities and the lack
of resources available to maintain or improve existing facilities or to
build new ones" (CSAT, 2000, p. 13)
Substance abuse treatment lacks
generally accepted standards of care and quality improvement protocols.
Because care is frequently defined differently across different payers
and providers, the care provided might vary for the same diagnosis, making
some courses of treatment ineffective. This variation is compounded by
cost reduction strategies of third-party payers, that might affect clinical
decisions. This situation often leads to the provision of care that does
not match the specific needs of the individual, and results in less effective
treatment (CSAT, 2000, p.13).
How much Do
Addiction and Addiction Treatment Cost?
While managed care and public
policymakers generally consider chemical dependency treatment as an added
"cost," the far greater costs are incurred when we choose not
to provide adequate treatment.
The overall cost of AOD problems
(excluding nicotine) in the United States is conservatively estimated
at $274.8 billion per year (NIDA/NIAAA, 1997).
The estimated population of the United States in 1999 was 270 million
people. Based on a cost of $274.8 billion, that averages $1017 per year
for every man, woman, and child. Untreated addiction expenditures in the
Santa Barbara County, with a population of 399,347 (Census 2000), can
therefore be estimated at $406.1 million. Part of this cost is higher
consumer prices due to lost productivity. Some of it is for higher auto
and accident insurance premiums and private health care costs, and the
rest goes for taxes for the alcoholics and addicts in the criminal justice,
welfare, public health, and mental health systems.
An average of the combined
costs of residential, outpatient, and methadone treatment established
by the Physicians Leadership on National Drug Policy is $3,150. Since
that figure is computed for drug treatment only (excluding alcohol), for
which methadone maintenance is common, the CRN suggests a higher average
cost of $5,000 to include treatment for alcoholism. Current outpatient
public treatment reimbursement in Santa Barbara County averages $1,700
for a full treatment stay of six months. If we combine the limited residential
and acute care treatment opportunities, the current slots are funded at
just over a third of the level they should be if they were providing comprehensive
and effective treatment and recovery services.
How many people
The Community Recovery Network
has estimated that in South County, 14,000 individuals are severely enough
impaired by AOD problems to require some level of treatment (CRN,
2001). If those figures are extrapolated County-wide, the total number
of persons requiring treatment can be estimated at 24,100 persons (this
estimate is conservative in that Probation and Social Services data suggests
that North County regions, especially Lompoc, are proportionately more
heavily impacted than the South Coast).
Who pays for
Current treatment in Santa
Barbara County is paid with the following resources:
Private Health Insurance:
Many private health insurance policies provide no benefits for chemical
dependency treatment or recovery support services, and others provide
very limited benefits. According to the American Society for Addiction
Medicine, private insurance benefits for chemical dependency treatment
have declined 75% in the past ten years. Additionally, Santa
Barbara County Public Health surveys indicate that over 24% of residents
aged 0 - 64 are uninsured.
Public Health Insurance:
Medicare provides some chemical dependency treatment service coverage,
but excludes prescription medication, case management, in-home assessment,
and other services necessary for comprehensive services for the elderly.
Medi-Cal reimburses for group counseling but only limited benefits for
individual counseling, and no reimbursement for case management, residential
services, or non-methadone detoxification services.
County Funded "Free"
services: There are some limited treatment services available that
are paid for by state and federal block grant funding, administered by
the County Alcohol and Drug program and provided by community non-profit
programs. The County of Santa Barbara provides approximately $50,000 annually
for AOD services as a match requirement for state funding.
Other Free or Subsidized
Services: The Santa Barbara Rescue Mission has a licensed residential
treatment facility for both men and women, paid for through their private
supporters. Other non-profit service providers underwrite services through
private fundraising activities.
Criminal Justice Services:
The State Department of Corrections provides funding through our County
Probation Department for addiction treatment for adolescents living in
Santa Barbara through the New Vistas program and in North County through
the Challenge Grant program. The "Sheriff's Treatment Program"
in the County Jail is partially funded through County Alcohol and Drug
program block grant funding and also through the facility's Inmate Welfare
Self-Pay Services: Most
AOD treatment programs accept fees for service. The cost of outpatient
services range from $1,300 to $3,500 for a six-month program.
Following are the "Thirteen
Principles" of effective treatment established by the National Institute
on Drug Abuse (NIDA, 1999).
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 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 instruction, 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 3 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 constructive
and rewarding non-drug-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.
7. Medications are an important
element of treatment for many patients, especially when combined with
counseling and other behavioral therapies. Methadone and levo-alpha-acetylmethadol
(LAAM) are very effective in helping individuals addicted to heroin or
other opiates stabilize their lives and reduce their illicit drug use.
Naltrexone is also an effective medication for some opiate addicts and
some patients with co-occurring alcohol dependence. For persons 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.
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 presenting for either condition
should be assessed and treated for the co-occurrence of the other type
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.
While 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 increase significantly 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, such as 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.
AOD treatment services are
conventionally divided into three categories, each with separate sub-categories:
Pre-treatment Engagement Services
- Initial Assessment
2. Treatment Service Phases
- Detoxification (residential
and outpatient; medical and social model)
- Stabilization (outpatient
and residential (each with varying degrees of intensity); day treatment;
medical and social model
- Rehabilitation Services
(education and supportive services such as job training, housing assistance,
primary medical services, child care, psychiatric services for previously
un-assessed mental health problems, etc.)
- Aftercare and Alumni Activities
3. Recovery Support
Debates sometimes arise among
professionals as to which model or style of treatment is better. This
is a little like arguing about whether taxicabs are superior to steam
ships. The AOD system of care - like the transportation infrastructure
- would optimally be "multi-modal" to accommodate diverse needs.
The reality is that within any given segment of the population in need
of treatment, the scope, duration and intensity of any of these services
will vary (CADPAAC, 2000). Indeed, there are individuals
with AOD problems who can successfully recover without any formal treatment
at all. For some, free and private mutual support groups such as 12-Step
programs are sufficient, either alone or in combination with "clean
and sober housing" opportunities. For each individual, a different
approach to services is required based on his or her degree of impairment
and the supports or barriers to recovery that are present in his or her
life. Each mode of treatment is an appropriate part of an integrated treatment
The Community Recovery Network
believes "Recovery Support" is inappropriately placed in the
above conventional continuum. It should not be "tacked on" as
something undefined that occurs following formal treatment, but rather
needs to pervade all of the elements of the continuum.
Recovery, which is a life-long
process, transcends treatment, which is finite in time and scope. Regardless
of the modes of treatment that are effective for a client, one of the
accepted predictors of long-term success is involvement with "extra-mural"
recovery support programs or activities. While 12-Step programs fill these
needs for a majority of successful clients, additional or alternate resources
are used including faith-based support, non-secular mutual aid groups,
family, and peers.
Assessment and Case Management
Also missing from the service
continuum described above is Case Management. To optimize success, client
needs must be assessed in their totality (CADPAAC,
2000). The domains of physical health, mental health, social functioning,
legal status, vocation and education, and family and relational issues
all have a bearing on the specific course and components of an AOD treatment
episode. Clients need to enter the continuum of care at the optimum level
of care, and transition through to other levels as they progress in recovery,
and specialized program tracks need to be available and appropriately
accessed for women, youth, older adults, persons with co-occurring mental
or physical disabilities. The system needs to be characterized by a culture
of innovation centered around client outcomes and the willingness to use
new approaches and to work with new partners.
One of the ways that recovery
can pervade the service continuum is through "Recovery-Based Assessment
and Case Management." In our current system of care in Santa Barbara
County, case management is often seen as a function of either the provider
agency or of the referring agency. The CRN supports a comprehensive Case
Management service that is neutral so that referral decisions that are
made can be made solely on which treatment components are appropriate
based on assessment and client choice, free from provider bias.
The proposed Case Management
service (CMS) would be representative of the full ethnic, racial, and
gender diversity of the County population. Persons employed by the CMS
would be trained and experienced and ultimately certified by the County
in all of the modes by which persons successfully recover from AOD problems;
in family intervention and harm reduction strategies, and in diagnosis
and assessment of AOD problems. They would be knowledgeable of all treatment
and recovery resources as well as of all referring agencies and entities
in the regions they served.
The CMS would be mobile, and
on-call 24 hours a day. They would have the capacity to respond within
minutes to requests for intervention or assessment services from any public
or private person or agency. Successful recovery requires trusting relationships,
and the CMS specialty would be in establishing these bonds trust and mutual
respect with all of their clients, with whom they would continue through
all phases of treatment and rehabilitation. They would also act as the
point of contact and follow-up with the referring agency or entity. Elements
of this model have been successfully implemented in perinatal case management
services in South County, in specific drug court venues, and in Santa
Cruz and other Counties in California. Providers of treatment would continue
to provide internal case support as required by quality assurance, and
would involve the CMS in casing and discharge planning.
Strategic Plan Recommendations
Based on the above "Barriers
to Treatment" discussion, the following Strategic Plan recommendations
are respectfully submitted for discussion.
- Utilize education, public
awareness campaigns, and training, to develop in Santa Barbara County
the expectation for AOD treatment such that no matter where in the human
services, health, or justice system an individual appears, his or her
AOD problem will be appropriately identified, assessed, referred, or
treated. ("No wrong door")
- Develop strategies of advocacy,
lobbying and education; grant development and monitoring, and County
general fund allocations to increase the resources available for AOD
treatment (i.e. Federal, State, local, and private).
- Develop a standard for AOD
treatment in Santa Barbara County that provides for a full continuum
of appropriate and continuing care to meet the needs of persons with
- Provide sustained support
to identify, assess, determine, and monitor need for treatment in all
communities and public systems in Santa Barbara County.
- Facilitate cross-system
consensus on critical data elements to measure quality of care and treatment
Following, submitted for discussion,
are Strategic directions based in part on recommendations by the County
Alcohol and Drug Program Administrators Association of California
- Research findings will guide
the evolution of treatment service models and will inform the provision
of services to clients.
- More clients will have access
to needed detoxification services, including pharmacological support,
acupuncture, and addiction medicine services.
- Treatment programs will
be supported to employ strategies for the removal of barriers to access
and participation, such as age, childcare, transportation, language,
culture, mobility, hearing, sight, and other hindrances.
- Programs for clients with
children will be supported in developing services for these children
which address their developmental and psychosocial needs.
- Programs will be able to
identify and document primary recovery outcomes.
- Training and technical assistance
services will be available at meaningful levels. Program staff will
be supported in taking advantage of them for professional advancement
and to improve client outcomes.
- Staff compensation will
be attractive to persons entering and already in the field.
- The County will have a balanced
framework in which roles, responsibilities, and professional standards
are set forth for staff with experiential, academic, certification,
and other standards.
- County service systems will
be responsive and creative in adapting to client needs. The service
system will be seamless from the client's perspective.
- Service integration will
be achieved without loss of specialization needed to respond effectively
to client needs.
- Clients will have coordinated
access to all needed services independent of organizational boundaries.
- Outcomes will likewise be
framed in terms of the client and will not be constrained by mandate
(e.g., the service system will not discriminate against clients on the
basis of the consequences that resulted in their arrival at treatment.)
- Ongoing cross training and
skill building in AOD screening will be provided to staff of other systems
to improve identification and intervention with clients having AOD problems
and to help make the system seamless.
- Ultimately, the funding
will follow the client to the system where the outcomes occur - from
jail to treatment programs. Public funds will support the system or
configuration of systems) which best produce the desired outcomes.
- With appropriate safeguards
for confidentiality, there will be cross-system data linkages that better
communicate data on clients and services for care coordination.
- Representatives of the recovery
community, including family members, and private providers will have
formal representation in all public planning and implementation venues
related to AOD issues.
- These strategies and goals
will be incorporated as policy at the County level, with appropriate
timelines and funding support for their implementation.
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of Addictions Treatment, Piscataway, NJ: Center
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from Drug Strategies)
A. et.al. (2000). "Drug Dependence, a Chronic Medical Illness: Implications
for Treatment, Insurance, and Outcomes Evaluation," Journal
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and NASADAD (1999). National Association of State Alcohol and Drug Abuse
Directors and the national Association of State Mental health Program
Dialogue on Co-Occurring Mental health and Substance Abuse Disorders.
Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism
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Drug Addiction Treatment: A Research-Based Guide. National Institutes
of Health, U.S. Department of Health and Human Services.
National Drug Control Policy (1996). "Parity
for Substance Abuse," Memo.
Barbara County Public Health Department (1999). Community Health Status
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