Report to Congress - Nov 2002
REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE DISORDERS AND MENTAL DISORDERS
To meet the multiple and complex needs of individuals with co-occurring disorders and their families, SAMHSA believes that States must have the capacity to make appropriate use of their Substance Abuse Prevention and Treatment and Community Mental Health Services Block Grant funds - consistent with the statute on Performance Partnerships on which the formula grant programs are now based. In close collaboration with key stakeholders, SAMHSA will continue to clarify how States can best use the resources of both Block Grant programs to serve people with co-occurring substance abuse disorders and mental disorders.
To achieve the goal of creating a community-based system of services that can be individualized to serve persons with co-occurring substance abuse disorders and mental disorders, related and relevant policy issues must be examined. SAMHSA will seek to work with CMS in further examining and clarifying existing Medicare and Medicaid policies to enhance opportunities to effectively serve individuals with co-occurring disorders.
SAMHSA will continue to work with its key constituents and Federal partners to explore these statutory and policy issues as they relate to the prevention and treatment of co-occurring disorders. To that end:
· SAMHSA will explore with CMS, in conjunction with AHRQ, ways to utilize existing reimbursement mechanisms for the assessment, diagnosis and treatment of people with co-occurring substance abuse disorders and mental disorders. Further, SAMHSA will provide State Medicaid directors and mental health and substance abuse authorities with information on how co-occurring disorders can be addressed within their respective State Medicaid plans.
· SAMHSA will continue to identify and disseminate successful strategies for use of Block Grant funds to treat co-occurring disorders. States with a track record of recognized, statewide, systems-level change - among them New Mexico, Connecticut, Washington, Oregon, Missouri and Arizona - will join with SAMHSA to provide State-to-State peer support.
SAMHSA concurs with the growing consensus in the field that all mental health and substance abuse service providers must be able to screen, assess, and, as needed, provide or refer for treatment to meet the needs of individuals with co-occurring substance abuse disorders and mental disorders without regard to disease severity, duration or symptomatology. SAMHSA's discretionary grant, professional training, and technical assistance activities over the next 5 years will be designed to help States develop, enhance, and phase in evidence-based practices supported by SAMHSA's State Services and Treatment Capacity Building Goals. This will enhance State flexibility to help mental health and substance abuse providers develop the capacity to:
· Prevent co-occurring disorders including delaying onset, reducing severity and preventing relapse.
· Screen all individuals that present at primary care, substance abuse, mental health, criminal justice, homeless, and educational facilities for the presence of co-occurring disorders.
· Assess the level of severity of co-occurring disorders.
· Treat both the substance abuse disorder and the mental disorder in a comprehensive and coordinated manner that is seamless to the client and, where feasible, that involves the client's family. This may involve consultation/collaboration with other providers, if the provider does not have the ability or expertise to offer integrated treatment.
· Train providers to screen, assess, and develop prevention and treatment plans for people who have co-occurring disorders.
· Evaluate the impact of prevention and treatment services on individuals who have co-occurring disorders and their families.
SAMHSA has begun a collaboration with NASMHPD and NASADAD and representatives of mental health and substance abuse State authorities to develop a set of unified co-occurring performance measures using the State Services and Treatment Capacity Building Goals to help develop the Performance Partnership Block Grants. SAMHSA will provide training and technical assistance to help States implement the performance measures.
SAMHSA will use its discretionary grant authority - along with technical assistance and training - as incentives to help States develop the infrastructure and expand capacity to create comprehensive and flexible systems of care for people with co-occurring substance abuse disorders and mental disorders. A new Co-Occurring State Incentive Grant for the treatment of persons with co-occurring substance abuse disorders and mental disorders will begin in fiscal year 2003.
The primary purpose of SAMHSA's Co-Occurring State Incentive Grants is to enable States to develop and enhance their service system infrastructure in order to increase their capacity to serve people with co-occurring substance abuse disorders and mental disorders. Infrastructure enhancement activities may include, for example, network building, aggregated funding planning, integrated management information systems, training and technical assistance to provider organizations, and development of coordinated intake/assessment/placement. States will be expected to select one or more of three capacity expansion goals addressing screening, assessment, and treatment. States will be expected to define performance measures for expected outcomes related to each of the goals they select. Over time, State experience with these performance measures should lead to development of standard performance measures for use by all States.
Increased system capacity is necessary but alone is not sufficient to meet the needs of people with co-occurring disorders. Intervention and treatment practices must be evidence-based and state-of-the-science. It is SAMHSA's responsibility to make sure that service providers not only have access to this information, but also are well schooled in it.
To help move new scientific knowledge to the treatment community, SAMHSA has been working with its colleagues at the National Institutes of Health - including the National Institute on Alcohol Abuse and Alcoholism, the National Institute on Drug Abuse, and the National Institute of Mental Health - and the Agency for Healthcare Research and Quality to forge a comprehensive "Science-to-Services" agenda responsive to the needs of the field. As a first step, SAMHSA will work with the Institutes to identify gaps in research on evidence-based prevention and treatment practices and to recommend future research priorities. Among areas for future investigation are:
· The various windows of opportunity across the life span in which co-occurring disorders may be prevented.
· The effectiveness of specific interventions (e.g., group therapy, case management) for people who have co-occurring disorders.
· The identification of validated, reliable, and standardized screening and assessment tools (including testing for drugs and alcohol), for co-occurring disorders that are age, gender and race/ethnicity appropriate and can be used by a range of providers in varying service settings.
· Epidemiological studies regarding cohorts of people with co-occurring substance abuse disorders and mental disorders whose levels of disease severity place them into one of the four quadrants of the conceptual framework developed for co-occurring disorders.
· The cost-effectiveness of varying levels and types of interventions - whether prevention or treatment - for people with co-occurring disorders, including costs and cost-offsets in other service systems, such as criminal justice, primary health care, child welfare, homeless services, and emergency medicine.
· Service system research to determine how financial incentives and accountability measures affect service system change.
Furthermore, the "Science-to-Services" agenda will investigate the effectiveness of specific interventions for the following high-risk populations:
· Children and adolescents
· Women and men who have been physically and/or sexually abused
· People who are homeless
· People with HIV/AIDS
· People who are making the transition from the criminal justice system to the community
In addition, SAMHSA will examine the complex issues regarding the use of psychoactive medications to treat mental disorders for individuals who also have co-occurring substance abuse disorders, looking toward the creation of a robust research base on which to make sound clinical judgments in this area. More research needs to be conducted, synthesized, and disseminated regarding: (1) the clinical use of psychotropic medications by a patient actively using substances of abuse; (2) the use of such medications by an individual who has a substance abuse disorder; (3) the effect of prescribed psychotropic medications on patterns of substance abuse; (4) the effect of substance abuse on the effectiveness of psychotherapeutic medications; and (5) the role psychotherapeutic medications may play in relapse-oriented, substance use-related symptoms.
The Science-to-Services Workgroup, co-sponsored by SAMHSA and NIH, will be asked to take up these issues and put them on a faster track for exploration. This should produce a steady flow of information that could help clinicians determine which medication, if any, would be appropriate for a specific individual given the severity of their condition.
Results of this research will be used by SAMHSA to promote implementation of known evidence-based practices in its grant programs. Together, SAMHSA and the Institutes will evaluate the fidelity, ease of implementation, generalizability, costs and cost-offsets, and problems in application of evidence-based practices. Results of these studies will inform the next cycle of research, implementation, and evaluation.
SAMHSA will provide technical assistance to States, tribes, Territories, local jurisdictions, and services providers to encourage use of current, state-of-the-science, evidence-based prevention and treatment practices to meet the needs of people with co-occurring substance abuse disorders and mental disorders. The Agency's training and technical assistance centers 6 will be encouraged to coordinate with one another to facilitate exchange of information and technologies about co-occurring disorders to reach the greatest number of providers possible, making best use of SAMHSA's resources and knowledge dissemination capacity. Evaluations on the impact of these training and technical assistance centers will demonstrate how they have made best use of SAMHSA's resources and knowledge dissemination capacity.
SAMHSA will ensure broad distribution of current and relevant technical assistance materials, including:
· The new Treatment Improvement Protocol for substance abuse services providers, Substance Abuse Treatment for Persons with Co-Occurring Disorders (CSAT, in press).
· The Integrated Co-Occurring Disorders Treatment Toolkit, being developed and evaluated for use by mental health administrators and providers, consumers, and family members as part of the SAMHSA Evidence-Based Practices Project.
·The technical assistance report, Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders.
TIPs, toolkits, and SAMHSA reports are available through SAMHSA's clearinghouses, the National Mental Health Information Center and the National Clearinghouse on Alcohol and Drug Information (NCADI), and are available on the SAMHSA website (www.samhsa.gov).
Constituencies from both the mental health and substance abuse services communities identified the dearth of education and training in the area of co-occurring disorders as one of the single most significant barriers to the provision of effective prevention and treatment services. SAMHSA remains committed to the development and dissemination of appropriate training materials for both mental health and substance abuse staff and will support the work of its training and technical assistance centers in this area.
SAMHSA will ensure development of a workforce educated and trained to address co-occurring disorders by evaluating the impact of the following actions:
· SAMHSA in fiscal year 2003 will create a National Co-Occurring Disorders Prevention and Treatment Technical Assistance and Cross-Training Center to develop, coordinate, and provide cross-training to mental health, substance abuse, education, homeless, criminal justice, and primary care providers. It will address all age groups, including youth and older adults. Training and technical assistance will be offered to State authorities and providers.
· SAMHSA will support State-to-State technical assistance in the development and implementation of education and training programs. SAMHSA will enhance and disseminate information about these innovative practices already ongoing in a number of States.
· SAMHSA will work with key professional organizations (e.g., National Association of Social Workers, American Psychological Association, American Psychiatric Association, National Association of Alcohol and Drug Abuse Counselors, American Academy of Addiction Psychiatry and the State Association of Addiction Services) and encourage them to contribute to and use SAMHSA materials to help inform the content of professional curricula.
· SAMHSA will direct its Minority Fellowship Program (MFP) - the only Federal program designed to help increase the number of racial and ethnic minorities entering our Nation's mental health and substance abuse workforce - to focus on training about co-occurring substance abuse disorders and mental disorders.
Prevention and both early identification and intervention of mental and substance abuse disorders are appropriate for individuals of all ages, but are especially critical for young people and those individuals whose mental and/or substance use problems have not risen to the level of seriousness to require substance abuse and/or mental health treatment. SAMHSA will work to ensure availability of evidence-based prevention and early intervention programs by:
· Reaching out to primary care practitioners, pediatricians, obstetrician-gynecologists, homeless providers, school guidance counselors, school-based clinics, and jails/prisons to educate them about the importance of screening and assessing their patients for the presence of mental and substance abuse disorders, and to provide them with information about appropriate screening and assessment methods, including alcohol and drug testing resources.
· Supporting activities to help communities adopt and adapt effective, evidence-based family interventions to reduce the risks for substance abuse and mental disorders. This includes SAMHSA's continued focus on strengthening collaborations with faith-based and community organizations through skills-building sessions.
· Further developing SAMHSA's National Registry of Effective Prevention Programs and broadening the Agency's efforts to identify and disseminate evidence-based programs for the prevention and treatment of co-occurring disorders.
· While ensuring compliance with Section 1956 of the U.S. Public Health Service Act, encouraging States to make concerted and creative use of the 20 percent prevention set-aside in the SAPT Block Grant to initiate activities that may forestall or prevent the development of substance abuse disorders in individuals at risk for developing co-occurring mental disorders.
· Working with the U.S. Department of Education to enhance partnerships at the State and local levels to respond to prevention and treatment needs of children and adolescents in schools and in mental health and substance abuse settings.
6 SAMHSA's training and technical assistance centers include the CSAT Addiction Technology Transfer Centers (ATTCs) and Treatment Improvement Exchange (TIE), the CSAP Centers for the Application of Prevention Technology (CAPTs), and the CMHS Mental Health Services Technical Assistance Centers.