LEGISLATIVE ANALYST REPORT

TO: HONORABLE MEMBERS OF THE BOARD OF SUPERVISORS
FROM: Jesse Martinez, Legislative Analyst
DATE: April 12, 2002
FILE: 012178
SUBJECT: Intermediary Care Facilities (public inebriate treatment)

SUMMARY OF REQUESTED ACTION

A motion (introduced by Supervisor Newsom) requesting the Office of the Legislative Analyst (OLA) to prepare a report comparing the best practices and/or models, otherwise known as Intermediary Care Facilities, used in other major cities in the treatment of public inebriates, including but not limited to the cities of Portland, Oregon; Seattle, Washington; and Denver, Colorado.

EXECUTIVE SUMMARY

This report examines models in 4 counties nationwide: Denver County (Colorado), Multnomah County (Portland, OR), and, San Mateo County (California).

The OLA found that the jurisdictions surveyed generally reflected an acceptance that a comprehensive approach to alcohol abuse treatment is the best approach.

For instance, King County provides a holistic manner to treatment. It offers residential and outpatient treatment as well as specialized services such as the "Crisis Triage Unit." This unit is located within a hospital and serves clients with a dual diagnosis scheme. Case managers are also available to manage the varying needs as applicable.

The OLA recommends that, as a matter of policy, the Board urge departments (housing, public health, human services) to adopt some of the models in this report. Implementation of any or all of these practices can significantly improve treatment for the segment of the population in need of specialized services in San Francisco.

BACKGROUND

The California Department of Alcohol and Drug Programs (DADP) directs and coordinates the state"s

efforts to prevent or minimize the effects of alcohol-related problems, narcotic addiction, and drug abuse. Services include prevention, early intervention, detoxification, and recovery.

The California treatment system is primarily administered by the counties, although county officials must

comply with a number of state and federal regulations¹ regarding provider licensing and the allowable uses of certain funding streams.

The department licenses more than 1,800 programs statewide, about half of which receive public funding. In addition, DADP collects client characteristic data from these providers and county-level data on treatment capacity, enrollment, and waiting lists. Little information is collected regarding treatment outcomes.

Since July 1995, more than 600,000 Californians have received publicly funded treatment of some type. Of these, 64 percent were male and 36 percent female. The average age of those in treatment has dropped slightly in recent years, from 38 in 1995-96 to 36 in 1997-98, due to an increasing proportion of adolescents and young

adults. People in treatment represent a variety of races and ethnic backgrounds, although the treatment population is predominately white.

POLICY AND PRACTICE

Types of Substance Abuse Treatment. Substance abuse treatment programs can be categorized in a number of ways. The State groups common treatment programs into two main categories, detoxification and recovery. Each category includes a range of treatment options, both residential and outpatient. All of these treatment options are available in California, although each county offers a different mix of services.

Detoxification. Detoxification is the process of withdrawing from alcohol or other drugs, which may be done in an outpatient or residential program. Detoxification is primarily seen as a short-term way to stabilize clients and prepare them to move into the recovery phase of treatment. Detoxification by itself is not considered an effective means of treating substance abuse.

Recovery. Outpatient and residential treatments that help addicts remain sober are included in this category. They are clustered into four main groups, each encompassing a wide variety of programs with different approaches to recovery. These programs may include group, individual, or family counseling; education and vocational training; social skills training; and other components that help participants change their lifestyles in order to maintain sobriety. Many programs have both an active treatment component and an "aftercare" component that supports clients when they are back in the community and at a greater risk of relapsing. Aftercare commonly includes participation in a self-help group, including "12-step" programs.

California"s Treatment Mix. According to DADP, recovery programs accounted for 92 percent of the available slots, while detoxification programs made up the remaining 8 percent. 50 percent of the recovery slots were in outpatient drug free programs, with an additional 35 percent in narcotic treatment programs.² About 10 percent of the recovery slots were in residential treatment programs, and 5 percent were in day treatment programs.

POLICY ISSUE

DADP identified several problems in the state"s substance abuse treatment system. These include lengthy waiting lists in a number of counties, no statewide plan for addressing the demand for treatment services, and a need in particular for treatment services aimed at adolescents.

For local policymakers, the challenge is equally great. The need is for a willingness to ineffective options. As a disease with strong links to family, addiction must be treated with the best possible services and community support. At a time of greatly increased concern about the effectiveness of public spending, knowing which kinds of treatments are effective is an important policy tool that can increase the overall accountability of the alcohol and other drug treatment system. However, these new data are useful only if policy makers approach with concern for the overall health of society, rather than the personalized stigma attached to alcohol and other drug abuse.

JURISDICTIONS

(see Appendices for in-depth data on individual jurisdictions)

CONCLUSION AND RECOMMENDATIONS

The jurisdictions surveyed did reflect an acceptance that a comprehensive approach to the issue of alcohol abuse treatment is the best model. A few, King County (Seattle) and San Mateo, have commenced serious efforts in implementing this holistic method. Empirical evidence of "success" and indeed, `best practices," should be forthcoming in the years to come.

Research indicates that substance abuse treatment is cost-effective to society in general. While the research generally indicates those treatment results in savings to government, we did not find a reliable estimate of cost-effectiveness specifically to government; that is, a comparison of the public savings and costs of program interventions.³

Recommendations

All the counties surveyed, including San Francisco, believe that too often the treatment programs are curtailed in their scope of services to just focusing on "being clean and sober." The OLA recommends that the Board of Supervisors urge departments to improve education, improved employability, more satisfying parenting and partnering relationship skills, and independent living skills of maintaining housing, meeting nutritional and health care needs, and practicing financial management.

APPENDIX

In-depth jurisdictions in the Appendix are:

San Francisco

Seattle, WA (King County)

Denver, CO (Denver County)

Portland, OR (Multnomah County)

San Mateo County (California)

SAN FRANCISCO⁴

Policy/Law

Policy and Laws Governing treatment:

In California policies and laws governing treatment are contained in the Constitution, 29 Codes of Law, and Codes of Regulations with 28 Titles. Numerous laws pertain to substance abuse treatment.⁵ San Francisco has long been reviewing and improving the manner by which alcohol abuse treatment is modeled.⁶

According to San Francisco representatives, laws mandate that the substance abuse treatment is "voluntary," meaning no individual can ever be committed against his/her will into a treatment program. This is perceived as a barrier to treatment continuity and resolving the alcohol abuse issue and efforts to remedy by treatment.

APPENDIX-continued

However, police and health care professionals may hold individuals in a psychiatric facility for up to 72 hours under California Welfare and Institutions Code 5150 or 2 weeks under 5250 if they meet criteria as "a danger to themselves or others." Being under the influence of drugs or alcohol is not sufficient once the person becomes

alert, oriented and able to refuse custodial treatment. The danger must be a clear and present. Endangering one"s health slowly over a long period of time because of repeated substance abuse does not meet the criteria. Likewise, being under the influence of drugs or alcohol is not itself a crime. Another misdemeanor or felony offence must occur before an individual can be taken into police custody. In court the judge does not sentence the offender to treatment, but rather, in counties like San Francisco, offers defendants with non-violent drug or alcohol related charges the option of attending treatment in lieu of jail time. Pre-plea cases go through the Drug Court system; post-

Conviction cases are processed under the Substance Abuse and Crime Prevention Act of 2000 (ballot proposition 36).

Client assessment process

The former system of access to treatment that depended on each individual finding the program that matched his or her needs resulted in unequal access to San Francisco"s Community Substance Abuse Services (CSAS) limited resources. Those fully mobile individuals with previous treatment experience tended to have the fastest access. Therefore, the Treatment Access Program (TAP) was developed to centralize the assessment process for vulnerable populations⁷ and facilitate placement into treatment equal to placement rates populations.

San Francisco"s substance abuse treatment system is scaled by intensity of service along a continuum of care. Current modalities of treatment are:

Primary Prevention: These consist of mostly educational services such as providing information through media, health fairs, school based classroom education, telephone hotlines, alternative activities to keep individuals, usually youth, off the streets and out of proximity to drug or alcohol environments. Efforts to influence community planning, e.g., the placement of liquor licenses, are managed by another department within DPH.

Secondary Prevention: These services consist mainly of outreach activities targeted toward specific at-risk populations such as intravenous drug users on the street, pregnant women using drugs, men having unprotected sex with men while under the influence of drugs or alcohol, homeless individuals under the influence on the streets. Services also include interventions, brief screenings and referrals to appropriate resources.

Drop-In Intervention Centers: The services work in tandem with outreach services. Individuals receive some basic health services such as medical assessment, snacks, showers, and clean clothes while being offered intervention opportunities, brief screenings and referrals to appropriate resources.

Outpatient Counseling: These services are classified as treatment instead of prevention/intervention and may consist of individual, group counseling or family counseling and case management by trained substance abuse treatment professionals usually on a once or twice weekly basis. The opportunity to meet with peer counselors who have overcome similar life experiences is helpful in substance abuse service continuum. Some outpatient services are billable to Medi-Cal for eligible individuals

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Extensive Outpatient Counseling: Also classified as treatment, these are more frequent or longer duration outpatient services and include alternative therapies such as acupuncture, meditation, educational sessions on auger management or life skills activities such as patenting classes, managing personal finances, relaxation techniques.

Day Treatment: This service is potentially billable to Medi-Cal for eligible individuals and consists of a structure program consisting of counseling, alternative therapies, and life skills activities described above for at least three days per week and at least six hours daily. Treatment episodes typically last 90-180 days.

Residential Treatment: Twenty-four hours of structured treatment, alternative therapies, life-skills, clean and sober recreation and including meals, overnight housing and vocational planning. Treatment typically lasts for 30 days to 1 year.

Detoxification: San Francisco offers residential social model detox (no prescription medications) for up to seven days, and residential medically managed detox (medication prescribed and managed) for up to 21 days.

Number of Clients

Clients, who have received services in the treatment portion of the continuum of care, e.g., outpatient, intensive outpatient, day treatment, residential, detoxification, and maintenance, have been registered in a master CSAS database beginning in 1991. Over a ten-year period, 80,000 unduplicated clients have been recorded in treatment modalities (Prevention and ancillary data have not been entered in the master database).

Annual clients in Treatment. The number of clients receiving State certified treatment services has risen from approximately 13,000 annually in the mid- 1990s to 15,000 in the past year.

Daily Total of Individuals: On any typical weekday, there are 5,000 individuals receiving CSAS funded services, not only treatment but inclusive of prevention and ancillary.

Alcohol services: In Fiscal Year 2000-2001, of the 43,000 unique treatment episodes provided, 15,000 cases (almost 33%) showed alcohol as the primary problem. This compares to 43% nation-wide. Of the 14,500 unduplicated clients seen in 2000-2001,4,300 individuals chose alcohol as their drug of choice.

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Costs (Source: direct table from DHS)

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Successes

Successful Program⁸

Redwood Center, a program of Community Awareness and Treatment Services (CATS), is the example of a highly successful alcoholism treatment program. CATS Redwood Center is one of San Francisco"s longest running residential alcohol and drug treatment programs for men. It is the only program contracting with CSAS that is located outside of San Francisco. The program is either 45 or 90 days duration and targets primarily homeless men or those exiting jail waiting for longer-term programs. Annually, about 240 clients register for services. Of those discharged, 75% complete their treatment goals. Several are discharged into other longer-term transitional programs.

Barriers

Limited availability of resources:

Even with CSAS" $45 million budget for direct client services, there remains limited ability to reach all target populations in need and provide the depth of service in each treatment modality necessary to make a lasting impact.

Underserved target populations: The SF publicly funded continuum of care focuses on the marginalized disadvantaged individuals who do not have access to private insurance or other resources. Even so, CSAS is not able to meet all needs.

Adolescents growing up with alcoholic and addicted parental figures: These are most severely at-risk because they are early victims of trauma, neglect, disordered lifestyles, and may carry some genetic propensities.

Homeless, multi-disordered, severely marginalized individuals: The needs of this diverse group continue to exceed the CSAS resources. The needs are for 1) specially trained outreach workers and 2) specially and uniquely designed drop-in intervention centers and housing opportunities. Because these services are intended for people who may still be under the influence of substances, there are added costs for on-site health care and for maintenance of the physical premises, e.g., plumbing, laundry, bedding, security.

Age related trends: The system has not been able to plan ahead for aging of the whole population and what that means for increasing alcohol use and related health care needs.

APPENDIX-continued

SEATTLE, WA (KING COUNTY)

Policy/Law

In Washington there is a state statute⁹ that authorizes and establishes a continuum of treatment for alcoholics and addicts within available funds. This statute also authorizes counties to establish alcoholism and other drug addiction program. In order to be eligible for state funding the county is also required to form an administrative board and appoint a county coordinator for alcohol and other drug services. The county alcoholism and other

drug treatment program, with the advice and guidance of the board, directs treatment services within that county (including prevention services).

Treatment is not mandatory but there is a provision in the law for involuntary detention for up to 72 hours if a person is found to be incapacitated or gravely disabled in a public place¹⁰, and for involuntary treatment of persons who meet certain criteria related to incapacity and grave disability¹¹

Client assessment

Clients may be assessed by any state certified treatment agency. Publicly funded clients are assessed by the state Department of Social and Health Services for financial eligibility and by a designated Assessment Center for eligibility and need for treatment services. Clients must be chemically dependent and actively addicted (have used alcohol or drugs within the last 90 days) to be eligible for publicly funded treatment. The type of treatment, length of stay, and appropriate program are determined by an assessment of the client"s use history, past treatment history, client needs, legal/criminal justice system obligations, and other social service needs using the American Society of Addiction Medicine (ASAM) Patient Placement Criteria.

Treatment system

Residential treatment services are contracted through the state Division of Alcohol and Substance Abuse. There are 5 public funded adult residential treatment programs in King County. Outpatient services are contracted with private non-profit community based treatment agencies. There are 10 public funded adult outpatient treatment agencies and 2 opiate substitution treatment programs in the county.

In addition to residential and outpatient treatment sites there are other specialized services for alcohol or drug addicted persons. A "Crisis Triage Unit" has been centrally located in the county"s major hospital/trauma center (Harborview Medical Center) to address the crisis needs of persons who may be suffering from co-occurring disorders (mental health and substance abuse). This is a cooperative project between the hospital, mental health system and the chemical dependency system. The county contracts with a private non-profit agency for 45 publicly funded detoxification beds and 60 sobering support center beds. Case managers work with the chronic

APPENDIX-continued

recidivist clients in the sobering center. They assist clients in finding housing, income assistance, life skills and primary medical care needs. The county also operates an Emergency Service Patrol (ESP) van that picks up and transports publicly inebriated individuals to appropriate services (sobering support, hospital, shelters).

Numbers of clients:

In 2001, 4,107 individuals were assessed. There were 26,415 admissions to the sobering support center of which 110 received case management services; the ESP van made 22,234 pick ups; approximately 2,250 clients received detoxification services; and around 8,600 clients received outpatient services.

Costs:

These figures are estimated costs for 2001:

Assessment Center: 13 FTEs $1,105,000

Sobering Support Center (contracted) $1,200,000

Emergency Service Patrol 12 FTE $1,100,000

Detoxification Services (contracted) $1,700,000

Outpatient Services (contracted) $2,100,000

$7,205,000

Success

King County"s success is based on evidence and outcomes-based practices. The county requires contracted agencies to utilize client centered individually tailored treatment/care plans and to base treatment completion on progress made toward those mutually agreed upon goals in the treatment plan. With the chronic public inebriate population (CPI) the county strives to make a positive change in the individual"s life through better living situations, income support, and greater self-determination. A reduction in the use of costly crisis and emergency services by CPI clients is also a measure of success.

In the county"s most recent HUD Annual Progress Report they reported that 66% of the case managed clients (n=110) had maintained improved housing. The county projects that 40% of newly engaged case managed clients will attain improved housing situations. The county does not have a mechanism in place to track actual reduction in use of emergency/crisis services but on a case by case basis they can track some information. The county estimates that even a 10% reduction would be considered successful given the cost of ER visits and Fire/Paramedic response costs these days.

Barriers to treatment

Some of the barriers encountered by the county involved efforts in providing the services needed by clients: lack of adequate funding; lack of available treatment resources (treatment on demand); lack of appropriate housing for our clients; and lack of funding for outreach and case management services.

APPENDIX- continued

DENVER, CO (DENVER COUNTY)

Law

State enabling legislation¹² mandated that the Alcohol and Drug Abuse Division (ADAD which is part of Dept. of Human Services), provide for the funding of treatment programs with federal and state dollars, develop and implement standards and regulations by which treatment programs are licensed, and maintain directories of

licensed treatment programs. Substance abuse treatment is voluntary in Colorado except in situations where courts have imposed treatment requirements (Driving Under the Influence/DUI, certain other drug related offenses, involuntary commitments).

Assessment

Licensed, funded treatment programs are required to use specific assessment and placement instruments. Non-funded licensed treatment programs are not required to use the same assessment and placement

instruments as funded programs, but any instruments used must be ADAD-approved.

Treatment

Services provided within the network encompass traditional outpatient treatment, intensive outpatient treatment, day treatment, transitional residential treatment, therapeutic community, non-medical detox and intensive residential treatment and methadone maintenance.

Number of clients:

There are 253 alcohol and drug abuse treatment sites, and 451 sites specific to treatment for DUI (Driving Under the Influence). Denver serves approximately 70,000 drug and alcohol clients a year, and about 28,000 DUI clients per year.

Cost

According to Denver representatives, the 2001 CASA Columbia survey¹³ ranked Colorado 49^th of the 50 states in per capita spending on substance abuse prevention and treatment, at a "whopping 12 cents." The only state spending less per capita was Georgia, upon whom CASA had no information (California ranked 8^th in

APPENDIX- continued

spending).Colorado has no Medicaid benefit for substance abuse treatment, except on a very limited basis for pregnant women and some medical detox.

Success

Denver looks for a client treatment goal completion of 50%. However, their client treatment completion is around 68 to 75%.

Barriers

Lack of resources, distance to treatment (rural), lack of transportation (rural and urban) and cost to clients (no free treatment in Colorado, though there is a sliding fee scale) are the major barriers to treatment.

PORTLAND, OR (MULTNOMAH COUNTY)

Law

Treatment is voluntary in Oregon unless the person is court mandated or referred by their probation officer. Sobering clients can also be taken in on a police hold. They have one clause in the administrative rules

which states that police encountering people who are intoxicated and incapable of caring for themselves may take the person to jail, however, it goes on to say that the police can also take the person to the nearest

appropriate treatment center and the treatment center must take the person.¹⁴

Assessment

Multnomah County generally uses a tool called the Multnomah County Assessment 3 (MCA3) which is a compilation of several assessment tools. They also use the American Society of Addiction Medicine (ASAM)¹⁵ criteria, and is used to measure severity of addiction and the level of treatment that the client needs. Oregon has adopted the ASAM to meet Oregon needs.

The county has 21 contracted agencies, which serve almost 18,000 unduplicated clients.

FY00-01

Adult beds-186 at a cost of $6,602,700.

Outpatient 437 beds at a cost of $1,083,228.

APPENDIX- continued

Success

Allowance for how funds flow from state to local areas, more flexibility allowed in designing services.

Outpatient contracts have been restructed to allow providers to supplement the publicly funded rates.

Dual diagnosis (integrated substance abuse diognosis & mental health services) has increased funding for these services.

Barriers

Demand for treatment outstrips capacity-less than half (40%) of the adults seeking treatment get into treatment.

Fewer than 1 in 7 adults seeking residential treatment get service.

Recruitment and retention of qualified staff is a problem due to a non-competitive pay scale.

Under the Dual Diagnosis--

Inadequate data system to collect information on clients.

Inadequate funding for subsidized free housing.

There is insufficient funding for management of treatment houses.

Lack of housing stock appropriate for treatment houses.

SAN MATEO

Policy/law

According to representatives, the county"s strategic plan includes a comprehensive needs assessment and the data indicates that substance abuse among adults and adolescents is correlated to increases in arrests, domestic violence, and other problems. According to county representatives, efforts to prevent, intervene, and treat the problems caused by substance abuse in San Mateo County are inadequate. However, their plan identifies the problems and barriers and has developed priority projects for funding. County stakeholders are now requesting major systemic changes, improving the interdisciplinary response, responding to new threats such as the methamphetamine crisis, and help in removing barriers to implementation.

Cient Assessment

The county needs assessment aims to describe the nature and scope of alcohol and drug problems in San Mateo County. A variety of data indicators are reviewed to describe and quantify the overall problem, current trends,

APPENDIX- continued

and issues for specific sub-populations. They summarize the assessment into six major groups of indicators of alcohol and drug problems:

1. Alcohol and Drug Treatment Indicators

2. Health Indicators

3. Hospital Utilization Indicators

Criminal Justice Indicators

4. Motor Vehicle Indicators

5. Adolescent AlcohoVDrug Use Indicators

The indicators highlight a number of local issues.

Waiting Lists: State reports¹⁶ have noted that San Mateo County has the second longest waiting time for alcohol/drug treatment services of the 15 largest California counties (San Francisco ranks 10^th). Each month there are 300-500 persons on waiting lists for treatment modalities such as residential detoxification, residential, treatment, and outpatient treatment.

Dual Diagnosis Clients: National data (See CALDATA) show that dual diagnosis with a mental disorder and San Mateo County has the lowest number of alcohol/drug treatment slots per 100,000 population of the 15 largest California counties. San Mateo has 11 slots per 10,000 population, compared with the statewide average of 28.

Treatment/clients

In an effort to reduce the waiting list length and time, funding for a treatment readiness program is being instituted.The design of this readiness program includes both a Center that will provide treatment readiness services such as large group, assessment, case management, referral and linkage to treatment, and funding for the participating treatment agencies to increase their capacity to provide pre-treatment groups for the clients waiting to receive services at their particular agency. The advantage to this type of program is that the client is immediately engaged in services, matched to the appropriate level of service, and clients with complex needs can receive case management or other services to help ready themselves for substance abuse treatment.

Comprehensive assessments are conducted using the Addiction Severity Index. Clients with 2 mental health problems will receive substance abuse as well as mental health assessment services. The client continues to receive group and individual therapy at either the treatment readiness program at the treatment site. Referrals are objective and driven by the needs of the clients and appropriate to the level of service required. An 800 number access system may be developed, the center will be family friendly and provide family assessments, education regarding County Alcohol and Drug Services (AOD) and other issues. Completion target is for FY03.

The San Mateo County Mental Health System has about 4,000 clients per year who are seriously mentally ill. Approximately 2,000 are dually-diagnosed with mental illness and substance abuse disorders, yet the County has little capacity to effectively serve this population. AOD treatment providers lack mental health expertise;

APPENDIX- continued

mental health providers lack AOD expertise. There is no case management program for dually diagnosed clients, despite their need for multiple services. County treatment services designed for this population is minimal. There is no men"s residential treatment, and there is no substantive program for individual outpatient counseling. Dual-diagnosis patients have a poorer prognosis and are nearly twice as likely to be re-hospitalized during one-year follow-up.

According to the County, clients may receive services for their mental illness, but not for their substance abuse problem (or vise versa), and the disorder results in high rates of recidivism either in the form of re-admission to mental health services or substance abuse services. The county proposes a project addressing the dual-diagnosis treatment capacity problem by implementing an integrated dual-diagnosis treatment system following the guidelines of the national Center for Substance Abuse (CSAT) Treatment Improvement Protocol 9 and incorporating the experience of the San Mateo County treatment providers. The proposed program will be a collaboration between the County Mental Health Services Division and Alcohol and Drug Services. The new program will provide intensive case management and dedicated dual-diagnosis residential and outpatient treatment. The programs will be staffed by people who will receive training in both mental health and substance abuse treatment for dual-diagnosis clients.Contracting for services with the County"s diverse providers will aid the project in addressing the range of race, cultures, and ethnicities in the County. The outcome evaluation will measure the increase in treatment capacity for dual-diagnosis clients and assess treatment effectiveness, including changes in alcohol and drug use, physical and mental health, employment and social functioning, retention in treatment and treatment completion, and service utilization.

Post-Incarceration Treatment Capacity Expansion

San Mateo County releases approximately 6300 inmates from incarceration every year. Approximately 5040 of these need AOD treatment, but the County staff in the jail system can place only 70 clients per year in drug treatment after incarceration. According to the County, the reason is that they lack the capacity to assess, case manage, temporarily house, and treat this population. The County proposes to implement a linked set of services, following the best practices as recommended in CSAT Treatment information Protocols. Case managers will meet inmates immediately on release, conduct assessments, create a transition plan, and case manage to ensure the plan"s implementation. A six-bed transitional housing facility, with some AOD services, will be established to house and support inmates while treatment and longer-term housing is arranged.

Programs will focus on life transition issues, including finding employment. The programming configuration will promote transition; for example, the programs will offer services in the evening so that during the day clients can look for work and then work at the jobs they find. Psychiatric coverage will be provided to better serve dually-diagnosed clients. Evaluation will assess a variety of outcomes including increased rates of abstinence from AOD, reduced recidivism (re-arrest and re-incarceration), improved functioning in mental health, employment, and social and family functioning, increased retention in treatment and treatment completion, and reduced utilization of services overall.

APPENDIX- continued

Success/cost

Reduced waiting time from 50 days in April 1997 to 19 days in July 1999 and increased slots from 1 per 10,000 population in April 1997 to 17 per 10,000 in July 1999.

Created a new modal, "Treatment Readiness," for clients on wait lists, which often get discouraged and disappear. These outpatient supportive services help to engage the client until they can be admitted to treatment

Utilized $1.5 million in county expansion funds to substantially increase services in the modalities of treatment readiness (477 clients per year), outpatient (378 per year), 94 residential beds.

Obtained $2.1 million in grants to further expand substance abuse treatment services (549 clients in outpatient services and 80 residential beds) for Latinos, Native Americans, drug court clients and difficult to treat metamphetamine users.

Barriers

The San Mateo County AOD Treatment System has a basic continuum of services, but several key modalities are missing and capacity does not match the demand. Most, if not all, of the community-based treatment agencies need enhancements to their existing service delivery system (i.e., add case managers/aftercare services/pre-treatment). Some of the services do not exist currently, such as medical detoxification services.

There are a number of reasons why the gaps are so severe:

Prevention and early intervention funds have historically been limited.

Funding limitations have limited the county"s ability to address long-standing needs for AOD specific services.

The demand for treatment is increasing as collaboration improves among systems dealing with substance abuse (criminal justice, mental health, primary health, hospita1 services).

Many problems are due to complex rules and regulations, NIMBY (Not in my backyard) problems, finding space that is affordable and managing unique regional concerns.

The county believes that the costs of untreated substance abuse are "staggering and are felt in areas such as health, criminal justice, HIV services, mental health, and other areas." They reason that for every dollar spent on substance abuse treatment; at least seven dollars are saved in other areas such as criminal justice or health.¹⁷

¹ California Legislative Analyst Office, "Substance Abuse Treatment in California," July 13, 2002

² See LAO, July 13, 2002

³ On going research by the National Institute on Alcohol Abuse & Alcoholism (NIAAA), Nancy P. Barnett, Ph.D. and Suzanne M. Colby, Ph.D., Peter M. Monti, Ph.D., and Mary Lou McMillan, MPH.

⁴ All data and information is derived from the San Francisco Department of Human Services as presented.

⁵ Health and Safety Code, Division 10, Uniform Controlled Substances Act, 11000-11999 recognizes addiction and the need for treatment in the population and establishes voluntary treatment systems jointly managed by the State Department of Alcohol and Drugs and the individual counties. Welfare and Institutions Code, Division 5, Community Mental Health Services, Part 1, (The Lanterman-Petris-Short Act), 5150-5176 establishes the condition "a danger to self or others" under which a person may be committed into treatment. Family Code, Division 11, Minors, Part 1, Age of Majority, 6920-6929 establishes age 12 and older as the age of personal consent to treatment without parental consent or knowledge. Penal Code, 1000-1000.8 Marijuana Laws, 1211 Drug Diversion programs, 6240-6246 and 8000-8002 Substance Abuse Community programs, and 13860-13864 Drugs in Schools. These create "deferred entry of judgment" allowing Drug Courts to be established.

California Code of Regulations (CCR), Title 9, Rehabilitative and Developmental Services, Division 4, Alcohol and Drug Programs create the procedures for narcotic replacement treatment and residential licensing of treatment programs.

⁶ Supervisor Kennedy proposed consideration of the types of services provided by city agencies for public inebriates, to determine whether the programs are effective, and whether plans exist to establish permanent programs or services for them (File 480-86). Supervisor Walker requested that the City Attorney issue an opinion on the use of Proposition 52 monies in terms of construction and rehabilitation of a community-based facility for a voluntary detoxification program for public inebriates to be staffed by health care and social workers with particular references to the following questions (October 11, 1988)

Resolution urging the Mayor to urge the Health Commission, the Police Commission and the Sheriff to extend for public inebriates who are charged with "drunk in public" (Section 647F of the Penal Code) a community-based social model detoxification and treatment program with medical accessibility for the acute and long term care of these clients (Public Inebriates PolicyFile 219-90-1).

⁷ Vulnerable populations have been identified as having no previous treatment experience, dual disordered, hospitalized,

Proposition`36"referrals

⁸ Measures of Successful Treatment. The substance abuse database records baseline for the following behaviors for the 30-day period prior to treatment and the status on discharge for the same behaviors. Success

is defined as improvement in the selected subset of three or four elements chosen for the treatment plans.

Addiction: frequency of USB (quantity of use is not measured in the current system)

Health: stabilization of disease symptoms, improved heath care habits, taking appropriate medications, improved health

Mental Health: stabilization of disease symptoms, improved mental heath care habits, taking appropriate medication, improved mental health, emotional and spiritual wellbeing

Socialization skills: establish alternatives to,& heavy drug/alcohol using

community, establish clean and sober friends, clean and sober leisure activities, improved family relationships

Educational status: improvement aimed at completing GED, specialized vocational training, enrollment and completion of college courses

Employment skills: skills leading to getting and maintaining employment

⁹ Title 70 Revised Code of Washington (RCW) Public Health and Safety, 70.96A

Treatment for alcoholism, intoxication, and drug addiction

¹⁰ RCW 70.96A.120

¹¹ RCW 70.96A.140

¹² Section 14-4-102 (13). Colo. Rev. Stat., §18-6-803.8(3)(a)-(c)(1999)

¹³ The National Center on Addiction and Substance Abuse at Columbia University,633 Third Avenue, 19th floor

New York, NY 10017-6706, see "Shoveling Up: The Impact of Substance Abuse on State Budgets," January 2001,page15.

¹⁴ Oregon Revised Statutes 426.460, Chapter 426 - Persons with Mental Illness; Sexually Dangerous Persons

¹⁵ ASAM Patient Placement Criteria for the Treatment of Substance-Related Disorders, (Second Edition -- Revised ): (ASAM PPC-2R) was released in April, 2001, 4601 North Park Ave, Arcade Suite 101 Chevy Chase, M.D. 20815

¹⁶ "California Counties, A Look at Program Performance," Legislative Analysts" Office May 1998.

¹⁷ (see California Drug and Alcohol Treatment Assessment/CALDATA. Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services. Website: aspe.hhs.gov)