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 Press,1990).

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).

A. 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 could help.
• 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 questions.
  
• The hours were inconvenient.
  
• A member of their family objected.
  
• Their family thought they should go but they didn't think it was necessary.
  
• They couldn't speak English well enough.
  
• They were afraid they would lose their job.
  
• They couldn't arrange for child care.
  
• They had to wait too long to get into the program.
  
• They didn't think the problem was serious enough.

B. 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, p 9.).

Criminal Justice Systems

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).

Healthcare Systems

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.

Mental Health Systems

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 services.

Social Service Systems

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.

Other Cross-System Disconnects

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.

C. Resource Allocation and Financing

Funding

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)

Standards of Care

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 need treatment?

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 addiction treatment?

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 Fund.

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.

What Constitutes Good Treatment?

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 of disorder.

9. Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. 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 and Outreach

1. Identification

• Intervention
• Referral
• 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 infrastructure.

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.

Recovery-Based 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.

D. Strategic Plan Recommendations

Based on the above "Barriers to Treatment" discussion, the following Strategic Plan recommendations are respectfully submitted for discussion.

1. 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")
2. 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).
3. 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 AOD problems.
4. Provide sustained support to identify, assess, determine, and monitor need for treatment in all communities and public systems in Santa Barbara County.
5. Facilitate cross-system consensus on critical data elements to measure quality of care and treatment outcomes.

Following, submitted for discussion, are Strategic directions based in part on recommendations by the County Alcohol and Drug Program Administrators Association of California (CADPAAC):

1. Research findings will guide the evolution of treatment service models and will inform the provision of services to clients.
2. More clients will have access to needed detoxification services, including pharmacological support, acupuncture, and addiction medicine services.
3. 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.
4. Programs for clients with children will be supported in developing services for these children which address their developmental and psychosocial needs.
5. Programs will be able to identify and document primary recovery outcomes.
6. 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.
7. Staff compensation will be attractive to persons entering and already in the field.
8. 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.
9. County service systems will be responsive and creative in adapting to client needs. The service system will be seamless from the client's perspective.
10. Service integration will be achieved without loss of specialization needed to respond effectively to client needs.
11. Clients will have coordinated access to all needed services independent of organizational boundaries.
12. 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.)
13. 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.
14. 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.
15. With appropriate safeguards for confidentiality, there will be cross-system data linkages that better communicate data on clients and services for care coordination.
16. 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.
17. These strategies and goals will be incorporated as policy at the County level, with appropriate timelines and funding support for their implementation.

E. References

Adler, Jonathan (1999). The Buzz On Drugs, Newsweek, September 6, 1999.

CADPAAC (2000). Strategic Framework 2000. County Alcohol and Drug Program Administrators Association of California, 1029 J Street, Suite 340, Sacramento, California 95814.

CRN (2001). "Community Treatment Scorecard: Addiction Treatment and Recovery: Needs, Trends, Costs, and Resources in the Santa Barbara South Coast. Community Recovery Network, Santa Barbara.

CSAT (2000). Changing the Conversation. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, November 2000.

CSAT (2001). The Impact of Substance Abuse Treatment on Employment Outcomes Among AFDC Clients in Washington State. CSAT's Technical Assistance Publications (TAPs), 2001.

Culpepper Foundation and the Robert Wood Johnson Foundation (1998). Behind Bars: Substance Abuse and America's Prison Population, New York: The National Center on Addiction and Substance Abuse at Columbia University, by Steven Belenko.

Gentilello, L., et.al. (1995). Alcohol Interventions in Trauma Centers: Current practices and Future Directions. Journal of the American Medical Association, Vol. 274, No. 13.

Grant, B. (1996). Barriers to Alcoholism Treatment: Reasons for Not Seeking Treatment in a General Population Sample, NIAAA Division of Biometry and Epidemiology.

Join Together (1996). Fixing a Failing System: How the Criminal Justice System Should Work with Communities to Reduce Substance Abuse. Report from a Join Together Policy Panel, February, 1996, Join Together, Boston.

Join Together (1998). Treatment for addiction: Advancing the Common Good. August, 1999, Join Together, Boston.

Join Together (2001). Welfare Sanctions Hurt Addicted More.

Langen, J., et al. (1994). Socio-economic Evaluations of Addictions Treatment, Piscataway, NJ: Center of Alcohol Studies, Rutgers University.

Legal Action Center (September, 1997). Making Welfare reform Work: Tools for Confronting Alcohol and D rug Abuse Problems Among Welfare Recipients. (Available from Drug Strategies)

McClellan, A. et.al. (2000). "Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation," Journal of the American Medical Association, Vol. 284, No. 13.

NASMHPD and NASADAD (1999). National Association of State Alcohol and Drug Abuse Directors and the national Association of State Mental health Program Directors. National Dialogue on Co-Occurring Mental health and Substance Abuse Disorders. August, 1999.

National Institute on Drug Abuse/National Institute on Alcohol Abuse and Alcoholism (1995). "The Economic Costs of Alcohol and Drug Abuse in the United States, Executive Summary."

NIDA (1999). Principles of Drug Addiction Treatment: A Research-Based Guide. National Institutes of Health, U.S. Department of Health and Human Services.

Officeof National Drug Control Policy (1996). "Parity for Substance Abuse," Memo.

Santa Barbara County Public Health Department (1999). Community Health Status Report.

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