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    Document Summary
    - Report Published -

    Senate Document No. 8
    PUBLICATION YEAR 2009

    Document Title
    Executive Summary of the Joint Subcommittee to Study Strategies and Models of Substance Abuse Treatment and Prevention (SJR 77, 2008)

    Author
    Division of Legislative Services, Joint Subcommittee

    Enabling Authority
    SJR 77 (Regular Session, 2008)

    Executive Summary
    The Joint Subcommittee to Study Strategies and Models of Substance Abuse Treatment and Prevention pursuant to Senate Joint Resolution 77 (2008) was established to (i) identify and characterize the nature of substance abuse in the Commonwealth; (ii) identify current state policies and programs targeting substance abuse prevention and treatment; (iii) examine the cost of such policies and programs to the Commonwealth; (iv) identify and examine policies and prevention programs from other leading states in the field of substance abuse and prevention; and (v) benchmark the Commonwealth's substance abuse prevention and treatment programs and policies against those of the leading states. The joint subcommittee met four times during the 2008 interim to carry out these objectives.

    July 31, 2008

    The first meeting of the Joint Subcommittee to Study Strategies and Models of Substance Abuse Treatment and Prevention pursuant to Senate Joint Resolution 77 (2008) was held Thursday, July 31, 2008, at the General Assembly Building in Richmond.

    Joint Legislative Audit and Review Commission Report: Mitigating the Cost of Substance Abuse in the Commonwealth

    The meeting became with a review of the Joint Legislative Audit and Review Commission's report, Mitigating the Cost of Substance Abuse in the Commonwealth, presented by Ms. Nathalie Molliet-Ribet, Project Leader, Joint Legislative Audit and Review Commission. Ms. Molliet-Ribet stated that substance abuse costs the Commonwealth approximately $613 million in 2006, with $595 million, or 96% of the total cost, resulting from criminal justice-related expenditures, primarily the costs of housing offenders convicted of drug-related crimes. Ms. Molliet-Ribet noted that during the same period, state and local governments spent $102 million to provide substance abuse treatment and prevention services. She stated that evidence conclusively shows that treatment works, and that the fiscal cost of substance abuse to the Commonwealth and localities can be reduced through treatment and prevention services. Concluding the presentation, Ms. Molliet-Ribet described a number of recommendations, drawn from the Joint Legislative Audit and Review Commission's report, for increasing the effectiveness of substance abuse treatment and prevention services and limiting the costs of substance abuse to the Commonwealth and local governments.

    DMHMRSAS Response

    Mr. Raymond Ratke, Deputy Commissioner of the Department of Mental Health, Mental Retardation, and Substance Abuse Services, presented the Department's response to the Joint Legislative Audit and Review Commission report, highlighting efforts undertaken by the Department to comply with the recommendations contained in the report.

    Substance Abuse Treatment and Prevention Efforts - National Experts

    The joint subcommittee then heard information on substance abuse treatment and prevention from national experts in the field. Dr. Mady Chalk discussed elements of successful and cost-effective substance abuse treatment programs, noting that substance abuse is a chronic disease that needs to be managed in a manner similar to management of other chronic diseases. Dr. Chalk reiterated the point made earlier that treatment works to limit the impact of substance abuse, and volunteered to provide information to the joint subcommittee on promising substance abuse treatment models in other states. Dr. Joel Grube presented information on substance abuse prevention models specifically targeting adolescent and under-aged drinking. He highlighted programs which have proven to be successful in reducing substance abuse among these populations, including increasing alcohol taxes and graduating licensing.

    Substance Abuse Challenges Affecting the Southwest Region of Virginia

    Following presentations by Dr. Chalk and Dr. Grube, a group of speakers representing a coalition of interested stakeholders from the southwestern part of the Commonwealth addressed the joint subcommittee. Mr. Douglas Meade of Occupational Enterprises, Inc. described the purpose of the coalition, highlighting the importance of communication and cooperation to achieving their goals. Mr. Meade characterized southwest Virginia as "under attack" by drugs. He stated that the coalition is working to inventory effective substance abuse programs.

    Mr. Ron Allison, Executive Director of the Cumberland Mountain Community Services Board, expressed concerns regarding the effects of current low Medicaid reimbursement for drug abuse treatment. He explained that in southwest Virginia, the only consistently available treatment for person suffering from substance abuse problems is a five to seven day detoxification program which, absent sufficient support and follow-up services, accomplishes little. Mr. Allison noted a need for data sharing among the agencies and institutions providing treatment and for gender-specific treatment, particularly for pregnant women, and pointed out that prevention programs based on evidence-based practices are successful and should be incorporated into substance abuse treatment programs. Finally, Mr. Allison observed that, since the drugs most abused are legally acquired prescription drugs, area physicians need to develop pain management programs.

    Mr. Tom Casteel, Director of the Washington County Department of Social Services and coalition member, described the effect of substance abuse on local social services departments, and explained that substance abuse has become the most common reason for a child to enter foster care in southwest Virginia, resulting in a substantial increase in foster care needs. Mr. Casteel also stated that cases of substance-exposed infants are rising steadily.

    Mr. Dennis H. Lee, the Commonwealth's Attorney for Tazewell County, noted that the county crime rate tripled after the introduction of OxyContin to the region and that as much of as 90% of crime in the county was related to substance abuse. Mr. Lee stated that Tazewell County had built a new jail which, due to the sudden and massive increase in substance abuse-related crimes, was full beyond capacity at the time it opened. He said the county has a fledgling, nonstatutory drug court that has been successful in addressing substance abuse problems in the county, but that the drug court lacks sufficient funding and currently relies on community resources to function. Acknowledging that Tazewell has found some programs that work such as the drug court and day reporting centers, Mr. Lee stated that the programs are woefully underfunded and Tazewell is a community in crisis.

    Mr. Bruce Kravitz of the Southwestern Virginia Alliance for Manufacturing spoke briefly about the need for skilled factory labor in the southwestern portion of the state and the difficulty in finding or keeping good employees. He said that many potential good workers either fail, or refuse to submit to, drug screening and that this has resulted in a difficulty in filling open positions.

    Mr. Mark Larson of Occupational Enterprises, Inc. stressed the need for a "system of care" approach in treating substance abuse issues, and stated that the following are needed to create a successful program: drug courts, residential treatment centers, an integrated information system, and aftercare including provisions for jobs, housing, daycare, and transportation. He noted that one dollar spent on substance abuse treatment could save four to seven dollars in other costs.

    Recovery Community Treatment Options

    The final speaker of the meeting was Mr. John Shinholser, President of the McShin Foundation, a nonprofit substance abuse treatment facility in Richmond. Mr. Shinholser described the goals of the McShin Foundation and how the foundation works to achieve these goals. He stressed the importance of including persons who have been through the recovery process in substance abuse treatment programs. By way of conclusion, Mr. Shinholser emphasized the need to think clearly about substance abuse treatment and prevention programming, to ensure that the best and most effective programs are in place.

    Septemeber 25, 2008

    The second meeting of the Joint Subcommittee to Study Strategies and Models of Substance Abuse Treatment and Prevention pursuant to Senate Joint Resolution 77 (2008) was held Thursday, September 25, 2008, at the General Assembly Building in Richmond.

    Department of Corrections Response to JLARC Study

    The Virginia Department of Corrections' provided a response to the Joint Legislative Audit and Review Commission's study on mitigating the costs of substance abuse in the Commonwealth and an overview of substance abuse programming offered through the Department, with a focus on Therapeutic Communities and Transitional Therapeutic Communities. Mr. Dudley Bush provided an overview of the development and history of the Therapeutic Community (TC) modality, noting that the TC model, which utilizes highly structured recovery practices including social learning and cognitive therapy as well as peer accountability to produce results, was introduced in the early 1960s and has been modified to meet the needs of modern prisons. In Virginia, the Department of Corrections currently provides just over 1600 TC beds in three institutions. The program includes five phases, with the inmate completing four phases in prison and one in the community. Mr. Bush then explained the Transitional Therapeutic Community (TTC) model, which provides additional cognitive and social learning therapy for inmates following release and while living in the community. Currently, there are 121 TTC beds available in Virginia. These models, Mr. Bush noted, are research-based best practice treatment modalities.

    Dr. Jean Mottley, Ph.D., explained the research and scientific evidence supporting the use of TC and TTC programs. She noted several national and Virginia-focused studies supporting the effectiveness of these models. Dr. Mottley stated that TTC participants were found to have lower re-arrest and reconviction rates than inmates who completed prison-based TC or nonprison-based TC alone. Inmates completing prison-based TC had lower re-arrest rates than non-prison TC program completers. Additionally, average number of days between release and re-arrest were higher for TTC and prison-based TC completers. Dr. Mottley concluded by highlighting several changes that have been made in the programs since 2005 that have increased the success of the TC and TTC programs including the following: staff levels have stabilized, TC administrator positions have been filled, the Indian Creek Correctional Center TC program has been fully implemented and is functioning at its full capacity, a cognitive behavioral skills curricula has been integrated into the TC programs, and transitional specialist positions have been filled at all facilities with TC programs.

    Virginia Association of Community Services Boards Response to JLARC Study

    Ms. Mary Anne Bergeron presented the Virginia Association of Community Services Boards' response to the Joint Legislative Audit and Review Commission's report, highlighting information on substance abuse services offered through community services boards. Ms. Bergeron noted that over 517,000 Virginians aged 12 or older are dependent on or abuse drugs or alcohol, or both. During FY 2007, community services boards, the main source of public substance abuse treatment services in the Commonwealth, served 53,905 of these persons.

    Ms. Bergeron stated that many community services boards are limited in their ability to provide services. She noted that a study by the Office of the Inspector General for the Department of Mental Health, Mental Retardation and Substance Abuse Services found that over 70% of community services boards reported no capacity or inadequate capacity for substance abuse services. Moreover, in communities where community services boards are able to provide services, the average waiting period before services begin is 25.4 days. Ms. Bergeron stated that some of this lack of capacity, contributing to the lack of capacity or inadequate capacity and long waiting times can be linked to the loss of SABRE funs, eliminated in FY 2002, and subsequent failures to adequately fund services. Ms. Bergeron concluded by offering several recommendations to increase community services boards services and address the growing problem of substance abuse in the Commonwealth, including: full implementation of recovery focused systems of care, use of evidence-based practices and evaluation of services, stabilization of the private provider base, and increased funding for implementation of evidence-based prevention and treatment strategies. To fund these objectives, Ms. Bergeron recommended: establishing a Substance Abuse Treatment and Prevention Fund funded with five percent of net proceeds of the Alcoholic Beverage Control Board, dedication of Tobacco Settlement funding for CSB prevention programs, direction of new revenue resulting from opening of new ABC stores and Sunday openings of existing stores for treatment and prevention services, and an increase in user fees on tobacco and alcohol products.

    Drug Courts

    Judge Catherine Hammond of the Henrico County Drug Court gave the final presentation of the meeting, providing information on drug courts generally and the Henrico County Drug Court specifically. Judge Hammond highlighted the need for drug courts as a tool to break the cycle of drug and alcohol abuse and incarceration. She then highlighted the link between substance abuse and incarceration noting that 50% of all convicted jail inmates were under the influence of drugs or alcohol at the time they committed the offense for which they were incarcerated. During the period 2001 through 2006, she noted, drug offenses made up 23% to 26% of all new court commitments to the Virginia Department of Corrections. In total, 29,352 persons were arrested in Virginia for drug offenses in 2006. Drug courts, Judge Hammond stated, offer a way to address underlying substance abuse problems and limit commitments to the Department, while also reducing crime. Evidence cited by Judge Hammond indicates that rates of recidivism can be drastically decreased through the use of drug courts. Moreover, studies indicate that drug court completers experience significantly better outcomes in the criminal justice system after treatment has ended, including higher rates of employment upon release.

    Judge Hammond then described how drug courts work, stating that a drug court is a specialized docket within an existing court system that combines immediacy and accountability of legal sanctions and the power of judicial supervision with comprehensive substance abuse treatment and case management to participating individuals. Each participant is required to appear in court once a week, maintain employment, undergo frequent urine screenings to ascertain whether the person continues to refrain from using drugs or alcohol, participate in group and individual therapy, and pay all restitution and court costs. The average period of involvement with a drug court is 12 to 18 months. Upon completion of the full program, some courts will reduce or dismiss the charges against a person. Currently, Judge Hammond stated, 15 adult drug courts operate in Virginia. In addition, there are eight juvenile drug courts, one DUI court and three family drug courts in the Commonwealth.

    November 18, 2008

    The third meeting of the Joint Subcommittee to Study Strategies and Models of Substance Abuse Treatment and Prevention pursuant to Senate Joint Resolution 77 (2008) was held on Tuesday, November 18, 2008, at the General Assembly Building in Richmond. Following opening remarks by Senator Hanger, the work of the joint subcommittee was commenced.

    Virginia Recovery Community Remarks

    Mr. John Shinholser, Executive Director of the McShin Foundation, a recovery resource foundation, spoke about the importance of including recovering addicts and members of the recovery community in the substance abuse treatment process. Mr. Shinholser gave a brief overview of the history and development of recovery community organizations, then identified ways in which existing clinical and professional networks could better coordinate with the recovery community to enhance services and bring about better results for individuals seeking treatment. In conclusion, Mr. Shinholser recommended reimbursement for recovery support services provided by recovery community organizations, equitable recognition of peer training and credentialing, maximizing the authentic recovery community experience, and increasing the role of recovery based organizations at every level.

    Department of Mental Health, Mental Retardation, and Substance Abuse Services Response to the JLARC Report on Mitigating the Cost of Substance Abuse to the Commonwealth

    Mr. Ken Batten, Director of the Office of Substance Abuse Services, presented information on the Department of Mental Health, Mental Retardation, and Substance Abuse Services' efforts to respond to recommendations made in the Joint Legislative Audit and Review Commission's report on Mitigating the Costs of Substance Abuse in the Commonwealth, and improving quality, capacity, access, and accountability of substance abuse services in the Commonwealth. Mr. Batten pointed out that current data does not allow the Department to accurately report the effectiveness of services provided by the 40 community services boards, that evidence based practices (EBPs) are not uniformly utilized in service delivery, and that access to services is limited by capacity and other barriers including a lack of funding. To address these problems, the Department is working to establish standards of care; consistent data collection, analysis and reporting services to study treatment and prevention efforts; effective quality and compliance monitoring processes; and effective IT systems. However, efforts are hampered by recent budget cuts, and could be further limited by new cuts in funding.

    Report on Outpatient Substance Abuse Services Available Through Community Services Boards in Virginia

    Mr. James Stewart, Inspector General for Mental Health, Mental Retardation, and Substance Abuse Services, described recent efforts of the Office of the Inspector General to review substance abuse outpatient services for adults, and to determine the range and capacity of all substance abuse services currently available through community services boards. Mr. Stewart reported that the range, variety, and capacity of substance abuse services available were found to be not adequate to meet the needs of consumers in the majority of Virginia communities. Specifically, many community services boards reported inadequate or no capacity in medical and social detoxification programs, medically assisted outpatient treatment, day treatment, intensive outpatient treatment, group counseling, individual counseling, psycho-education group therapy, family support therapy, aftercare services, residential services, and case management. Further most community services boards reported inadequate or no capacity for jail and prison based services, or community based services, including drug courts, for persons involved with the criminal justice system. This lack of availability of services was found to result in an average waiting time from first call to first appointment of 25.4 days. The report also found that for many persons needing services, the services were prohibitively expensive, further reducing access. The full report is available on the website of the Joint Subcommittee Study Strategies and Models of Substance Abuse Treatment and Prevention and the website of the Office of the Inspector General.

    Department of Education Substance Abuse Challenges

    Ms. Jo Ann Burkholder, Coordinator, Department of Education spoke on the impact of substance use on education. Ms. Burkholder noted that substance use and abuse negatively affects the academic progress and success of students, leading to lower grades, higher truancy, lower expectations, and higher drop-out rates. She stressed the importance of prevention efforts and early intervention among students, pointing out that students' brains are still developing, and that the impacts of substance use on adolescent brains can disrupt brain functioning in critical areas. Ms. Burkholder then described the Department's efforts to prevent and reduce substance use among students, highlighting Student Assistance Programming; drug use and violence prevent activities funded with Safe and Drug Free Schools and Communities Act Funds in Virginia's 132 school divisions; and evidence based curricula and programs implemented in the Virginia educational system.

    Medication Therapy for Substance Abuse Disorders

    Mr. Morrie Olson, Medical Advisor, Reckitt Benckiser Healthcare, presented information on medication therapy for substance abuse disorders, specifically addressing medical treatment of opioid dependency. He described the role of medications in substance abuse treatment, and past and current uses of medication to treat opioid addiction, most notably the use of methadone. Mr. Olson then discussed a second option, buprenorphine, a synthetic opioid, available for medical treatment of substance abuse disorders. Mr. Olson stated that the drug Suboxone can reduce the misuse, abuse, and diversion of buprenorphine, reduce potential public health problems, bring about changes in treatment delivery, and improve treatment.

    Discussion of Potential Recommendations

    At the end of the meeting, the joint subcommittee solicited suggestions for recommendations from stakeholders, and decided to discuss and vote on budget and legislation recommendations for the 2009 session at the next meeting of the joint subcommittee.

    December 8, 2008

    Substance Abuse Services Council

    Ms. Patty Gilbertson, Chair of the Substance Abuse Services Council, addressed the subcommittee regarding the work of the Council and suggestions for further action. Ms. Gilbertson described the composition of the Council and the agencies that participate on the Council, the purpose of the Council and past actions of the Council. She then stated that the Council supported the continuation of the SJR 77 joint subcommittee. Ms. Gilbertson highlighted the impact of abuse and misuse of prescription and over-the-counter drugs on the Commonwealth, the importance of funding and promoting prevention services, substance abuse risks and problems among older Virginians, and the importance of drug courts in addressing substance abuse problems. Ms. Gilbertson concluded by encouraging the joint subcommittee to explore these issues, and expressing the willingness of the Substance Abuse Services Council to work together with the joint subcommittee.

    Perinatal Substance Abuse

    Ms. Martha Kurgens described the extent and nature of perinatal substance abuse problems in the Commonwealth. She stated that over 12,000 infants are exposed to alcohol, over 6,000 are exposed to prescription medications taken for other than medical reasons, and over 4,500 infants are exposed to illicit drugs prior to birth in the Commonwealth each year. Ms. Kurgan explained that substance exposed newborns are at higher risk for premature delivery, low birth weight, neurological and congenital problems, increased risk of Sudden Infant Death Syndrome, developmental delays, neglect or abuse, and mental health or substance abuse problems as they age. She stated that state general fund expenditures related to perinatal substance abuse totaled $1.4 million, with an additional $774,000 in Medicaid expenses. Ms. Kurgens also described the characteristics of substance abusing pregnant women, the challenges associated with treating substance abusing pregnant women, and some options for improving the treatment of substance abusing pregnant women.

    Substance Abuse and Addiction Recovery Alliance

    Mr. Mark Blackwell, Executive Director, Substance Abuse and Addiction Recovery Alliance (SAARA) Virginia, explained the purpose and goals of SAARA, a treatment option that utilizes peer counseling and members of the recovery community in providing services. Mr. Blackwell then offered two recommendations for legislation. The first option called for a $.04 increase in the beer and wine excise tax, and use of funds collected to support substance abuse services. The second proposal called for creation of a Substance Abuse Services Trust Fund, funded with $18 million projected to be earned through new ABC stores in the Commonwealth, and Sunday openings of ABS stores in the Commonwealth.

    Recommendations of the Joint Subcommittee:

    The meeting concluded with a discussion of potential recommendations of the joint subcommittee. Recommendations approved by the joint subcommittee included:

    * DMHMRSAS should identify evidence based practices and work with substance abuse services providers to implement evidence based practices throughout the Commonwealth, and should take steps to provide training to local providers regarding implementation and ongoing evaluation of evidence based practices.

    * DMHMRSAS should consider establishing fiscal incentives to encourage local providers to implement evidence based practices.

    * Criminal justice programs that receive public funding should employ evidence based practices and to be able to demonstrate positive outcomes.

    * DOC and DJJ should collect and analyze client specific outcome data on inmates who participate in substance abuse services at state facilities and provide necessary resources to support data collection and analysis.

    * DMHMRSAS should collect and analyze accurate client outcomes data from community services boards, to determine the needs of the Department and the community services boards.

    * The Commonwealth should mandate a school-based survey of adolescents to collect data on substance use and abuse.

    * DOC, DJJ, and DCJS should adequately provide offenders under their agencies' responsibility with substance abuse screenings and, when necessary, assessments in order to identify inmates requiring substance abuse treatment.

    * DOC, DJJ, and DCJS should enter into standardized contractual agreements with third party providers of substance abuse services that will hold providers accountable for quality of services provided, including requirements for reporting on clients' progress and timeliness of providing services.

    * DMHMRSAS should, together with local community services boards, to develop a training curriculum or tool for judges that would address the effects of substance abuse, the benefits of training, and the treatment options available in the locality.

    * Funding for drug treatment courts in the Commonwealth should be maintained, and legislation establishing drug treatment courts in Franklin and Tazewell counties should be supported.

    * The Commonwealth should explore options for maximizing the role of Recovery Community Organizations in substance abuse treatment.

    * DMHMRSAS should work together with community services boards to implement medication assisted treatment options.

    The joint subcommittee recognized that many of these recommendations would require funding and that budget amendments might be necessary to support the recommended actions.

    The joint subcommittee also recommended that the study be continued for an additional year, to allow for further exploration of the issues and development of more comprehensive recommendations.