H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM Director Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services “The Ripple Effect of Substance Abuse on Family and Community” October 29, 2008 Mandan, ND North Dakota Conference on Injury Prevention & Control

2 President George W. Bush September 2003 “Alcohol addiction and drug addiction continue to challenge our Nation. Addiction to alcohol or drugs destroys family ties, friendship, ambition, and moral conviction, and reduces the richness of life to a single destructive desire.”

Substance Abuse and Mental Health Services Administration/CSAT SAMHSA’s Mission: To build resilience and facilitate recovery for people with or at risk for substance abuse and mental illness. Center for Substance Abuse Treatment (CSAT) Mission: To improve the health of the nation by bringing effective alcohol and drug treatment to every community.

4 The Impact of Addiction Addiction impacts an individual’s behavior, health, thinking process, quality of life, and overall functioning. Alcohol & other drugs are powerful reinforcing psychoactive substances that take on a life of their own.

5 SAMHSA’s Role in Supporting Recovery from Substance Use Problems & Disorders SAMHSA works to ensure that science, rather than ideology or anecdote, forms the foundation for the Nation’s addiction treatment system. SAMHSA serves health professionals and the public by disseminating scientifically sound, clinically relevant information on best practices in the treatment of addictive disorders and by working to enhance public acceptance of that treatment.

SAMHSA/CSAT’s Public Health Approach Population-based Comprehensive and holistic Incorporates early intervention, treatment, recovery support, and health promotion Works across systems and professions Involves people in recovery, the community, the public and private sectors Evidence-based

7 We Face Multiple Challenges Reaching those in need of services Providing adequate resources Developing culturally-appropriate, evidence- based interventions Building and sustaining a qualified workforce Integrating substance use disorder services into the public health paradigm

8 Greater Burden on Public Sector Source: Health Affairs, July-August All SA = $9.3B Public = $4.6 B Private = $4.6 B 2003 All SA = $20.7 B Public = $16.0 B Private = $4.7 B Private Public Projections indicate that the burden on the public sector will continue to increase

A Greater Burden & Tighter Budgets At the same time that a larger percentage of substance abuse treatment costs are being placed on the public sector, states are facing tighter budgets: 29 According to the Center on Budget and Policy Priorities, 29 states face budget shortfalls in 2009 – ranging from $59 Million to $22.2 Billion. Funds need to be used effectively for programs that can show evidence of their success All of these factors make the challenges facing treatment providers even more difficult.

The Challenges Remain Despite tightening budgets and changing populations, the challenges of alcohol and substance abuse remain. According to the 2007 National Survey on Drug Use and Health (NSDUH): –In 2007, an estimated 19.9 million Americans aged 12 or older were current (past month) illicit drug users. –Slightly more than half of Americans (12 and older) reported being current drinkers of alcohol – more than a fifth of them participated in binge drinking at least once in the 30 days prior to the 2007 survey.

Drug Abuse

Past Month Use of Specific Illicit Drugs among Persons Aged 12 or Older: Source: NSDUH, 2007

Past Month Nonmedical Use of Prescription Drugs (Psychotherapeutics) among Persons 12+: Percent Using in Past Month + Difference between this estimate and the 2006 estimate is statistically significant at the.05 level.

Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2007 Note: Totals may not sum to 100% because of rounding or because suppressed estimates are not shown. 1 The Other category includes the sources: “Wrote Fake Prescription,” “Stole from Doctor’s Office/Clinic/Hospital/Pharmacy,” and “Some Other Way.” Bought/Took from Friend/Relative 14.1% Drug Dealer/ Stranger 4.1% Bought on Internet 0.5% Other 1 4.2% Free from Friend/Relative 6/6% Bought/Took from Friend/Relative 5.9% Drug Dealer/ Stranger 1.8% Other 1 1.8% Source Where Respondent Obtained Source Where Friend/Relative Obtained One Doctor 18.1% More than One Doctor 2.6% Free from Friend/Relative 56.5% More than One Doctor 2.9% Bought on Internet 0.1% One Doctor 81.0%

Estimated numbers of new nonmedical users in past year by type of drug, US, Source: SAMHSA NSDUH, 2006 and 2007

Mean Age at First Use for Specific Drugs among Past Year Initiates Aged 12 to 49: 2007 Source: SAMHSA NSDUH 2007

Percentage of Persons 9.40 – – – – 7.19 Illicit Drug Use in Past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on NSDUHs

Percentages of Persons Illicit Drug Dependence or Abuse in Past Year among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Alcohol Misuse

Past Month Alcohol Use Any Use: 51%(127 million) Binge Use:23%(58 million) Heavy Use: 7%(17 million) (Current, Binge, and Heavy Use estimates are similar to those in ) Source: NSDUH 2007

Percentages of Persons Alcohol Use in past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Percentages of Persons Binge Alcohol Use in Past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Percentages of Persons Alcohol Dependence or Abuse in Past Year among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Percentages of Persons Perceptions of Great Risk of Having Five or more Drinks of an Alcoholic beverage Once or Twice A Week among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Alcohol Related Deaths There are approximately 79,000 deaths attributable to excessive alcohol use each year in the United States This makes excessive alcohol use the 3rd leading lifestyle-related cause of death for the nation. Source: Centers for Disease Control

Alcohol-Related Emergency Room Visits According to the Drug Abuse Warning Network (DAWN), in 2005 approximately 492,655 Emergency Department (ED) visits involved alcohol alone or in combination with another drug – 34% of all drug misuse/abuse ED visits. –Approximately 145,759 of these were alcohol-related ED visits for patients under the age of 21. –Two-thirds of the alcohol-related ED visits for minors involved alcohol alone.

Immediate Health Risks from Inappropriate Drinking Unintentional injuries. Risky sexual behaviors. Miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life. Alcohol poisoning Violence, including intimate partner violence and child maltreatment. Source CDC: Alcohol-Attributable Deaths Report, Average for United States

Unintentional Injuries Falls – An average of 5,532 deaths per year are related to alcohol Drownings – An average of 868 deaths per year are related to alcohol Traffic injuries – An average of 13,819 deaths per year are related to alcohol-related motor vehicle traffic crashes – An average of 183 deaths per year are related to motor-vehicle non-traffic crashes Source CDC: Alcohol-Attributable Deaths Report, Average for United States

Intimate Partner Violence & Child Maltreatment About 35% of victims report that offenders are under the influence of alcohol. Alcohol use is also associated with 2 out of 3 incidents of intimate partner violence. Studies have also shown that alcohol is a leading factor in child maltreatment and neglect cases, and is the most frequent substance abused among these parents. An average of 168 children die every year as a result of alcohol related child maltreatment Source CDC: Alcohol-Attributable Deaths Report, Average for United States

Alcohol Impaired Driving: In 2006, approximately 30.5 Million persons aged 12 or older drove under the influence of alcohol at least once during the past twelve months. North Dakota – at 24.9% -- reported the second highest rate of drivers 18 and older who reported driving under the influence of alcohol during the past year – only Wisconsin (at 26.4%) reported more. Source: OAS, NSDUH 2007, combined data

Other Unintentional Injuries Other annual deaths related to alcohol include: An average of 1,158 deaths related to burns An average of 123 unintentional firearm deaths An average of 370 poisoning deaths related to alcohol poisoning An average of 5,416 deaths per year related to alcohol related poisoning (not alcohol) An average of 269 deaths per year related to hypothermia An average of 7,787 homicide deaths Source CDC: Alcohol-Attributable Deaths Report, Average for United States

Alcohol-related Suicide Suicide – Alcohol related suicide has been related to an average of 7,235 deaths per year – Another 31 deaths per year have been attributed to suicide by and exposure to alcohol Source CDC: Alcohol-Attributable Deaths Report, Average for United States

Substance Misuse can: Lead to: Worsened medical conditions (e.g. diabetes, hypertension, dental) and Worsened brain disorders (e.g. depression, psychosis, anxiety & sleep disorders) Unintentional injuries & violenceUnintentional injuries & violence Result in: Dependence, which may require multiple treatment services Low birth weight, premature deliveries, and developmental disorders, child abuse & neglect

Substance Misuse can: Contribute to or be associated with : Homelessness Criminal justice involvementCriminal justice involvement The effect and abuse of prescribed medications Unemployment Gambling Bankruptcy Legal Issues (e.g. DUI, DWI, domestic violence)Legal Issues (e.g. DUI, DWI, domestic violence) Dropping out of school

Substance Misuse can: Induce or facilitate: Medical diseases (e.g. Stroke, dementia, hypertension, cancers, dental) Acquiring Infectious diseases & infections (e.g. HIV, Hepatitis C) Suicide attempts or tendenciesSuicide attempts or tendencies

Impact of Addiction on the Family Addiction is a developmental and inter-generational disease –Majority of persons who abuse or are dependent on psychoactive substances begin alcohol and drug use as teens –Children of parents who use are more likely to use themselves Children of substance abusing and dependent parents are at increased risk for – Abuse and neglect – Poor academic, health and psycho-social outcomes – Genetic propensity to addiction

Drug Use and Criminal Activities An annual average of 1.2 Million adults (18 years & older) were arrested for serious violent or property offenses from 2002 to An annual average of 60.1% of adults who were arrested from 2002 to 2004 for any serious offense were more likely to have used an illicit drug in the past 12 months than those who were not arrested (13.6%). Source: Illicit Drug use among Persons Arrested for Serious Crimes, NSDUH Report, December 16, 2005

The rate of substance abuse or dependence among adult offenders on probation or parole supervision is more than four times that of the general population 1 (38.5% vs. 9%) Nearly 3/4ths of state prison inmates are in need of some substance abuse intervention: –31.5% of male inmates and 52.3% of all female inmates require intensive services such as residential treatment programs. 2 1 NSDUH Report (2006) 2 Belenko and J. Peugh, Estimating drug treatment needs among state prison inmates, Drug and Alcohol Dependence (2005), Drug Use and Criminal Activities

Criminal Justice, Substance Abuse and Mental Health: The Impact on Society 72% of persons under justice supervision - jail/prison/probation/parole have a Co-Occurring Substance Abuse Disorder More than 60% of male arrestees have tested positive for at least 1 illegal drug 670,000+ offenders return to the community from State prison each year Almost 70% recidivate within 3 years of release 69% have Substance Abuse disorder Less than 10% receive treatment Source: US Department of Justice, Office of Justice Programs, The Bureau of Justice Statistics

20.8 Million Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use Felt They Needed Treatment and Did Make an Effort Did Not Feel They Needed Treatment Felt They Needed Treatment and Did Not Make an Effort 1.8% 93.6% Past Year Perceived Need for and Effort Made to Receive Specialty Treatment among Persons Aged 12 or Older Needing But Not Receiving Treatment for Illicit Drug or Alcohol Use: 2007 (955,000) (380,000) (19.5 Million)

Reasons for Not Receiving Substance Use Treatment: Persons Aged 12+ Percent Reporting Reason Not Ready to Stop Using No Program Having Type of Treatment No Health Coverage and Could Not Afford Cost No Transportation/Inconvenient Might Cause Neighbors/Community to Have Negative Opinion Able to Handle Problem without Treatment Those who Needed & Made the Effort to Get Treatment But Did Not Receive Specialty Treatment Source: NSDUH, combined Might Have Negative Effect on Job Did Not Know Where to Go for Treatment

North Dakota State Indicators Source: NSDUH average

Special Populations: Underage Drinkers & Adolescents

Underage Drinking According to the 2007 National Survey on Drug Use and Health (NSDUH), 10.7 million persons aged 12 to 20 reported drinking alcohol in the past month. Approximately 18.6% of them were binge drinkers, and 6% were heavy drinkers. 56.3% of current underage drinkers reported that their last use of alcohol in the past month occurred in someone else’s home (vs. 29.4% who reported it occurred in their own home).

Underage Drinking 30.2% of underage drinkers paid for the alcohol the last time they drank – 8.2% bought it themselves. Among those who had someone else pay for the alcohol, 37.2% got it from an unrelated person aged 21+, 20.7% from another person under 21, and 19.5% got it from a parent, guardian, or other adult family member. Source: 2007 NSDUH

Adolescents Drink Less Frequently than Adults But More Per Occasion Source: SAMHSA National Survey on Drug Use and Health 2007

Alcohol Use and Binge Drinking Rise Rapidly Over Ages 12 to 20 Source: SAMHSA National Survey on Drug Use and Health 2007

Percentages of Persons Alcohol use in Past Month among Persons Aged 12 to 20, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

Percentages of Persons Binge Alcohol use in Past Month among Persons Aged 12 to 20, by State: Percentages, Annual Averages Based on 2005 and 2006 NSDUHs

5,000 deaths among youth under 21 per year from alcohol related injuries including homicides (1,600) and suicides (300) Physical and sexual assaults; unwanted/unintended sexual activity Altered academic/vocational trajectories Possible adverse effects on developing brain Direct Consequences of Underage Drinking

Underage Drinking and Driving: 2007 Source: NSDUH, 2007

Parent Awareness of Youth Substance Use According to the 2006 National Survey on Drug Use and Health (NSDUH), the percentage of year olds using the following substances during the past year totaled: –17% for cigarettes –32.9% for alcohol –13.2% for marijuana Parent awareness is high for adolescent cigarette use, but remains low for alcohol use. Findings regarding parent awareness of adolescent marijuana use are mixed. Source: SAMHSA, NSDUH, 2006

Parent Awareness There appears to be a link between the level of parent’s awareness of the child’s substance use and the reported use during the past year. –This is particularly true for one-parent households. Reported past-year usage of alcohol, cigarettes, and marijuana by children in one-parent households was consistently higher for father- child pairs than for mother-child pairs. –Reported parent awareness of the child’s usage was consistently higher in mother-child pairs. Source: SAMHSA, NSDUH, combined data

One Parent Homes vs. Two-Parent Homes Mother-Child Pairs Father-Child Pairs Percentage of Youths aged in Parent-Child Pairs Who Reported Past Year Substance Use: Source: SAMHSA, NSDUH, combined data

Mother-Child vs. Father-Child Pairs Source: SAMHSA, NSDUH, combined data Percentages of Parents in Parent-Child Pairs Who Were Aware of Their Child’s Substance Use (where the child had used in the past year):

Special Population: Returning Veterans

57 Substance Abuse and Veterans The military enforces a strict schedule of drug testing – with severe consequences for those who are found abusing drugs. Alcohol remains the primary substance of abuse among veterans 1 Between 2005 and 2006, the Army saw an almost three-fold increase in “alcohol-related incidents,” according to the DOD Task Force on Mental Health. 75% of combat veterans with lifetime PTSD also met criteria for alcohol abuse or dependence. 2 1 National Survey on Drug Use and Health, Saxon, et al.,. (1998). Archives of General Psychiatry, 55:

58 PTSD, Alcohol Consumption and Deployment In one study of a non-treatment seeking sample of 800 US Army Iraq war veterans, an increase in PTSD symptoms between pre-deployment and post-deployment was associated with increased drinking from pre- to post deployment. 1 1 Vasterling, JJ et al, Journal of Rehabilitation Research & Development, vol.45(3), 2008

An estimated 30.7% of troops returning from Iraq and Afghanistan have a mental health condition or reported experiencing a traumatic brain injury (TBI). Mental Health Needs of Returning Vets Source: Rand Center for Military Health Policy Research, Invisible Wounds: Mental Health & Cognitive Care Needs of America’s Returning Veterans, retrieved 4/18/08 from

Prevalence of Serious Psychological Distress (SPD), SUD, and Co-Occurring SPD and SUD in the Past Year among Veterans, by Gender: 2004 to 2006 Source: The NSDUH Report, November 1, 2007

61 The Younger Veteran Population Has Specific Challenges Among depressed veterans, younger individuals (18-44 years) committed suicide at the highest rate (95 suicides per 100,000 person-years) 1 Veterans aged 18 to 25 have the highest rate of serious psychological distress (SPD) and substance use disorder (SUD) at 8.4%, with veterans 55 or older having the lowest rate at 0.7%. 2 1 Hampton, T., PhD, Research, Law Address Veterans’ Suicide, JAMA, 12/19/07 2 The NSDUH Report, November 1, 2007

Mental Health and Co-Occurring Illness Among Veterans Veterans with family incomes of less than $20,000 per year were more likely to have had co-occurring SPD & SUD in the past year than veterans with higher family incomes. 1 According to the Department of Veterans Affairs, 18% of the veterans recently back from tours of duty are unemployed. Of those employed since leaving the military, 25 percent earn less than $21,840 a year. 1 The NSDUH Report, November 1, 2007

An Holistic Approach to Recovery: Integrating Resources to Create a Client-centered Recovery Process

64 The Recovery Process Recovery from alcohol and drug problems is a process of change through which an individual achieves abstinence and improved health, wellness, and quality of life. Source: CSAT National Summit on Recovery, 2005

65 Challenges for a Traditional Approach Traditional treatment approaches provide challenges that translate into less cost-effective use of funds: 52.3% of those admitted to U.S. public substance abuse treatment programs in 2006 were re-entering treatment: –21.3% for the second time, 17.4% for the third or fourth time, and 13.6% for the fifth or more time. 1 One recent study found the that median time from first treatment to 1 alcohol- and drug-free year was 9 years – with 3 to 4 episodes of treatment. 2 ¹SAMHSA, Office of Applied Studies. Treatment Episode Data Set (TEDS). Highlights National Admissions to Substance Abuse Treatment Services 2 Dennis, M.L. et al, The duration and correlates of addiction and treatment careers, Journal of Substance Abuse Treatment 28 (Suppl. 1): S51-S62

66 Description of Recovery-Oriented Systems of Care A recovery-oriented systems of care approach supports person-centered and self-directed approaches to care that build on the strengths and resilience of individuals, families, and communities to take responsibility for their sustained health, wellness, and recovery from alcohol and drug problems. Source: CSAT National Summit on Recovery, 2005

Recovery-Oriented Systems of Care: A Paradigm Shift Recovery-Oriented Systems of Care shift the question from “How do we get the client into treatment?” to “How do we support the process of recovery within the person’s environment?”

68 Person’s Entry into treatment Discharge Severe Remission Resource: Tom Kirk, Ph.D Symptoms A Traditional Course of Treatment for a Substance Use Disorder

69 Acute symptoms Discontinuous treatment Crisis management Severe Remission A Traditional Service Response Resource: Tom Kirk, Ph.D

70 Promote Self Care, Rehabilitation A Recovery-Oriented Response Continuous treatment response Resource: Tom Kirk, Ph.D Severe Remission

71 Improved client outcomes Severe Remission Recovery Zone Symptoms Time Helping People Move Into A Recovery Zone Resource: Tom Kirk, Ph.D

Recovery-Oriented Systems of Care Approach In the recovery-oriented systems of care approach, the treatment agency is viewed as one of many resources needed for a client’s successful integration into the community. No one source of support is more dominant than another. Various supports need to work in harmony with the client’s direction, so that all possible supports are working for and with the person in recovery. Source: Addiction Messenger, November 2007, Vol. 10 Issue 11, published by the Northwest Frontier ATTC.

73 Benefits of Moving into a Recovery Zone Chronic care approaches, including self- management, family supports, and integrated services, improve recovery outcomes 1 Integrated and collaborative care has been shown to optimize recovery outcomes and improve cost-effectiveness 2 1 Lorig et al, 2001; Jason, Davis, Ferrari, & Bishop; 2001; Weisner et al, 2001; Friedmann et al, Smith, Meyers, & Miller, 2001; Humphreys & Moos, 2001)

ROSC offer a comprehensive menu of services and supports that can be combined and readily adjusted to meet the individual’s needs and chosen pathways to recovery. Individual Family Community Family/ Child Care Housing/ Transportation Financial LegalCase Mgt VSO & Peer Support Physical Health Care PTSD &Mental Health Alcohol/Drug Services Vocational Education Cultural & Spiritual HIV Services Services & Supports Recovery Wellness Health Adolescent Care

ROSC encompass and coordinate the operations of multiple systems… Individual Family Community Family/ Child Care Housing/ Transportation Financial LegalCase Mgt VSO & Peer Support Health Care PTSD & Mental Health Alcohol/Drug Treatment Vocational Educational Spiritual Addiction Services System Mental Health System Primary Care System Child Welfare and Family Services Housing System Social Services Health Insurance DoD & Veterans Affairs Indian Health Services Criminal & Juvenile Justice Systems Vocational Services HIV Services Faith Community HealthWellness Services & Supports Systems of Care Recovery Tribal Authorities Education System Adolescent Svcs.

…providing responsive, outcomes-driven approaches to care. Individual Family Community Family/ Child Care Housing/ Transportation Financial Legal Case Mgt VSO & Peer Support Health Care PTSD &Mental Health Alcohol/Drug Treatment Vocational Educational Spiritual Addiction Services System Mental Health System Primary Care System Child Welfare and Family Services Housing System Social Services Health Insurance DoD & Veterans Affairs Indian Health Services Criminal & Juvenile Justice System Abstinence Employment Crime Homelessness Evidence-Based Practice Cost Effectiveness Perception Of Care Social Connectedness Access/Capacity Retention Vocational Services HIV Services Faith Community Menu of Services Systems of Care Recovery Wellness Health Tribal Authorities Education System Organized Recovery Community Adolescent Svcs.

77 Goals of a Recovery-Oriented Systems Approach To support preventive strategies related to substance use problems & disorders; To intervene early with individuals with substance use problems; To support sustained recovery for those with substance use disorders; and To improve individual, family and community outcomes.

Benefits of a Recovery-oriented Systems Approach Reasons for integrating an ROSC approach into current programs: The ROSC approach more effectively responds to individuals, families, and communities It supports a framework for structuring policy development and planning It provides an opportunity to apply knowledge gained from recovery-oriented research

North Dakota SAPT Block Grant Outcomes North Dakota received $5.14 Million in SAPT Block Grant funds in FY 2007/2008. The latest available outcome data are from FY 2006: Source: SAMHSA, SAPT BG 2006 Clients reporting…AdmissionDischargeRate of Change No alcohol use59.6%84.5%41.8% No drug use71.3%85.6%20.1% No arrests84.6%89.5%5.8% Being employed45.4%54.0%19.0% Being housed98.0%98.2%0.2%

The Ripple Effect: Tsunami of Destruction and Despair The evidence is substantial that the impact alcohol misuse and illicit drug use ripples across the lives of individuals, their families and the community at large. We must remember that a ripple can become a tsunami: with neglect and denial we get a tsunami of destruction and despair.

The Ripple Effect: Tsunami of Hope & Recovery With Prevention & Treatment we can cast a pebble of Hope into the pool of substance misuse, abuse and dependence. There are many pathways to Recovery, the benefits of Recovery ripple across the lives of individuals, the community and society. With the commitment of the community, the ripple of that commitment will become a tsunami of Hope & Recovery for those at risk or suffering from substance use disorders..

SAMHSA Resources SAMHSA Website: www:samhsa.gov SAMHSA Substance Abuse Treatment Facility Locator at SAMHSA Health Information Network is our new clearinghouse – SAMHSA-7 – Monday-Friday 9 am – 4:30 p An international reference for distance education opportunities SHIN for publication ordering or information on funding opportunities – – TDD line HELP – SAMHSA’s National Helpline (average # of tx calls per mo.- 24,000)