Issue Brief. Substance Abuse: State Actions to Aid Recovery

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1 Issue Brief Health Policy Studies Division Contact: Robert J. Burns, 202/ or October 11, 2002 Substance Abuse: State Actions to Aid Recovery Summary The hidden costs of substance abuse and chemical dependency place an enormous burden on state budgets, economic productivity, and the well being of individuals and families. Of the $81.3 billion that states spent on substance abuse in 1998, approximately $78.3 billion (95.3 percent) went toward eradicating the crime, death, disease, and other social problems associated with the use of alcohol, tobacco, and illicit drugs. Only $3.4 billion (3.7 percent) was spent on the direct treatment and prevention of substance abuse and chemical dependency. Collectively, however, these costs account for 13 percent of total state spending. 1 One in four deaths in the United States is attributable to substance abuse and addiction. 2 Forty percent of all traffic fatalities and 8 percent of all motor vehicle crashes involve alcohol. 3 Tobacco use is responsible for nearly one in five deaths. 4 In 1998, the United States spent $12.9 billion treating substance-abuse-related accidents and illnesses, including cancer, emphysema, hypertension, heart disease, and pregnancy-related complications. 5 The social consequences of substance abuse are enormous. More than one third of the families involved with the child welfare system have alcohol or other drug problems that contributed to the abuse or neglect of their children. 6 More than half (52 percent) of all state prison inmates were under the influence of alcohol or drugs at the time of their arrest, and nearly one in six state inmates committed a crime to support a drug habit. 7 Substance abuse is also associated with high rates of suicide, divorce, unwanted pregnancy, domestic violence, disability, workplace absences as well as lost productivity, unemployment, poverty, and homelessness. Many of the problems associated with substance abuse and addiction can be minimized or prevented through state actions to coordinate public and private resources, build public awareness about the chronic nature of chemical dependency, invest in evidence-based prevention and treatment strategies, and improve access to treatment for current abusers. Substance Abuse Treatment & Prevention Expenditures by Funding Source, 1997 Other Private 3% Out-of-Pocket 9% Private Insurance 24% Other Federal 4% Medicare 8% Other State & Local 20% SAPT Block Grant 12% State Medicaid 8% Federal Medicaid 12% Total Expenditures = $11.4 billion Source: National Expenditures for Mental Health and Substance Abuse Treatment 1997 (Rockville, M.D.: U.S. Department of Health and Human Services, 2000). Actual State Substance Abuse Spending by Budget Category, 1998 Ot her 1.0% Treat ment, Prevent ion, Research 3.7% Consequent ial Spending 95.3% Pubic Safety 1.9% 1.9% Mental Health/ Developmental 7.2% Disabilities 7.2% Child/Family 9.5% Assistance 9.5% Justice 37.7% Educat ion 20.3% Healt h 18.7% Total Expenditures = $81.3 billion Source: National Center on Addiction and Substance Abuse, Shoveling Up: The Impact of Substance Abuse on State Budgets (New York, N.Y.: Columbia University, 2001).

2 Page 2, Substance Abuse: State Actions to Aid Recovery Recommendations Actions states can take immediately: 1. Coordinate stakeholder resources to create and sustain effective substance-abuse policies: o challenge stakeholders to develop a comprehensive statewide plan to address substance abuse and chemical dependency; and o designate authority for managing state substance-abuse-related investments to a cabinet-level agency, coordinating council, or state substance abuse agency. 2. Build public awareness about the chronic nature of chemical dependency and the societal benefits of treatment: o issue proclamations and use the bully pulpit to mobilize stakeholders and elevate substance abuse as a public policy concern; and o support social marketing and media campaign efforts to affect individual behavior and public attitudes towards substance abuse. 3. Implement cost-effective programs to prevent, reduce, or minimize the incidence of drug abuse and its negative consequences: o o require state agencies to measure the cost-effectiveness of prevention and treatment programs; and require state agencies to report on the short- and long-term effect of prevention and treatment programs in their annual budgets. 4. Encourage private insurers and businesses who purchase benefits for their employees to offer adequate coverage for treatment of chemical dependency: o support parity laws requiring private insurers to offer substance-abuse coverage equal to that of physical illness; o require insurers to offer a minimum level of coverage for substance-abuse treatment when purchased separately from standard medical coverage. 5. Leverage federal funds to expand coverage for substance-abuse treatment services: o leverage Medicaid optional services and waiver authority to expand coverage for substance-abuse treatment services; and o use TANF dollars to fund non-medical substance-abuse services and permit substance-abuse treatment to count toward a work requirement under the TANF program. 6. Require effective and sustainable treatment alternatives as part of sentencing for chemically dependent offenders: o expand the use of drug courts; o add treatment as a component of mandatory minimum sentencing requirements; and o empower judges to order a full continuum of treatment services in lieu of prison for low-risk, first-time offenders.

3 Page 3, Substance Abuse: State Actions to Aid Recovery A Closer Look at Substance Abuse Substance Abuse Defined Substance abuse is defined as the problematic use of alcohol, tobacco, and illicit drugs. The term is often used to describe a wide range of chronic conditions and social behavior legal and illegal associated with the use of mind- or mood-altering substances. The condition is often described or identified in three ways: 8-9 Recreational use: the low or infrequent exposure to alcohol and other drugs that can be considered social, occasional, or experimental, where damaging consequences are rare and minor; Abuse: the repeated, non-compulsive use of alcohol and other drugs. The condition causes functional problems but is not associated with withdrawal. Substance abuse is often associated with the sporadically heavy and intensive use of alcohol and other drugs, where the effects are unpredictable and sometimes severe. Dependence (or addiction): a chronic, recurring medical illness marked by the persistent use of alcohol and drugs despite the functional problems associated with their use. Chemical dependency, which includes addiction to alcohol and tobacco, is often associated with the use of large or frequent doses followed by symptoms of compulsion, craving, and withdrawal. The Causes of Substance Abuse and Chemical Dependency Environmental, physiological, and psychosocial factors are the leading causes of substance abuse and chemical dependency and present the best opportunities for treatment and prevention. For the most part, the recreational use and abuse of alcohol, tobacco, and illicit drugs is recognized as a personal behavior influenced by a number of environmental factors. These include exposure to prouse messages, the wide-spread availability of alcohol and tobacco products, and other variables such as age, education, socioeconomic status, population density, and proximity to high-traffic areas. All of these factors have a significant influence on public attitudes and behaviors. Chronic Disease or Social Behavior? Approaching chemical addiction as a long-term chronic illness yields positive results. An evaluation of outcome studies in 24 states revealed consistently that long-term substance abuse treatment is a cost-effective means of reducing criminal activity, increasing employment and worker retention, improving physical and mental health, and strengthening familial and social functioning. Chemical dependency (or addiction) is a chronic disease that does not resolve itself spontaneously and is rarely cured completely. However, like other chronic diseases including obesity, hypertension, and diabetes, and asthma sobriety can be maintained through a prescribed treatment regimen administered throughout a person s lifetime. Substance abusers are often faulted for not adhering to their treatment regimen, which generally involves a combination of education, counseling, and medication. This perception is fueled by the fact that percent of substance abusers relapse to the point of addiction within one year following treatment (and often go through treatment multiple times before maintaining sobriety). Ironically, the relapse rates for substance abusers are not unlike those for individuals with other chronic diseases, such as diabetes, hypertension, and asthma. Approximately percent of adult patients with diabetes and percent of adult patients with hypertension and asthma experience a recurrence of symptoms each year to the point where they require medical treatment. The rates of failure to adhere to their prescribed treatment regimen are also similar. The challenge for policymakers and the public is to understand the chronic nature of chemical dependency and to recognize the societal benefits of treatment. Source(s): National Association of State Alcohol and Drug Abuse Directors. Alcohol and Drug Treatment Effectiveness: A Review of State Outcome Studies (Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors, 2001); McLellan AT, Lewis D, O Brien CP, Kleber HD. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA, October 4, 2000, volume 4, no. 13: pp It must be recognized, however, that continued drug use is not always a matter of poor personal judgment or bad behavior. While the initial use of any drug is voluntary, genetic and psychosocial factors play a critical role in the continuing use of a substance to the point of dependence. In fact, chemical dependency (or addiction) is not a voluntary behavior; rather, it is a chronic disease that rarely can be cured completely:

4 Page 4, Substance Abuse: State Actions to Aid Recovery Susceptibility to addiction is similar to that of other chronic diseases, such as type 2 diabetes, hypertension, and asthma; 10 As with other chronic illnesses, substance abusers often return to treatment multiple times (or make repeated attempts to quit on their own) before they can maintain sobriety. Relapse rates for substance abusers are not unlike those for individuals with other chronic diseases, including type-1 diabetes, hypertension, and asthma. 11 As with other chronic diseases including hypertension, diabetes, and asthma, and obesity sobriety can usually be maintained through a treatment regimen of education, counseling, and medication administered throughout a person s lifetime. An evaluation of outcome studies in 24 states consistently revealed that longterm substance-abuse treatment is a cost-effective means of reducing criminal activity, increasing employment and worker retention, improving physical and mental health, and strengthening familial and social functioning. 12 The Social Costs of Substance Abuse Deaths, illnesses, disabilities, and other social problems caused by substance abuse place an enormous burden on state budgets and the economy in general. Alcohol is the single largest cause of traffic fatalities in the United States. 13 Cigarette smoking is responsible for 87 percent of all lung cancers, the leading cause of death in the United States. 14 Substance abusers tend to have higher health care costs and use services more frequently. 15 Alcohol and other drug use are known contributors to suicide, divorce, unwanted pregnancy, domestic violence, disability, workplace absences and lost productivity, unemployment, poverty, and homelessness. Taken together, the use of alcohol, tobacco, and illicit drugs: costs states $3.4 billion annually in direct treatment and prevention and an additional $77.9 billion in cleaning up the crime, death, disease, and other social consequences associated with their use; 16 accounts for 13 percent of all state spending (when combining the related death, disease, crime, unemployment, poverty, and other social costs associated with their use); 17 costs employers $131 billion annually in lost productivity and twice as much per employee in medical and worker compensation claims than similar costs for drug-free employees Human Costs of Substance Abuse More deaths, illnesses, and disabilities are caused by substance abuse than by any other preventable health condition. One in four deaths in the United States is attributable to alcohol, tobacco, or illicit drug use. In fact, substance abuse ranks behind only coronary disease as the leading cause of death in the United States. Substance abuse and chemical dependency place an enormous burden on individuals, families, and society, including: pregnancy-related complications (pre-term delivery); low birth weight babies; fetal alcohol syndrome; sudden infant death syndrome; impaired psychological development; cancer(s); cirrhosis; cardiovascular disease; respiratory problems; communicable diseases; traffic fatalities; disabilities; workplace absenteeism and poor performance; job-related accidents; employee turnover; unemployment; divorce, separation, and family dysfunction; domestic violence; child neglect; crime (thefts, homicides, assaults); poverty; and homelessness. Source: Horgan C., et al, Substance Abuse: The Nation s Number One Health Problem (Princeton, N.J.: Robert Wood Johnson Foundation, 2001).

5 Page 5, Substance Abuse: State Actions to Aid Recovery State Options for Action Coordinating stakeholder resources to create and sustain effective substance-abuse policies; Building public awareness about the chronic nature of chemical dependency and the societal benefits of treatment; Implementing cost-effective programs to prevent, reduce, or minimize the incidence of drug abuse and its negative consequences; Engaging private insurers to offer adequate coverage for treatment of chemical dependency; Leveraging federal funds to expand coverage for substance-abuse treatment services; and Requiring effective and sustainable treatment alternatives as part of sentencing for chemically dependent offenders. Coordinate Stakeholder Resources Substance-abuse policy is often characterized by the fragmented efforts of a number of stakeholder groups, including community groups, providers, federal agencies, state substance-abuse authorities, law enforcement officials, human services agencies, educators, local government, providers, recovering addicts, and others. Governors can employ a variety of mechanisms to channel public resources and develop more consistent, costeffective policies to address substance abuse. Governors can use their executive powers to better coordinate substance-abuse resources within state government. They can also engage stakeholders through permanent commissions and interim workgroups task forces, roundtables, blue-ribbon commissions to recommend systemic changes to existing state substance-abuse policies. Five states Connecticut, New York, Ohio, Oklahoma, and South Carolina have established cabinetlevel agencies to develop policy and coordinate statewide activities around substance abuse. Kentucky created the Agency for Substance Abuse Policy within the Governor s office to coordinate the prevention and treatment efforts of public agencies and private service providers. The agency has a twoyear budget of $5 million funded largely with tobacco settlement funds. In addition to developing a strategic plan for using public funds, the agency is establishing a mechanism for distributing funds to support local efforts. 20 Minnesota established the State Agencies Focused on Effectiveness (S.A.F.E.) Coordinating Council to ensure that the many substance abuse and violence prevention programs operating throughout the state were working toward a common goal. Since its inception, the council has made fourteen recommendations for streamlining the grant processes across all state agencies, among them the delegation of signature authority to assure the rapid sign-off of grant agreements. The council also has developed a resource guide linking state agencies with descriptions of the various grants available to them. The guide and other resources are available through the council s Web site (http://www.safe.state.mn.us/). 21 Maine established its Office of Substance (OSA) abuse as the central mechanism for administering all of its federal block grant funds. The OSA was given oversight of federal block grant and tobacco settlement monies through enabling legislation. Through an executive order by the Governor, the OSA now also administers federal juvenile justice and Safe and Drug-Free Schools and Communities funds. Consolidating these funds into a single state agency has helped the state avoid duplication of effort and made it easier to work with local programs. 22

6 Page 6, Substance Abuse: State Actions to Aid Recovery Build Public Awareness A critical challenge for policymakers is to foster public understanding of the chronic nature of chemical dependency and to recognize the societal benefits of treatment. Governors can issue proclamations and use the bully pulpit to mobilize stakeholders and to elevate substance abuse as a public policy issue. They also can support a variety of social marketing and media campaigns to affect public attitudes towards substance abuse. New York Gov. George Pataki proclaimed a day of recovery to raise citizen awareness about substance abuse and the importance of recovery programs. In Washington, Gov. Gary Locke proclaimed Fetal Alcohol Syndrome Awareness Month to encourage the development of prevention and education programs that could eradicate the birth defect caused by maternal alcohol use. In South Carolina, Gov. Jim Hodges proclaimed a Recovery Month to focus on the availability and effectiveness of addiction treatment. In addition, Gov. Don Sundquist called on citizens in Tennessee to recognize the incidence of co-occurring mental health and substance-abuse disorders by issuing a Co-Occurrence Day proclamation. The Governor s Commission for a Drug-Free Indiana developed a marketing campaign, called Deal With It, to encourage citizen advocacy for a drug free state. The campaign features brochures and other printed materials that can be ordered by community organizations. It also offers a hotline for individuals to get in touch with their local drug-free advocates or for citizens to learn about treatment options. The commission also has established a special fund to help community leaders mobilize their local advocacy efforts. State Officials in New Hampshire are working with a non-profit organization, New Futures, to strategically foster, promote, and support effective strategies to reduce alcohol, tobacco, and other drug problems. New Futures uses traditional marketing techniques to measure public attitudes, opinions, and perceptions about alcohol and other drug problems in the state. The information is used to mobilize local, state, and national resources. The organization s activities are guided by a board of directors that includes representatives from the state substance-abuse authority, the division of juvenile justice services, and the state legislature. Implement Evidence-Based Prevention Initiatives Difficult budget climates require policymakers to ensure investments are being made in cost-effective prevention programs with a demonstrable record of success. Governors can use their executive authority to cultivate effective evidence-based prevention programs within state government and throughout local communities. Evidence-based programs are programs that require demonstrable evidence of their costeffectiveness at reducing or minimizing the incidence of drug abuse and its negative effects. In Kansas, the Governor s Substance Abuse Prevention Council was established by executive order to develop a comprehensive coordinated system of prevention throughout the state. The council developed a guideline of model concepts and principles called the Kansas Planning Framework for designing, implementing, and evaluating the effectiveness of substance-abuse prevention programs and activities. Each state agency is now legislatively required to incorporate the Framework concepts into its own prevention planning efforts. South Carolina created the Governor s Cooperative Agreement on Prevention (G-CAP) to manage a three-year, $9 million federal State Incentive Grant administered by the Cabinet-level Department of Alcohol and Other Drug Abuse Services. Focusing on science-based prevention strategies and directed at ages 12-17, the program in its first year saw the development of 19 community-based coalitions. The Governor s Office coordinates an advisory oversight group composed of provider agencies and community stakeholders.

7 Page 7, Substance Abuse: State Actions to Aid Recovery Colorado created a new division within the Department of Public Health and Environment with the authority to consolidate a number of state prevention-oriented substance-abuse programs for children and youth. Through memoranda of understanding, programs across 10 state departments are expected to link their planned program goals and outcomes with one or more of the performance measures adopted by the new division. Both public and private programs will be ineligible for state funding until they adopt at least one of the 75 performance measures established by the new division. Engage Private Insurers States are well positioned to leverage resources from the private sector and the federal government to sustain coverage for substance-abuse treatment during difficult budget years. Private insurers traditionally have been reluctant to provide coverage for substance-abuse treatment, mainly because of its perceived costs and the availability of government-supported services. In response, a number of states have enacted parity laws that to varying degrees require insurers to offer the same level of benefits for chemical dependency as for physical illness. 23 Massachusetts parity law requires insurers to extend full coverage for chemical dependency for individuals with co-occurring mental health and substance-abuse disorders. The parity laws in Indiana, North Carolina, and South Carolina require insurers to extend substanceabuse benefit protections for all state employees. Five states Connecticut, Delaware, Kentucky, Minnesota, and Vermont have enacted comprehensive parity laws requiring insurers operating in the state to provide equivalent coverage for substance abuse treatment as for physical illness. Leverage Federal Resources Medicaid coverage for treatment of chemical dependency is limited. The basic Medicaid program covers only medical-related services associated with substance abuse, such as detoxification, inpatient and outpatient hospital services, and physician services. However, states may purchase optional services under Medicaid to extend coverage for substance-abuse treatment. While purchasing these services does require state match, it also provides an opportunity for states to leverage additional federal dollars in support of their substance-abuse priorities. The six optional services that may be purchased under Medicaid are rehabilitative services, clinical services, inpatient psychiatric services, services of other health professionals, prescription drugs and targeted case management. A summary of these optional treatment services is contained in Appendix A. Twenty-nine states have used Section 1115 or Section 1915(b) waivers to cover substance-abuse treatment services under Medicaid. Most of those waivers were also used to cover mental health services. However, Iowa and Minnesota have used Section 1915(b) waivers to provide substance-abuse benefits exclusively. 24 A number of states are using the federal Temporary Assistance for Needy Families (TANF) program to reach vulnerable groups and facilitate their entry into treatment. Federal TANF dollars may be used for non-medical services, supports, and employment-related activities for needy families affected by substance abuse. Under its TANF program, New Jersey counts substance-abuse treatment as a work activity. Ohio, Utah, and Wisconsin use a portion of their TANF dollars to fund substance-abuse prevention and treatment services for children (or their families) whose income is at or below double the official income poverty guideline. In addition, North Carolina and South Carolina use TANF dollars to support non-medical substance-abuse services in residential treatment centers that accommodate children. South Carolina also targets substance-abuse services for TANF recipients through Partners in Achieving Independence through Recovery and Self-Sufficiency

8 Page 8, Substance Abuse: State Actions to Aid Recovery (PAIRS), a partnership of the cabinet-level Departments of Alcohol and Other Drug Abuse Services and Social Services. Require Treatment for Addicted Offenders States are incorporating a variety of treatment alternatives for chemically dependent offenders to help reduce drug-related crime and to relieve the financial burden of substance abuse on the criminal justice system. Many states are using diversion programs and probation-based drug courts to push offenders into treatment. Nearly 700 drug courts are in operation throughout the United States, with close to 500 more planned for development. 25 Drug courts give judges the flexibility to order treatment, frequent testing, and close monitoring of drug offenders in lieu of incarceration. A program in Connecticut empowers judges to order a full continuum of treatment alternatives for lowrisk, first-time offenders. Some alternatives even combine substance-abuse treatment with community service requirements. The program operated on a budget of $55 million during fiscal year 2000, which supported treatment services for both juveniles and adults. A study of the program revealed that nonparticipants were rearrested at three times the rate of program participants. 26 Washington reduced by six months from 24 to 18 months the mandatory minimum sentences for several offenses related to selling heroin or cocaine. Roughly 75 percent of the savings derived from reduced prison rolls will go to counties for court-supervised treatment programs. The remainder will be spent on treatment programs run by the state prison system. Delaware funds a program that provides drug-addicted inmates access to treatment in the last months of their incarceration followed by work-release and intensive aftercare services in the community. A University of Delaware study revealed that 18 months after release, 71 percent of program participants remained arrest-free, and 76 percent remained drug-free (compared to 30 percent and 19 percent of nonparticipants, respectively). The program is funded with $4 million each year from the state and treats approximately 13,000 inmates annually CONCLUSION States are working hard to curb the enormous burden of substance abuse on state budgets, economic productivity, and the well-being of individuals and families. Governors are using a variety of tools to advance their substance-abuse priorities, including coordinating councils, proclamations, social marketing, evidencebased prevention programs, parity laws, Medicaid optional services and waivers, TANF programs, drug courts, and offender treatment in lieu of incarceration. Expanding on these efforts in the future, Governors will continue to pursue cost-effective policies to affect the larger social and economic problems associated with substance abuse and chemical dependency. This paper was researched and written by Robert J. Burns and funded through a cooperative agreement with the Health Resources and Services Administration, U.S. Department of Health and Human Services.

9 Page 9, Substance Abuse: State Actions to Aid Recovery 1 National Center on Addiction and Substance Abuse, Shoveling Up: The Impact Of Substance Abuse on State Budgets (New York, N.Y.: Columbia University, 2001). 2 Horgan C., et al, Substance Abuse: The Nation s Number One Health Problem (Princeton, N.J.: Robert Wood Johnson Foundation, 2001). 3 U.S. Department of Transportation, National Highway Traffic Safety Administration, Traffic Safety Facts 2000: Alcohol (Washington, D.C.: NHTSA, 2001). 4 American Cancer Society, Cancer Facts & Figures 2001 (Atlanta, G.A.: American Cancer Society, 2001). 5 Office of National Drug Control Policy, The Economic Costs of Drug Abuse in the United States, (Washington, D.C.: Executive Office of the President, 2001). 6 Young NK, Gardner SL, Dennis K, Responding to Alcohol and Other Drug Problems in Child Welfare: Weaving Together Practice and Policy (Washington, D.C.: Child Welfare League of America, 1998). 7 U.S. Department of Justice, Office of Justice Programs, Substance Abuse and Treatment, State and Federal Prisoners, 1997 (Washington, D.C.: Office of Justice Programs, Bureau of Justice Statistics, 1999). 8 National Conference of State Legislatures, Treatment of Alcoholism and Drug Addiction: What Legislators Need to Know, (Washington, D.C.: National Conference of State Legislatures, 2000). 9 Gerstein DR, Henrick, JH, eds., Treating Drug Problems 1, Institute of Medicine (Washington, D.C.: National Academy Press, 1990, 59; Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, Washington, DC: American Psychiatric Association; McLellan AT, Lewis D, O Brien CP, Kleber HD. Drug Dependence, a Chronic Medical Illness: Implications for Treatment, Insurance, and Outcomes Evaluation. JAMA, October 4, 2000, volume 4, no. 13: pp Ibid. 12 National Association of State Alcohol and Drug Abuse Directors. Alcohol and Drug Treatment Effectiveness: A Review of State Outcome Studies (Washington, D.C.: National Association of State Alcohol and Drug Abuse Directors, 2001). 13 National Highway Traffic Safety Administration, Traffic Safety Facts 2000: Alcohol (Washington, D.C.: U.S. Department of Transportation, 2001). 14 American Cancer Society, Cancer Facts & Figures 2001 (Atlanta, G.A.: American Cancer Society, 2001). 15 French, M.T., McGeary, K.A. (2000) Chronic Illicit Drug Use, Health Services Utilization, and the Cost of Medical Care. Social Science and Medicine, 50 (12), National Center on Addiction and Substance Abuse, Shoveling Up: The Impact Of Substance Abuse on State Budgets (New York, N.Y.: Columbia University, 2001). 17 Ibid. 18 National Institute on Drug Abuse, NIDA Info Facts (Bethesda, M.D.: U.S. Department of Health and Human Services, 1999). 19 Substance Abuse and Mental Health Services Administration, Substance Abuse and Mental Health Statistics Sourcebook, 1998 (Rockville, M.D.: U.S. Department of Health and Human Services, 1998). 20 Substance Abuse and Mental Health Services Administration, A Framework for Strengthening State Substance Abuse Prevention Systems: Sharing Practical Experiences (Rockville, M.D.: Center for Substance Abuse Prevention, 2002). 21 Ibid. 22 Ibid. 23 Drug Strategies, Inc. Critical Choices: Making Drug Policy at the State Level (Washington, D.C.: Drug Strategies, Inc., 2001); Mental Health and Substance Abuse Parity. Issue Brief (July 1, 2002). National Conference of State Legislators, Washington, D.C. 24 State Profiles on Public Sector Managed Behavioral Health Care and Other Reforms (Washington, D.C.: Substance Abuse and Mental Health Services Administration, 1998). 25 Belenko, S. Research on Drug Courts: A Critical Review, 2001 Update, (New York, N.Y., National Center on Addiction and Substance Abuse at Columbia University, 2001). 26 Drug Strategies, Inc. Critical Choices: Making Drug Policy at the State Level (Washington, D.C.: Drug Strategies, Inc., 2001). 27 Ibid. 28 Martin, Stan, et al., Three-Year Outcomes of Therapeutic Community Treatment for Drug-Involved Offenders in Delaware: From Prison to Work Release to Aftercare, Prison Journal 79 (3) (September 1999):

10 Page 10, Substance Abuse: State Actions to Aid Recovery APPENDIX A Summary of Optional Substance Abuse Services Covered Under Medicaid States may purchase optional services under Medicaid to extend coverage for substance-abuse treatment. While purchase of these services does require a state match, it also provides an opportunity for states to leverage additional federal dollars in support of their substance-abuse priorities. Optional Medicaid purchasing options include: Rehabilitative Services Option (aka, the Rehab option ) may be used to cover a broad and flexible range of services, including: assessments; psychosocial rehabilitation services; day treatment; life skills training; drug-abuse treatment; training and education on medication issues; and crisis intervention services. These may be provided in any setting, including clinics, nursing homes, senior centers, residential treatment centers, group homes, and other community-based settings. The Rehab option is by far the most common service option used to expand coverage for substance-abuse treatment. Clinic Services Option may be used to cover individual, group, and family counseling; physician services; medication management; and emergency/crisis services from a wide variety of agencies and clinics. Inpatient Psychiatric Services Option may be used to cover services in institutions for children under the age of 21 and for older adults over the age of 65 with mental disorders in institutions for mental diseases (IMDs) that require acute inpatient care to ensure their safety and/or address serious substance abuse problems. Services of Other Health Professionals Option may be used to cover the services of other health professionals, such as psychological testing or psychiatric social work services. Prescription Drugs Option may be used to cover psychotropic medications and other prescription drugs used to treat substance-abuse disorders. Targeted Case Management Services Option may be used to cover case management services to assist enrollees in gaining access to needed medical, social, educational, and other services that are called for in a mental health or substance-abuse treatment plan. (This option may be targeted to high-risk geographic areas and population groups, such as mentally ill elders prone to violence.) Personal Care Services Option may be used to cover services for individuals who require more personal care [Title XIX, 1905(a)(4)], such as those suffering from severe psychiatric disorders. U.S. Department of Health and Human Services. Contracting for Managed Substance Abuse and Mental Health Benefits: A Guide for Public Purchasers (Rockville, M.D.: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1998).

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