Substance Abuse Prevention and Treatment Agency 2011 Annual Report

Transcription

1 Substance Abuse Prevention and Treatment Agency Nevada Division of Mental Health and Developmental Services Department of Health and Human Services Brian Sandoval, Governor Michael J. Willden, Director Department of Health and Human Services Richard Whitley, MPH, Acting Administrator Division of Mental Health and Developmental Services State Fiscal Year 2011

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3 Substance Abuse Prevention and Treatment Agency Deborah McBride, MBA, Agency Director William Bailey, Data Team Supervisor Charlene Herst, Prevention Team Supervisor Layne Wilhelm, Treatment Team Supervisor Gaylene Nevers, Health Program Specialist I

4 ACKNOWLEDGEMENTS Thanks to the following SAPTA team members for their contributions: Darla Beers ~ Directories and editing Margaret Dillon ~ Overview sections Minden Hall ~ Directories and editing Charlene Howard ~ Prevention sections Bill Kirby ~ Prevention sections Nan Kreher ~ Treatment and Prevention sections Gregg Leiss ~ Fiscal sections Steven McLaughlin ~ Treatment sections Tonya Wolf ~ Treatment and Prevention sections

5 Table of Contents TABLE OF CONTENTS List of Charts... ii List of Tables... iii List of Maps... iii I. Agency Overview... 1 II. Treatment Assessment Capacity Planning Implementation Evaluation III. Prevention Assessment Capacity Planning Implementation Evaluation IV. Directories Treatment Directory 71 Prevention Directory...81 V. List of Acronyms i

6 Table of Contents TABLE OF CONTENTS LIST OF CHARTS Chart 1: SAPTA Revenue Sources, SFY Chart 2: SAPTA Revenue Sources, SFY Chart 3: SAPTA Expenditures, SFY Chart 4: NOMs Admission Geographical Comparisons, SFY Chart 5: NOMs Change from Admission to Discharge Geographical Comparisons, SFY Chart 6: Nevada Methamphetamine Admissions by Primary Drug to SAPTA, SFY Chart 7: Nevada Meth and Heroin Admissions, by Primary, Secondary and Tertiary Use, SFY SFY Chart 8: Drug and Related Arrests and Alcohol Related Crimes, Chart 9: Drug Related Murders in Nevada, Chart 10: Health Insurance Coverage for Nevada Funded Programs, SFY Chart 11: SAPTA Treatment Admissions, Nevada, SFY Chart 12: Adolescent Treatment Admissions, Nevada, SFY Chart 13: Adolescent Treatment Admissions by Gender, Nevada, SFY Chart 14: Admissions to Treatment by Race and Ethnicity, Nevada, SFY Chart 15: Admissions to Treatment by Referral Source, Nevada, SFY Chart 16: Admissions to Area of Residence, Nevada, SFY Chart 17: Admissions to Treatment by Drug of Choice, Nevada, SFY Chart 18: Pregnant Women and Injection Drug Users Admissions to Treatment, Nevada, SFY Chart 19: Admissions to Treatment by Level of Care, SFY Chart 20: Synar Noncompliance Rate for Nevada, FFY Chart 21: Prevention Participants by Area, Nevada, SFY Chart 22: Prevention Participants by Gender, Nevada, SFY Chart 23: Prevention Participants by Race and Ethnicity, Nevada, SFY 2010 and SFY Chart 24: Prevention Participants by Adults and Adolescents, Nevada, SFY 2010 and SFY Chart 25: Prevention Participants by Age Group, Nevada, SFY ii

7 Table of Contents (cont.) TABLE OF CONTENTS LIST OF TABLES Table 1: SAPTA Revenue Sources, SFY 2007 and SFY Table 2: Substance Abuse Treatment and Prevention NOMs... 8 Table 3: Estimates of Need for Treatment in Nevada, Table 4: Unmet Demand Estimate for Substance Abuse Treatment, Table 5: YRBS Questions on Drinking, Drug use, and Suicide Related Behaviors Table 6: Admissions to SAPTA Funded Providers by Primary Drug of Choice, SFY Table 7: Waiting List Trend Data, SFY SFY Table 8: Prevention Participants Served LIST OF MAPS Map 1: Binge Alcohol Use among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2008 and 2009 NSDUHs Map 2: Perceptions of Great Risk of Having Five or More Drinks, 2008 and 2009 NSDUHs Map 3: Prescription Drug Abuse in SFY 2011 by Zip code Map 4: Provider Admissions for all Drugs in SFY 2011 by Zip Code Map 5: Coalition Locations and Counties Served iii

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9 Section I AGENCY OVERVIEW Agency Overview Our Mission: The mission of the Substance Abuse Prevention and Treatment Agency is to reduce the impact of substance abuse in Nevada. The Substance Abuse Prevention and Treatment Agency (SAPTA) is located within the Nevada Division of Mental Health and Developmental Services (MHDS), in the Department of Health and Human Services (HHS). It is the designated Single State Authority for the purpose of applying for and expending the federal Substance Abuse Prevention and Treatment Block Grant issued through the Substance Abuse and Mental Health Services Administration (SAMHSA). The Agency has an office at 4126 Technology Way, 2nd Floor, in Carson City and an office located at 1840 East Sahara, Suite 111, in Las Vegas. The Agency provides funding via a competitive process to non-profit and governmental organizations throughout Nevada who provide direct substance abuse prevention or treatment services. The Agency plans and coordinates statewide substance abuse service delivery and provides technical assistance (TA) to programs and other state agencies to ensure that resources are used in a manner which best serves the citizens of Nevada. SAPTA actions are regulated under Nevada Revised Statutes (NRS) Chapter 458 Abuse of Alcohol and Drugs and Nevada Administrative Code (NAC) Chapter 458 Abuse of Alcohol and Drugs. Additionally, SAPTA and/or its subgrantees must meet certain requirements found elsewhere in the NRS, Code of Federal Regulations (CFR), Circulars published by the Office of Management and Budget (OMB), and/or Public Laws passed by the U.S. Congress. A related list, where other rules and regulations SAPTA implements and/or operates under, is shown below: NRS Chapter 484 Traffic Laws 42 CFR, Part 2 Confidentiality of Alcohol and Drug Abuse Patient Records 42 CFR, Parts 54 and 54a - Charitable Choice Regulations 45 CFR, Part 74 Uniform Administrative Requirements for Awards and Subawards to Institutions of Higher Education, Hospitals, Other Nonprofit Organizations, and Commercial Organizations; and Certain Grants and Agreements with States, Local Governments and Indian Tribal Governments 45 CFR, Part 96 Substance Abuse and Treatment Block Grants OMB Circular A-133 Audits of States, Local Governments, and Non-Profit Organizations Public Law Health Insurance Portability and Accountability Act (HIPAA) of 1996 Public Health Service Act 2005 In accordance with NRS , the functions of SAPTA include: 1. Statewide formulation and implementation for prevention, intervention, treatment, and recovery of substance abuse is identified in the Substance Abuse Prevention and Treatment Block Grant. (SAPT BG) 2. Statewide coordination and implementation of all state and federal funding for alcohol and drug abuse programs. 1

10 Section I Agency Overview 3. Statewide development and publication of standards for certification and the authority to certify treatment levels of care and prevention programs. 4. Needs assessment for prevention services in Nevada. The addiction landscape is expected to change considerably in the near future because of the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) and general health care reform mandated by the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of As federal requirements become known and related policies are implemented, the Agency s business practices will need to change accordingly. In order to best serve the citizens of Nevada, Agency staff is organized into five teams: The Data, Planning, and Evaluation team, which performs planning and evaluation functions and collects and reports data as required by SAMHSA. The Fiscal team which performs all financial functions. The Prevention team which provides oversight and technical assistance (TA) to Nevada s Coalitions and prevention program providers. The Treatment team, which provides oversight and TA to Nevada s treatment providers. The Support Staff team, which performs functions for the other teams and the Agency in general. Prevention is a process that prepares and supports individuals and communities in the creation and reinforcement of healthy behaviors and lifestyles. SAPTA funds prevention programs to reduce and prevent substance abuse statewide via one or more of the six prevention strategies that are promoted by the Center for Substance Abuse Prevention (CSAP). The six strategies include: information dissemination, prevention education, alternative activities, problem identification and referral, community based processes, and environmental strategies. In the past, SAPTA established a system whereby the Agency purchased substance abuse prevention services directly. However, starting July 1, 2008, all substance abuse prevention services were contracted out through Agency funded substance abuse prevention coalitions. Within the system, applicants are responsible for compliance with coalition, state, and federal requirements with regards to receipt of funding. The Agency currently funds private, non-profit treatment organizations and government agencies statewide using the Division Criteria for Treating Substance Related Disorders (DCTSRD) services and levels of care: Comprehensive Evaluations, Early Intervention, Civil Protective Custody, Detoxification, Residential, Intensive Outpatient, Outpatient, Transitional Housing, and Opioid Maintenance Therapy for adults that must be delivered in conjunction with outpatient treatment levels of care. Additionally, the Agency has an established Telecare modality which allows providers to better serve clients in remote areas of the state. As required in Programs Operating and Access Standards (POAS), SAPTA funded treatment providers must implement evidence-based treatment practices based on scientific research. Quality substance abuse treatment programs are designed to coordinate services that support both client counseling and provide a continuum of care. The National Institute on Drug Abuse (NIDA) has developed a research-based guide to treatment (Principles of Drug Addiction Treatment) that is utilized in the treatment field. Additionally, programs treating substance related disorders use the Diagnostic and Statistical Manual of Mental Disorders IV (DSM- IV), in conjunction with NIDA principles and DCTSRD to determine an appropriate level of care. 2

11 Section I Agency Overview FISCAL AND DATA SAPTA is funded from a number of federal and state sources. The Agency manages current funding and develops new sources to finance prevention and treatment services throughout Nevada. Table 1, shown below, details the funding amounts from various sources and depicts funding that went to providing treatment and prevention services. On page 5, Charts 1 and 2 itemize the percentage of SAPTA funding made up from various funding sources in State Fiscal Year (SFY) 2007 and SFY 2011 respectively. Revenue is net of reversions and balance forward amounts. Table 1. SAPTA Revenue Sources, SFY 2007 and SFY 2011 Revenue Source SFY 2007 SFY 2011 Revenue Source Explanation Substance Abuse Prevention and Treatment Block Grant (SAPT BG) Total 13,918,013 12,897,706 Substance Abuse Prevention and Treatment block grant received from the federal government; approximately 70% treatment and 20% prevention General Fund Total 3,699,970 10,730,882 These general funds are the State's "Maintenance of Effort" (MOE) funds required to receive SAPT BG funding. State Liquor Tax Total 951, ,514 State Incentive Grant (SIG) Total 3,606,279 0 Must be used for detoxification services and civil protective custody with an emphasis on serving rural areas. Federal grant to facilitate the development of local coalitions to reduce the use of alcohol, tobacco, and other drugs among Nevada's year olds. Grant ended September Strategic Prevention Framework (SPF-SIG) Total 349,809 1,083,645 Federal grant for the establishment of a strategic prevention network. Safe and Drug Free Schools (SDFS) Total 487,608 95,755 Federal grant for prevention services. This funding to SAPTA ended September Certification Fees Total 27,500 21,200 Fees received for the certification of alcohol and drug prevention and treatment programs. Data Infrastructure Total 17,056 81,518 Federal grant to fund data collection system for treatment programs. Other Federal Total 0 397,252 Division of Child and Family Services (DCFS) pass-through TOTALS Total 23,057,641 26,303, to 2011 Increase = 14% 3

12 Section I Agency Overview Chart 1. SAPTA Revenue Sources, SFY 2007 SFY 2007 General Fund 16% State Liquor Tax 4% SAPT BG 60% State Incentive Grant 11% Strategic Prevention Framework 2% Safe and Drug Free Schools 2% Certification Fees <1% Data Infrastructure <1% SAPT BG General Fund State Liquor Tax State Incentive Grant Strategic Prevention Framework Safe and Drug Free Schools Certification Fees Data Infrastructure Chart 2. SAPTA Revenue Sources, SFY 2011 SFY 2011 Other Federal 2% Safe and Drug Free Schools <1% SAPT BG 49% SPF 4% General Fund 41% Data Infrastructure <1% State Liquor Tax 4% Certification Fees <1% General Fund Data Infrastructure State Liquor Tax Certification Fees SAPT BG Safe and Drug Free Schools Other Federal SPF 4

13 Section I Agency Overview Chart 3 shown below details how SAPTA spends the money it receives from the revenue sources previously described. The expense amounts shown are in thousands and a percentage has been included to put a relational value on the dollars spent. Chart 3: SAPTA Expenditures, SFY 2011 SFY 2011 (millions) SAPTA Personnel $1.67 7% Women's Treatment Services $0.99 4% HIV/TB $0.72 3% Adolescent Treatment $2.32 9% Travel $0.01 0% Operating $1.13 4% Treatment $ % Primary Prevention $ % Prevention Coalition $2.39 9% Primary Prevention Prevention Coalition Treatment Adolescent Treatment HIV/TB Women's Treatment Services SAPTA Personnel Travel Operating NEVADA HEALTH INFORMATION PROVIDER PERFORMANCE SYSTEM (NHIPPS) Since July, 2006, SAPTA has used the Nevada Health Information Provider Performance System (NHIPPS). NHIPPS is a Health Insurance Portability and Accountability (HIPAA) compliant, web-based, electronic health record (EHR) application adapted from the award-winning Texas system, Behavioral Health Integrated Provider System (BHIPS). All SAPTA funded service providers use the NHIPPS system to gather service and outcomes data for Nevada citizens receiving prevention and treatment services. SAPTA provides ongoing TA and training for this open source system. NHIPPS Fiscal NHIPPS is also the vehicle by which providers receive their funding and basic performance tracking. Detailed grant, funding and service forecasts are entered annually, and grant reimbursement requests and funding allocation information are entered monthly. As monthly milestones for clinical services documentation are reached, online reports calculate performance statistics for clients served and services delivered. These reports allow SAPTA to monitor provider performance throughout the year, making adjustments and improvement recommendations as needed. Starting in July, 2012, SAPTA will move to a unit cost reimbursement model for funded treatment providers. This change will require system and business process modifications in development now. 5

14 Section I Agency Overview NHIPPS Treatment The treatment services component of NHIPPS is both a clinical and management tool that allows clinicians to screen and assess individual clients to determine their treatment needs, and allows providers to monitor performance statistics for their clinicians. Standardized screening and assessment tools are used to systematically generate a treatment plan that addresses the client s needs in a wide range of life categories. Treatment plans are also flexible and can be further tailored to meet the client s individual needs. With the proper client consent, providers can electronically refer and share pertinent client treatment records with other funded agencies. Information sharing improves overall quality in the client continuum of care by providing continuity in the treatment services provided. NHIPPS captures all of the National Outcomes Measures (NOMs) for treatment data required by the federal Substance Abuse Prevention and Treatment (SAPT BG), and SAPTA plans to enhance the NHIPPS Treatment component by adding an adolescent assessment tool, a patient placement assessment tool for gambling disorders, and improving the automated treatment plan to gain efficiency in that process. These updates were a priority for the 2011 fiscal year. In 2011, SAPTA partnered with the Reno Problem Gambling Center and other gambling treatment and research agencies to develop the Gambling Patient Placement Criteria (GPPC) in NHIPPS. This addition will allow SAPTA to share valuable gambling behavior and treatment data for a sector of clients receiving alcohol and drug addiction treatment services. NHIPPS Prevention The prevention services component in NHIPPS allows coalitions and direct services providers to capture data across all six Center for Substance Abuse Prevention (CSAP) strategies. Coalitions can collect information on event details, funding, donations, participants, populations served, and staff hours. They can also record population demographics and define services delivered using a variety of CSAP measures that are part of the SPF model such as CSAP strategies, risk and protective factors, intervening variables, cultural competency and sustainability. SAPTA continues to work on refining and standardizing data for improved analysis. Direct service providers capture details on prevention curricula and demographics on the participants served. These data are required for the federal Block grant. SAPTA was recently awarded funding under the Strategic Prevention Enhancement grant to expand our existing reports server. The current configuration is one that enables SAPTA to build day-to-day, tactical reporting for our management, providers, and other stakeholders. The State Prevention Enhancement (SPE ) project will add a data warehouse with web portal access to information and reports stored there. This will increase our access to information critical for strategic decisions. Our plan is to build an expandable framework for storing and reporting on a broad range of data relevant to prevention and treatment services in Nevada. 6

15 Section I Agency Overview NATIONAL OUTCOMES MEASURES (NOMS) The NOMs are designed to embody meaningful, real life outcomes for people who are striving to attain and maintain recovery; build resilience; and work, learn, live, and participate fully in their communities. The Substance Abuse and Mental Health Services Administration (SAMHSA) developed the NOMs domains in collaboration with the States. The NOMs are a key to SAMHSA's initiative to set performance targets for state and federally funded initiatives and programs for substance abuse prevention and mental health promotion, early intervention, and treatment services. Table 2 on the next page denotes the required treatment and prevention outcomes required. Although many of the outcome indicator requirements for substance abuse prevention programs are provided by the National Survey on Drug Use and Health (NSDUH), required program information and participant demographics for direct service programs are collected in the NHIPPS prevention module. Additional prevention modules, now being piloted, are collecting coalition and environmental data. This pilot became delayed due to short-staffing for a period. NHIPPS collects all required treatment outcome data. Charts 4 and 5 on page 9 in the treatment section show how Nevada compares to the Western States (Region 9) and the Nation for the six treatment NOMs now available. When comparing data between states, regions, and the nation there may be differences in how the data is collected. For instance, some states or providers may rely more on self reported data when measuring abstinence, while others emphasize drug testing. It is also possible the methodologies employed in cleaning and reporting data could vary from state to state. Nevada reports these measures based on an episode of treatment that may involve more than one admission in an episode of care. Some states may not have that ability. From charts 4 and 5, a few things can be seen when comparing Nevada to the Nation and Region 9. While a smaller percentage of clients came to treatment employed or in school, clients in Nevada showed more improvement from admission to discharge for the measure despite a bad economy. While a greater percentage of clients came to treatment with their housing needs met, clients in Nevada showed more improvement from admission to discharge for the measure. Clients in Nevada showed slightly more improvement from admission to discharge for clients being arrest free for 30 days. While a smaller percentage of clients came to treatment reporting no alcohol or drug use in the past 30 days, clients in Nevada showed more improvement from admission to discharge for these two measures. While a smaller percentage of clients came to treatment participating in self-help and social support groups, clients in Nevada showed more improvement from admission to discharge for the measure. Source: SAMHSA, 7

16 Section I Agency Overview SUBSTANCE ABUSE PREVENTION AND TREATMENT (SAPT) NOMS Table 2: Substance Abuse Treatment and Prevention NOMs Outcome Abstinence from Drug/Alcohol Use Increased/Retained Employment or Return to/stay in School Decreased Criminal Justice Involvement Increased Stability in Housing Increased Social Supports/Social Connectedness Increased Access to Services (Service Capacity) Increased Retention in Treatment-Substance Abuse Treatment Prevention Measure Source Measure Source 30 day substance use (nonuse/reduction in use) NSDUH NHIPPS Perceived risk/harm of use NSDUH Age of first use NSDUH Perception of disapproval/attitude NSDUH Perception of workplace policy NSDUH NHIPPS Attendance and enrollment NCES ATOD-related suspensions and expulsions NSDUH Reduction in/no change in number of arrests in past 30 days from date of first service to date of last service Increase in/no change in number of clients in stable housing situation from date of first service to date of last service Increase in/no change in number of clients in selfhelp (mutual support) groups at date of last service compared to date of first service Unduplicated count of persons served Penetration rate - numbers served compared to those in need Length of stay from date of first service to date of last service Unduplicated count of persons served Alcohol-related car crashes and injuries Alcohol and drug-related crime NHIPPS Not applicable NHIPPS NHIPPS NHIPPS & NSDUH NHIPPS NHIPPS Family communication around drug use Total number of evidencebased programs and strategies Percentage youth seeing, reading, watching, or listening to a prevention message Client Perception of Care Under Development Under Development Cost Effectiveness (Average Cost) Use of Evidence-Based Practices Reduction in/no change in frequency of use at date of last service compared to date of first service Increase in/no change in number of employed or in school at date of last service compared to first service Under Development Under Development NHIPPS NSDUH - National Survey on Drug Use and Health NCES - National Center for Education Statistics NHTSA - National Highway Traffic Safety Administration FBI-UCR - Federal Bureau of Investigation, Uniform Crime Reporting Program Number of persons served by age, gender, race, and ethnicity Percent of prevention setaside funds spent on evidence-based practices; cost per unit improved (Under Development ) Total number of evidencebased programs and strategies NHTSA FBI-UCR NSDUH & PRE / POST TESTS NHIPPS NHIPPS NHIPPS & PRE / POST TESTS NHIPPS 8

17 Section I Chart 4. NOMs Admission Geographical Comparisons, SFY 2011 Agency Overview Employed / In School Clients Housed Arrest Free Alcohol Abstinent Drug Abstinent Engaged in Social Support Activities Admission percents Nevada Western States United States Source: Chart 5. NOMs Change from Admission to Discharge Geographical Comparisons, SFY Employed / In School Clients Housed Arrest Free Alcohol Abstinent Drug Abstinent Engaged in Social Support Activities Change from Admission percent to Discharge percent. Nevada Western States United States Source: 9

18 Section II Treatment Assessment TREATMENT OVERVIEW The Agency ensures delivery of substance abuse treatment services throughout the state via a Performance Grant process. Performance grants require providers to meet negotiated scopes of work in order to receive reimbursement for expenses authorized under the subgrant. Quality as well as quantity criteria must be met. The Agency is currently working on a plan to enhance a Performance Based process. A Fee for Service/ Performance Based Contracting process is being developed in order to allow reimbursements to provide evidence-based treatment services throughout the state. This process will be implemented July 1, Only providers that are certified by the Agency may receive funding. All Agency funded providers must be in full compliance with state and federal regulations and laws governing substance abuse treatment programs. In addition, the Agency, working with the SAPTA Advisory Board, has created Substance Abuse Treatment Program Operating and Access Standards (POAS). Prior to the 2012 RFA, the Agency will be updating the POAS to address the Health Care Reform Act and to establish a working relationship with electronic third party billing. The POAS is described below. PROGRAM OPERATING AND ACCESS STANDARDS (POAS) All Agency funded providers must be in full compliance with state and federal regulations and laws governing substance abuse treatment programs. In addition, the Agency, working with the SAPTA Advisory Board, formed Substance Abuse Treatment POAS. The POAS are a progressive set of standards that support a Best Practices approach as found in the National Institute of Drug Abuse s (NIDA) Principles of Effective Treatment which total 13 in number. (NIDA, Principles of Drug Addiction Treatment: A Research-Based Guide, Oct. 1999). The treatment POAS focuses on the following areas: Availability, Assessment, Treatment, Pharmacology, Treatment Planning, Workforce Development, Clinical Case Management, State Outcome Measures, and Community Support Services. A more complete description of the Substance Abuse Treatment POAS can be found in Appendix B of the Substance Abuse Prevention and Treatment Agency Strategic Plan, The 2007 plan is available on the SAPTA web page. NEED FOR TREATMENT Nevada is the seventh largest state in the nation geographically and has 17 counties spread across 109,826 square miles. The population of Nevada is largely urban, with the majority of people living in three regions that include Clark County (72% of the population), Washoe County (16% of the population), and the balance of the state with 12% of the population. The population density in Nevada is among the lowest in the 50 states with 24.8 persons per square mile, compared to 87.4 nationwide. Nevada s economy is based on tourism and gambling, mining, machinery manufacturing, construction, and ranching. Various articles indicate that there is a strong indication that people employed in construction, hospitality (restaurants, entertainment) and mining have a higher prevalence of substance abuse than those employed in other industries. Gaming and tourism industries tend to provide an abundance of lower paying service jobs which result in a transient population which is susceptible to substance abuse.(nevada Department of Training and Rehabilitation, March 2010, SAMHSA, Worker Substance Use and Workplace Policies and Programs, June 2007 ) The results of the 2009 National Survey on Drug Use and Health show that Nevada ranks high nationwide on several measures of drug use and mental health. The NSDUH survey is done face to face at the home of the 10

19 Section II Treatment Assessment respondents and includes people 12 and older, those 12 to 17, 18 to 25, and those 26 and older. Also per the 2009 NSDUH, since 2004, Nevada has been in the top 20% in all age groups of states for people reporting non medical use of pain relievers in the past year (prescription drug abuse). Illicit Drug use other than marijuana in the past month includes cocaine, heroin, hallucinogens, inhalants and the non medical use of prescription pain relievers. Nevada ranked in the top quintile of states in every age group of people reporting use of these drugs in Nevada also ranked in the second to the top quintile in all age groups (except 12 to 17, which was at the top quintile) among people reporting illicit drug dependence or abuse in the past year. A related question asks whether respondents have needed but not received treatment for illicit drug use in the past year and Nevada ranked in the top quintile on this measure, also. The NSDUH asks two questions regarding mental health using DSM IV criteria. It asks a series of questions to establish whether a respondent has experienced a major depressive episode in the past 12 months and/or serious psychological distress. People who experience depression and/or psychological distress are more susceptible to substance abuse and addiction than others. Nevada ranked in the second to the top 20% in those reporting major depressive episode in the past year in (18 years or older). Data show that persons diagnosed with mood or anxiety disorders were about twice as likely to suffer also from a drug use disorder (abuse or dependence) compared with people in general. The same was true for those diagnosed with an antisocial syndrome, such as antisocial personality or conduct disorder. Similarly, persons diagnosed with drug disorders were roughly twice as likely to suffer from mood and anxiety disorders. (National Institute on Drug Abuse, Comorbidity: Addiction and Other Mental Illnesses, 2008). ESTIMATES OF NEED FOR TREATMENT IN NEVADA The table below gives population estimates for Nevada. The percentage of people who report abusing Alcohol and Other Drugs (AOD) is multiplied by the population to estimate the numbers of people affected. Table 3. Estimates for Need for Treatment in Nevada* Clark County AOD Abuse Cases Washoe County AOD Population Abuse Estimate Cases Balance of State AOD Population Abuse Estimate Cases Nevada * Numbers of Individuals with Alcohol or Drug Abuse or Dependence Problems Statewide and Regional, SFY 2011 AOD Abuse Cases Age Population Estimate Population Estimate 12 to ,881 11,755 28,382 2,492 23,012 2, ,275 16, to ,814 48,635 49,355 10,310 40,019 8, ,188 67, to 100 1,267, , ,688 21, ,860 17,320 1,753, ,442 Total 1,634, , ,425 34, ,891 27,700 2,261, ,014 Sources: 1) 2) 2010 State Demographer estimates updated in ) Age range allocations taken from the U.S. Census Bureau Profile of General Population and Housing Characteristics:2010;2010 Demographic Profile Data Nevada.pdf 11

20 Section II Treatment Assessment Table 4. Unmet Demand Estimate for Substance Abuse Treatment, 2011 Population Group Population Estimate* Total Need** Met Need *** Unmet Need+ Unmet Demand++ Adolescents (12-17) 185,275 19,000 2,504 16, Adults (18+) 2,076, ,000 31, ,239 7,462 Total Population 2,261, ,000 34, ,735 8,287 Sources: * State Demographers 2009 Population Estimates updated August 2008 ** Department of Health and Human Services, Substance Abuse and Mental Health Services Administration and 2008 State Estimates of Substance Use, Dependence on or Abuse of Any Illicit Drug or Alcohol in Past Year, by Age Group and State: Estimated Numbers (in Thousands), Annual Averages Based on 2007 and 2008 NSDUHs." *** The 2009 National Survey Substance Abuse Treatment Services (N-SSATS) data +The Unmet Need = Total Need minus Met Need ++ The Unmet Demand is 5% of the Unmet Need The SAMHSA attempts to estimate the number of people in the population who need treatment for substance abuse but who do not receive it. These numbers of Nevadans in this category are listed in the Unmet Need column in the table above. SAMHSA estimated that between 2007 and 2010, 38% cited having no health insurance, 30% of those who needed treatment did not receive it because they were not ready to stop using, 9% thought they were able to handle the problem without treatment, 8% had no transportation or it was inconvenient, 8% thought going for treatment might have a negative effect on their job, 7% had health coverage but did not cover treatment or did not cover the cost, 7% though it might cause neighbors or community to have a negative opinion, 7% did not feel the need for treatment at the time (Individuals may be included in more than one of these groups). ADOLESCENT NEED FOR TREATMENT The most commonly used illicit drug and the number one cause of adolescent treatment admissions in Nevada involve marijuana as the primary drug of choice. In SFY 2011, the total admissions to SAPTA funded treatment programs for marijuana/hashish abuse and dependence as the primary drug of choice was 18.0%. However, the percentage for adolescents was 69.0%. The reason that the number of adolescents treated for marijuana use is high is because if they are caught with marijuana, they are mandated to treatment by the juvenile justice system. Being mandated to treatment does not mean that they are addicted to or abusing marijuana. (L. Wilhem, Supervisor, SAPTA Treatment Team, October 2010). Marijuana use by adolescents is a cause for concern because research has shown that the younger people are when they start using drugs the more likely they are to develop abuse and dependence problems later in life. Marijuana is considered to be a gateway drug to other illicit drugs which may have more to do with the attitude that drug use is normal than with marijuana itself. (National Institute on Drug Abuse, Marijuana: Facts for Teens, Data from the 2009 Youth Risk Behavior Survey (YRBS) indicates that the percentage of Nevada youth who have tried marijuana for the first time before age 13 was about the same as the nation s youth. Nine point three percent of Nevada s high school students had tried marijuana before the age of 13 compared to the national average of 7.5% (p=.06, not quite statistically significant). 12

21 Section II Treatment Assessment The YRBS is completed every other year by middle school and high school students nationwide. Nevada data on selected questions is compared to national data. The questions denoted with italics are those measures from which high school students in Nevada are more likely than students nationwide to report having experienced that behavior. Results from the Nevada 2009 YRBS indicated that 35.6 percent of high school students had been offered, sold or given an illegal drug by someone on school property, compared to 22.7 percent of students nationwide. Table 5. YRBS Questions on Drinking, Drug Use and Suicide Related Behaviors Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2009, Surveillance Summaries, Online).Source: Nevada Youth Risk Behavior Survey, State Comparative Data 13

22 Section II Treatment Assessment The Nevada Medicinal Marijuana Program is a state registry program within the Nevada Department of Health and Human Services, Nevada State Health Division. Their role is to administer the provisions of the Medicinal Use of Marijuana law as approved by the Nevada Legislature and adopted on Policies will have to be created to address adolescents obtaining these use of marijuana for medicinal use cards, which may lead to increased access to marijuana. Nevadans with a qualifying medical condition who has obtained a valid Nevada Medical Marijuana Program card is excepted from criminal laws of the state for engaging in the medical use of marijuana as justified to mitigate the symptoms or effects of the person s debilitating medical condition. There is a growing issue of adolescents using synthetic marijuana, referred to as Spice, K2, and other names, which are sold as herbal incense and labeled not for human consumption to mask their intended purpose and avoid Federal Drug Administration (FDA) regulatory oversight of the manufacturing process. According to U.S. Customs and Border Protection, synthetic cannabinoids and related products appear to originate from foreign sources and are manufactured in the absence of quality controls and devoid of governmental regulatory oversight. These products and associated synthetic cannabinoids are readily accessible via the Internet. According to data from the 2011 Monitoring the Future study of youth drug-use trends, 11.4 percent of 12 th graders in the US used Spice or K2 in the past year. According to the American Association of Poison Control Centers, 2,915 calls were received relating to synthetic marijuana in 2010, and 5,741 calls were received in 2011 as of October 31. Local data on synthetic marijuana use will be reported as it becomes available. (Office of National Drug Control Policy (ONDCP), Fact Sheet: Synthetic Marijuana, December 2011) PREVALENCE OF SUBSTANCE ABUSE In SFY 2011, the SAPTA data showed the six most prevalent drugs for which clients were treated were: alcohol (36%), amphetamine/methamphetamine (22%), marijuana/hashish (18%), heroin (10%), prescription drugs (8%), and cocaine/crack (5%). These percentages apply to the primary drug of choice. Fifty-six percent of people treated in SAPTA funded programs used more than one substance. Among poly drug admissions, alcohol was the most common substance reported (64%), marijuana was the second most commonly reported substance (58%) followed by methamphetamine (44%). Younger clients were more likely to report poly drug use and eighty-six percent of those 20 and younger used marijuana with other substances. Table 6: Admissions to SAPTA Funded Providers by Primary Drug of Choice, SFY 2011 All Adults All Adolescents Total Admissions If Pregnant* No. % No. % No. % No. % Alcohol 3,893 39% % 4,092 36% 18 11% Methamphetamine/Other Amphetamine 2,391 24% 55 5% 2,446 22% 86 53% Marijuana/Hashish 1,192 12% % 2,011 18% 23 14% Heroin 1,131 11% 17 1% 1,148 10% 14 9% Cocaine/Crack 533 5% 5 1% 538 5% 7 4% Prescription Drugs 830 8% 62 5% 892 8% 10 6% Other 37 0% 26 2% 63 1% 3 2% Total 10, % 1, % 11, % % * Adolescents include those years old. Less than one percent of the 161 pregnant clients admitted to treatment were adolescents. 14

23 Section II Treatment Assessment ALCOHOL The consumption of alcohol continues to be a major public health issue globally, nationally and in Nevada. Thirty nine percent of SFY 2011 admissions to SAPTA funded treatment facilities were for alcohol. Alcohol is causally related to more than 60 different medical conditions. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension. (Lancet, 2005, February) The U.S. Department of Health and Human Services reported in NSDUH that 10.00% of people age 12 and older in Nevada had reported past year alcohol dependence or abuse in the past year. (The Nevada percentage in the previous year had been 7.91%). The national percentage in 2009 was 8.35%. The highest percentage reported in 2009 was by Alaska (13.54) and the lowest percentage was reported by Iowa (5.29). Nevada is in the middle of that range and this estimate means that there are 226,145 in the state that have abused or been dependent on alcohol within the past year. Drinking and Driving Nevada In 2010 in Nevada, 27 percent of those killed in vehicle crashes were involved in alcohol related crashes. The percentage of alcohol related fatalities has decreased approximately five percent since In 2010, Nevada had 69 alcohol-impaired driving fatalities involving a blood alcohol content (BAC) of.08 or more, which is 27 percent of the total fatalities in all crashes. In 2010 Clark County had 148 fatalities, which was 58 percent of all fatalities in Nevada. Washoe County had 30 fatalities, which is 12 percent of all Nevada fatalities. All other Nevada counties combined had 79 fatalities, which is 31 percent of all Nevada fatalities. (Traffic Safety Facts Nevada ; National Highway Traffic Safety Administration (NHTSA)) Driving Under the Influence Adults in the US drank and drove approximately 112 million times in Even though episodes of driving while drunk have gone down by 30 percent during the past five years, it is still a serious problem. In 2009, alcohol-impaired drivers, with BAC of at least 0.08 percent, are involved in about 1 in 3 crash deaths, resulting in nearly 11,000 deaths. In 2010, men were responsible for 4 in 5 episodes, which is 81percent of drinking and driving. Young men ages made up only 11 percent of the U.S. adult population, yet were responsible for 32 percent of all instances of drinking and driving. (Center for Disease Control, Vital Signs Fact Sheet: Drinking and Driving: A Threat to Everyone, October 2011) In 2009, 10,839 people were killed in alcohol-impaired driving crashes in the U.S. Rural areas and accounted for 57 percent (6,215) of these fatalities as compared to 42 percent (4,577) in urban areas. Data has also shown that over the 10 years from 2000 to 2009, alcohol-impaired-driving fatalities decreased by 19 percent nationwide. In rural areas alcohol-impaired-driving fatalities decreased by 23 percent while urban areas showed a 7-percent decrease. (Traffic Safety Facts NHTSA, 2009 Data, Rural/Urban Comparison, DOT HS ) Suicide and Alcohol Use Nevada The NSDUH asks respondents whether they have had symptoms of depression in the past year (called MDE, Major Depressive Episode). Nevadans historically are in the top 11 states in the percentage of people reporting having had MDE in the past year. SAMHSA reported (The NSDUH Report Co-Occurring Major Depressive Episode and Alcohol Use Disorder among Adults, February 2007) that adults who experience MDE in the past year were more than twice as likely to have alcohol use disorder as adults who did not have MDE. Alcohol abuse and binge drinking are also associated with having MDE and having had suicidal thoughts or having attempted suicide in the past year. Sixty two percent of NSDUH respondents who reported 15

24 Section II Treatment Assessment MDE also reported binge drinking and suicidal thoughts in the past year. Nevada s suicide rate per 100,000 (19.9) is twice the national rate (10.9) and are among the top two highest rates in the nation historically. Map 1. Binge Alcohol Use in Past Month among Persons Aged 12 or Older, by State: Percentages, Annual Averages Based on 2008 and 2009 NSDUHs Source: SAMHSA, Center for Behavioral Health Statistics and Quality, NSDUH, 2008 and Binge Drinking in Nevada The National Survey on Drug Use and Health defines binge drinking as drinking five or more drinks on the same occasion on at least one day in the past 30 days. Nationally, almost a quarter (23.5 percent) of persons aged 12 or older participated in binge use of alcohol in the past month in The national rate of binge alcohol use decreased among youths aged 12 to 17 from 9.3 to 8.8 percent), and decreases also were observed in the Midwest and South regions for this age group. Nationwide, the highest rates of binge alcohol use were in people age 18 to 25. Among the Nevada youth aged the binge drinking rate was 8.49 percent and youth aged the rate was Nevada ranked in the second to lowest quintile in this age group at percent of the population. (Results from the 2009 National Survey on Drug Use and Health, Volume I) Perceptions of Great Risk of Regular Binge Drinking The map shows that people in Nevada think that having five or more drinks once or twice a week is very risky behavior. In , 41.9 percent of persons aged 12 or older perceived a great risk of binge drinking. People's perceptions of the risk of binge drinking were moderately and inversely related to their actual rates of 16

25 Section II Treatment Assessment binge drinking at the State level in Of the ten states with the highest rates of binge drinking five states also had the lowest perceived risk of binge drinking: Iowa, Minnesota, North Dakota, South Dakota and Wisconsin. People in Nevada have a healthy perception of the risk inherent in binge drinking. Binge Drinking in People 18 to 25 Nationwide, the highest rates of binge alcohol use were in people age 18 to 25. Young adults aged 18 to 22 enrolled full-time in college were more likely than their peers not enrolled full time to use alcohol in the past month, binge drink and drink heavily. The nationwide pattern of higher rates of current alcohol use, binge alcohol use, and heavy alcohol use has remained consistent since People 18 to 25 in do not follow this pattern of excessive alcohol use. Nevada ranked in the second to lowest quintile in this age group at percent of the population. (2009 NSDUH, Volume I) Perceptions of Great Risk of Regular Binge Drinking Map 2 shows that people in Nevada think that having five or more drinks once or twice a week is very risky behavior. People s perceptions of the risk of binge drinking were moderately and inversely related to their actual rates of binge drinking at the state level in Of the ten states with the highest rates of binge drinking five states also had the lowest perceived risk of binge drinking: Iowa, Minnesota, North Dakota, South Dakota and Wisconsin. People in Nevada have a healthy perception of the risk inherent in binge drinking. Map 2. 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 2008 and 2009 NSDUHs Source: SAMHSA, Office of Applied Studies, National Survey on Drug Use and Health, 2008and

26 Percentage of Admissions Section II Treatment Assessment Chart 6. Nevada Methamphetamine Admissions to SAPTA by Primary Drug, SFY Methamphetamine Admissions METHAMPHETAMINE In January 2007, the Governor s Working Group on Substance Abuse, formerly the Governor s Working Group on Methamphetamine, was established to address the epidemic of meth use and abuse in the state. This effort continues and in June 2010, Nevada representatives participated in a National Meth Summit to Promote Public Health and Partnerships. These efforts have contributed to a reduction in the percentage of SAPTA clients being admitted for meth treatment from 34.9% in 2007 to 21.9% in Other factors have contributed to the decrease, such as supply, price and purity. 10 According to the National Drug Intelligence Center, from 0 mid-2008 through 2009, methamphetamine availability increased in the United States after a major decrease in 2007 due to government restrictions on the precursor chemicals (ephedrine). Drug availability indicator data show that meth prices, which peaked in 2007, declined significantly during 2009 and 2010, while meth purity increased. By late 2008, Mexican Drug Trafficking Organizations (DTOs) had adapted to the precursor restriction laws by smuggling ephedrine via new routes, importing non-restricted chemical derivatives instead of banned precursor chemicals and importing ephedrine from China and India. The primary source of meth consumed in the U.S. is Mexico along with an increase in the number of domestic manufacturing operations, which combined make methamphetamine readily available. (U.S. Department of Justice (DOJ), National Drug Threat Assessment, 2011) Meth seizure amounts in the U.S. increased in 2008 and increased again in 2009 and Along the Southwest border, seizure amounts more than doubled between 2008 (2,221 kilograms) and 4,486 kilograms in The increase in domestic methamphetamine production in 2009 and 2010 was fueled primarily by individuals and criminal groups that organized pseudoephedrine smurfing operations to acquire large amounts of the chemical from many local pharmacies. (U.S DOJ, National Drug Threat Assessment, 2011) MARIJUANA Marijuana is the most commonly used illicit drug and was used in the past 30 days by 6.36% of the U.S. population and 6.99% of the population in Nevada in 2009 (NSDUH State Estimates, ). Total admissions (adults and adolescents) to SAPTA funded treatment programs in 2011 for marijuana/hashish abuse and dependence as the primary drug of choice was 18.0%. Data from the 2009 YRBS indicates that the percentage of Nevada youth who had tried marijuana for the first time before age 13 was higher than the national percentage. The percentage of Nevada youth reporting past month marijuana use was 9.3% compared to the national average of 7.5%. (Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance United States, 2009, Surveillance Summaries, Online). Marijuana use by adolescents is a cause for concern because research has shown that age of initiation of marijuana use is a factor in subsequent use of hard drugs such as cocaine and heroin. (Escalation of Drug 18

27 Section II Treatment Assessment Use in Early-Onset Cannabis Users vs. Co-twin controls, Lynskey, MT et. al.) Early access to and use of marijuana may reduce perceived barriers against the use of other illegal drugs and provide access to these drugs. Sixty-nine percent of adolescents admitted to treatment in Nevada in 2011 were admitted for marijuana abuse. In 2003, the Nevada legislature passed a law (NRS 62E.620) that specified that if an underage person (<18) is caught with a controlled substance, which includes marijuana, he or she must be evaluated for substance abuse by a licensed professional. Thus an adolescent admitted to treatment for marijuana use in Nevada does not indicate that the user is addicted to or abusing the drug. It means that the minor was caught with some amount of marijuana and consequently mandated to an evaluation/assessment. COCAINE Cocaine availability has decreased sharply in the U.S. since National level cocaine availability data indicators (drug seizures, price, purity, workplace drug tests and emergency room data) point to significantly less availability in 2010 than in For example, federal cocaine seizures decreased 37 percent from 2006 (69,561kg) to 2010 (44,063kg). The price per gram of cocaine increased from $97.71 in early 2007 to $ in late 2010, while purity of the drug decreased from 67 percent to 47 percent. (U.S. DOJ, National Drug Threat Assessment, 2011). Nevadans aged 18 to 25 had the highest rate of cocaine use, 6.76 percent, compared to those aged 12-17, 1.50 percent, and Nevadans aged 26 and older, 1.78 percent. According to the 2006, 2007, and 2008 National Survey on Drug Use and Health Washoe County had a higher level of cocaine use than Clark County and the remainder counties combined. The drug comes into the country in Florida and is then shipped north via route 95 along the eastern seaboard. (State Estimates of Substance Use from the National Survey on Drug Use and Health) The percentage of 2011 NHIPPS admissions for cocaine addiction treatment was 7 percent in 2010 and 5 percent in (NHIPPS Admission data, 2011) The annual prevalence of cocaine use in high school students declined from a high in 1998 (5.4 percent) to a low of 2.9 percent in 2010, according to Monitoring the Future (MTF): a National Survey on Drug Use in Secondary School Students, The 30-day prevalence of use of cocaine in grades 8, 10, and 12 combined has increased 0.1percent between 2009 and (Monitoring the Future: National Results on Adolescent Drug Use, Overview of Key Findings 2010). The Youth Risk Behavior Survey asks high school students if they have ever used any form of cocaine (powder, crack or freebase). The percentage of Nevada students who reported lifetime cocaine use was the same (7.7 percent) in 2007 and in Nationwide, the percentage of students who reported lifetime cocaine use was slightly lower (7.2 percent) than Nevada but the difference was not statistically significant. PRESCRIPTION DRUG ABUSE Larry Pinson of the Nevada State Board of Pharmacy is leading Nevada's fight against prescription drug abuse. He had one startling statistic for us: "We're to the point now where we lose more people to prescription drug over dosage than we do to automobile accidents. It's my opinion we live in the most drug oriented society in history." (Prescription Drug Abuse in Nevada: An Epidemic, John Potter, Channel 2 News.) Nevada was one of the first states to establish its prescription drug monitoring program in Prescription Drug Monitoring Programs (PDMPs) allow physicians and pharmacists to log each filled prescription into a 19

28 Section II Treatment Assessment state database to help medical professionals prevent abusers from obtaining prescriptions from multiple doctors. To date 43 states have initiated such programs. Prescription Drug Overdose Deaths The Centers for Disease Control (CDC) reports that a high percentage of people who die from prescription opioid poisoning have a history of substance abuse and that most have more than one prescription drug in their systems at the time of death. A 2008 CDC study found that 82 percent of prescription drug related unintentional overdose decedents in West Virginia had a history of substance abuse and that 79 percent had used multiple substances that contributed to their deaths. (U.S. DOJ, National Drug Threat Assessment, 2010.) Approximately 7 million individuals aged 12 or older (2.8% of the age group), which is a 12 percent increase from 2008, were current nonmedical users of controlled prescription drugs in 2009, according to NSDUH data. (U.S. DOJ, National Drug Threat Assessment, 2011.) In July 2010, the CDC reported that drug overdose deaths were second only to motor vehicle crash deaths among leading causes of unintentional injury death in 2007 in the U.S. States in the Appalachian region and the Southwest have the highest death rates. Fifteen states in the two regions mentioned have rates of overdose deaths that are statistically significantly higher than the U.S. rate. The rate in West Virginia is 21.1 per 100,000 and Nevada has the sixth highest rate in the country at 16.0 per 100,000. Rural areas and medium sized cities have the highest prescription overdose death rates. (CDC, Unintentional Drug Poisoning in the United States, July 2010). In SFY 2011, approximately eight percent of admissions to SAPTA funded treatment facilities recorded prescription drugs as the primary drug of choice, which is a two percent increase from When considering primary, secondary and tertiary drugs used, nearly 16 percent of all admissions were prescription drug related, which is also a two percent increase from The map on the next page shows where clients admitted to treatment with prescription drug related admissions were from based on resident zip code. (2011 NHIPPS Admission Data.) HEROIN IN NEVADA In SFY 2011, approximately 13% of admissions to SAPTA funded treatment facilities were for heroin. The National Drug Threat Assessment 2011 indicates that heroin use in the U.S. has been increasing since Increased availability in some markets can be partly attributed to increased heroin production in Mexico. From 2005 to 2009, heroin production estimates for Mexico increased 342 percent, from 8 metric tons pure to 38 metric tons pure. (Interpol, International Drug Reports 2011). Per the U.S. DOJ, Treatment providers in some areas of the United States reported in 2008 that prescription opioid abusers switch to heroin as they build tolerance to prescription opioids and seek a more euphoric high. Further, treatment providers are reporting that some prescription opioid abusers are switching to heroin in a few areas where heroin is less costly or more available than prescription opioids. It is also common for some heroin abusers to use prescription opioids when they cannot obtain heroin. Diverted Controlled Prescription Drugs (CPDs) are often more readily available than heroin in all drug markets; however, heroin use increased in many areas of the country in 2009, possibly because of increased demand among abusers of prescription opioids who could no longer afford CPDs. Prescription opioids are typically more expensive than heroin. For example, oxycodone abusers with a high tolerance may ingest 400 milligrams of the drug daily (five 80-mg tablets) for an average daily cost of $400. (continued on page 22) 20

29 Section II Treatment Assessment Map 3. Prescription Drug Abuse in SFY 2011 by Zip Code 21

30 Section II Treatment Assessment These abusers could maintain their addictions with 2 grams of heroin daily, at a cost of one-third to one-half that of prescription opioids, depending on the area of the country and the purity of the heroin. (U.S. DOJ, National Drug Threat Assessment 2010) Heroin use in Nevada has increased as methamphetamine use has decreased. Chart 7 shows the percentage of clients admitted to SAPTA treatment programs who have been addicted to heroin and methamphetamine. Chart 7. Nevada Meth and Heroin Admissions, Primary, Secondary and Tertiary Use, SFY SFY Meth Heroin The availability of heroin in the U.S. is on the rise as a result of increased production in Mexico and decreased production of Columbian heroin. Some cocaine distributors are replacing their sales with heroin since it is more available and increasing its accessibility to new users in the Northeast and Mid- Atlantic regions. These new users frequently overdose on heroin because they are unfamiliar with their tolerance levels. Heroin enters the U.S. via routes in southern California, South Texas, and Arizona, where it is destined for western states. An increasing amount of South American heroin is smuggled across the Southwest Border and shipped to East Coast markets. (U.S. DOJ, National Drug Threat Assessment 2011) SUICIDE Nevada has the second highest rate in the nation at 19.2 per 100,000, which is double the national average of 10.9 per 100,000. Suicide is the sixth leading cause of death for Nevadans and is the third leading cause of death for Nevada youth age Native American Youth have the highest rate of suicide. Males make up 80 percent of suicide deaths at an average rate of 33.3 per 100,000. Nevada seniors over the age of 60 have the highest suicide rate in the nation, over double the national average rate for the same age group. More Nevadans die by suicide than by homicide, HIV/AIDS or automobile accidents. Firearms are used in 59 percent of suicide deaths in Nevada. (Suicide prevention Resource Center, State of Nevada Fact Sheet Online, 2011.) The factors that lead to suicide in substance abusers are substance abuse, the rise of substance abuse other than alcohol, having a major depressive disorder or major depression, loss of personal relationship or job, existing medical problems, living alone, communicating suicidal thoughts verbally or behaviorally, and the existence of previous suicide attempts. The misuse of legal drugs, which includes opioid dependence/abuse, misuse of prescription and over-the-counter drugs, legal drugs plus alcohol, and legal drugs plus illegal drugs increase a person s risk of suicide 10 to 86 times higher respectively. (CSAP s Prevention pathways: Online Courses, Holding the Lifeline: A guide to Suicide Prevention, pathwayscourses.samhsa.gov/suicide/suicide_references.htm#70.) 22

31 Section II Treatment Assessment SUBSTANCE ABUSE AND CRIME Drug use affects every sector of society, straining our economy, our healthcare and criminal justice systems, and endangering the futures of young people. While many challenges remain, overall drug use in the United States has dropped substantially over the past thirty years. In calendar year 2010, 14,967 adults were arrested for drug related crimes in Nevada, and 20,367 adults were arrested for alcohol related crimes. As can be seen in Chart 8 on the next page, Nevada has seen a rise in drug and alcohol related crimes over the past five years. (Nevada Department of Public Safety. Crime in Nevada 2010) Many smuggling operations originate with Mexican Drug Trafficking Organizations (DTOs). Mexican nationals supply the majority of available cocaine, marijuana, heroin and methamphetamine in Nevada. Drugs flow north from the Mexican border along I-5 in California and east on I-80 into Nevada. Trafficking and abuse of methamphetamine continues to be the region s primary drug threat. The Nevada High Intensity Drug Trafficking Area (HIDTA) has seen the price and availability of methamphetamine return to 2007 levels, when prevalence of the drug was very high in the state. The numbers of methamphetamine lab seizures in Nevada continues to decline with virtually all of the meth in Nevada coming from super labs in Mexico through middle men in San Diego or Los Angeles. Many violent crimes are committed by drug dealers in the course of trafficking operations while many property crimes are committed by methamphetamine abusers looking to obtain drug funds. (Office of NDCP, Nevada HIDTA Strategy, 2011.) Per the U.S. DOJ, The consequences of illicit drug use impact the entire criminal justice system, taxing resources at each stage of the arrest, adjudication, incarceration, and post-release supervision process. To help deal with that burden, many jurisdictions, including some in Nevada, have developed drug courts or other diversionary programs designed to break the drug addiction and crime cycle. Still, substance abuse remains prevalent in the criminal justice population. (U.S. DOJ. National Drug Threat Assessment 2010) In calendar year 2010, there were approximately 15,000 drug related arrests and over 25,000 alcohol related crimes. Drug related violent crimes such as beatings, kidnappings, or torture, are not reflected in that statistic. Chart 8 shows the number of drug related arrests and alcohol related crimes in Nevada over the past 5 years. (Nevada Department of Public Safety. Crime in Nevada 2010) Chart 8. Drug and Related Arrests and Alcohol Related Crimes, ,000 20,000 15,000 10,000 5, Drug Related Arrests - Adults Alcohol Related Crimes - Adults 23

32 Section II Treatment Assessment The consequences of illicit drug use impact the entire criminal justice system, taxing resources at each stage of the arrest, adjudication, incarceration, and post-release supervision process. Trafficking and abuse of methamphetamine continues to contribute considerably to crime in the state. Law enforcement representatives in the Nevada High Intensity Drug Trafficking Area (HIDTA) region recognize methamphetamine is the drug most connected to violent crime as well as property crime. Many violent crimes are committed by drug dealers in the course of trafficking operations while many property crimes are committed by methamphetamine abusers looking to obtain drug funds. (U.S. DOJ, Drug Market Analysis 2009) Per the Chart 9. Drug Related Murders in Nevada, U.S. Department of Justice, The consequences of illicit drug use impact the entire criminal justice system, taxing resources at each stage of 16 the arrest, adjudication, incarceration, and postrelease supervision process. To help deal with 14 that burden, many jurisdictions, including some in Nevada, have developed drug courts or other diversionary programs designed to break the 8 drug addiction and crime cycle. Still, substance 6 abuse remains prevalent in the criminal justice population. (U.S. Department of DOJ. National 4 Drug Threat Assessment 2010) 2 0 In calendar year 2010, for the most violent of crimes, there were 14 drug related murders in the state. Drug related violent crimes such as beatings, kidnappings, or torture, are not reflected in that statistic. Chart 9 shows the number of drug related murders in Nevada over the past 5 years. (Nevada Department of Public Safety. Crime in Nevada 2010) Chart 10: Health Insurance Coverage for Nevada Funded Programs, SFY 2011 None 70% Private Insurance 9% Medicaid / Medicare 11% Other 3% Unknown 7% HEALTH INSURANCE COVERAGE AND SUBSTANCE ABUSE PROGRAMS The majority of clients seen in SAPTA funded substance abuse treatment programs have no private or public health insurance coverage. This rate has changed little over time. For SFY 2011, 70% of clients had no health insurance. That represented a three percentage point decrease from 73% achieved the prior year. Chart 10 shows a breakdown of health insurance coverage for SFY

33 Section II Treatment Capacity WAIT LIST The Agency started collecting waiting list data during calendar year 2001, with SFY 2002 providing the first full year of data which could be measured. Historically, this data was collected manually, but it is now being collected in NHIPPS. SAPTA is now receiving better, more consistent data from service providers. Table 7 below details waiting list data as reported by SAPTA s providers. The data shows that in SFY 2011 fewer people waited for services since To receive treatment services clients have had to wait 19 days once placed on a waiting list. Table 7. Waiting List Trend Data, SFY * Measurement SFY 2007 SFY 2008 SFY 2009 SFY 2010 SFY 2011 Number of Clients 1,029 1,848 1,701 1,770 1,240 Average Days Clients Waited for Admission *Includes clients that waited 45 days or less. This Area is Intentionally Left Blank. 25

34 Section II Treatment Planning TREATMENT STRATEGIES AND PLANNING Planning involves the creation of a comprehensive plan with goals, objectives and strategies aimed at meeting the substance abuse treatment needs of the state. A major characteristic of planning requires the Agency and its partners to select program models and evidence-based policies, practices, and strategies as primary resources to improve treatment outcomes. State planning for substance abuse treatment services is a requirement of Nevada Statutes as well as a requirement of the federal SAPT Block Grant. There are five main categories SAPTA planning activities and goals continue to focus on: Increase Access to Treatment Improve Service Efficiency Improve Quality of Care Improve Care Coordination Improve Outcome Measurement The POAS describes specific objectives and strategies aimed to meet the above goals and help guide the agency in its efforts to meet all federal and state requirements. Relating to treatment, through the POAS, SAPTA has adopted a set of standards which: 1) encourage the full implementation of the NOMS, described on page 8; 2) adopt the National Academy of Science s Institute of Medicine (IOM) ten rules to redesign health care; and 3) further strengthen providers capacity to offer client-centered evidenced based treatment. Treatment is defined as the continuum of care an individual assessed as an alcoholic and/or drug abuser or addict receives through implementation of the Division s Criteria for Programs Treating Substance Related Disorders. Thus, SAPTA has identified approved levels of service and requires all funded providers to develop a comprehensive service network to assist clients in the treatment process. PERFORMANCE OUTCOMES FOR SERVICES The 2012 Request for Application for treatment services statewide will introduce a fee-for-service payment and is planned to continue through June The following criteria were established to adapt to the new fiscal structure and to assure that evidence-based practices are implemented. New Providers Performance indicators included in outcome measures Instruments or strategies used to collect outcome data (include a brief description of the reliability, validity, and sensitivity) Outcome Expectations Continued or Past Funded Providers Provide Details of Past utilization reports, (note: SAPTA will provide a utilization chart to objective reviewers along with the applications) Data associated with National Outcome Measures (NOMs) Performance indicators included for program specific outcome measures 26

35 Section II Treatment Planning Each treatment provider must provide financial information associated with its services. Identify experience with billing third party payees including Insurance and Medicaid and also with self -pay clients and SAPTA s sliding fee scale policy. Provide percentages to support proposed unit costs and detail eligibility determination. Eligibility Determination: Detail how providers accept individuals for payment through SAPTA sliding-fee scale, Medicaid, self-pay Insurance, or other. Budget: for internal review only of unallowable expenditures Fund map: for internal review only Provide details of unit costs Application Summary/Scope of Work This Area is Intentionally Left Blank. 27

36 Section II Treatment Implementation SUBSTANCE ABUSE PREVENTION AND TREATMENT BLOCK GRANT (SAPT BG) The SAPT BG is the primary source of funding for substance abuse treatment in Nevada. In FY 2011 SAPTA continued to enhance the full continuum of services statewide for individuals in need of treatment. Updating SAPTA s Program Operating and Access Standards (POAS) for the 2012 Request for Application will further develop the coordinated effort toward enhanced treatment performance and accountability. SAPTA has adopted a standardized assessment instrument; the utilization of the web-based client data system, the Nevada Health Information Provider Performance System (NHIPPS); and to regulate the Division s Placement Criteria, in order to increase access to various needed services. Nevada has fully implemented NHIPPS to standardize the collection and reporting of the National Outcome Measures (NOMs), and has the capability to report discharge data as required by the Treatment Episode Data Set (TEDS). Substance abuse treatment services are being provided for individuals meeting the criteria for abuse or dependency, appropriate placement, and a continuum of care. SAPTA utilizes criteria for programs treating substance related disorders based upon American Society of Addiction Medicine Patient Placement Criteria 2nd Revision (ASAM-PPC-2R) and non-asam levels of care recognized by the Agency to develop a seamless continuum of care. In addition, the Nevada State Legislature approved general fund dollars for treating Co-occurring Disorders in the amount of $986,000 for SFY These initiatives have been implemented in rural and urban settings aimed at integrating substance abuse treatment and mental health treatment for those individuals with mental illness. NHIPPS reports showed that there were a total of 11,190 clients served in SFY TRENDS IN TREATMENT The Agency s treatment philosophy recognizes that substance abuse addiction is a chronic, relapsing health condition. The Agency s major treatment improvement initiatives followed by a brief explanation include the following: Adoption of many recommendations contained in the national treatment plan, Changing the Conversation, created by the Substance Abuse and Mental Health Services Administration (SAMHSA) and SAPTA s Treatment Strategic Plan. Utilization of evidence-based substance abuse treatment and prevention practices and models. Development and Implementation of the Evidence-Based Practices Exchange (EBPE). Funded treatment providers must now report more complete data for all levels of service. Successful Application of the National Treatment Plan and SAPTA s Treatment Strategic Plan The Agency has a long track record of working to improve the quality of substance abuse treatment services supported with public funds. SAPTA s plans are consistent with national treatment plans developed by SAMHSA in the past. The 2011 and 2012 Block Grant documents the foundation for the changes that the Agency has implemented and will continue to promote through Central themes in these documents include the need to establish a seamless service system offering effective and integrated as necessary with mental health treatment and based on individual needs, rather than a prescriptive treatment model applied equally to everyone. Individuals enter and become engaged in the most appropriate type and level of substance abuse treatment and that they receive continuous services at the level(s) needed to enter into recovery. 28

37 Section II Treatment Implementation Utilization of Evidence-Based Substance Abuse Treatment Practices and Models There is an inverse relationship between successful treatment completion and admission rates, in part, because successful treatment completion often means longer lengths of treatment engagement and there are several studies indicating the minimum effective length of treatment engagement is 90 days. Additionally, as programs develop service systems that better engage clients, there is a decrease in the number of admissions. An example of this is the Agency s concern over the high percentage of clients who enter and exit the system having only received detoxification services. Many of these clients have several repeat admissions, never really engaging in the treatment process. Such service delivery ultimately does virtually nothing to improve the quality of the client s life and progress toward achieving recovery. Because the State has limited treatment capacity, if a program is successful at engaging the client in a longer treatment stay, the number of open beds available statewide decline proportionately. Development and Implementation of Evidence-Based Treatment Practices (EBTP) Aimed to promote the adoption and use of EBTP, this effort has been initiated in order to enhance treatment service delivery by designing training and TA activities for the State of Nevada. It is co-sponsored by the Centers for Application of Substance Abuse Technologies (CASAT) and the Mountain West Addiction Technology Transfer Center in conjunction with SAPTA and treatment providers. Funded Treatment Providers must now Report More Complete Data for all Levels of Service In order to foster the improved use of resources, a number of system changes have been required in addition to those cited above, including support for early intervention, care coordination, and comprehensive evaluation services. Care coordination, in addition to supporting staff to help with case management, may include childcare, transportation, and translation/interpreter services. Comprehensive evaluation was added as a funded level of service in order to help improve providers ability to provide services to the sector of the population in need of substance abuse treatment services that also have a diagnosable, co-occurring mental illness. COORDINATION OF SERVICES Today, an important issue in the development of accessible and affordable treatment is the need for better integration among service delivery systems. The tendency is for agencies to work independently; however, better communication through the formation of clearly defined, integrated relationships is needed among different service providers (e.g., substance abuse, mental health, primary care) and is now being supported. The past two decades have witnessed the emergence of an increasing number of individuals with co-occurring mental health and addictive disorders. These individuals typically do not fare well in traditional service settings. Additionally, their course of illness is often associated with poor outcomes across multiple service systems. Thus, many of these individuals have traditionally been served at higher costs due to higher levels of service utilization. National epidemiological data demonstrate clearly that the prevalence of these individuals is sufficiently high in some service systems and that co-morbidity must be considered an expectation, not an exception. In fact, the U.S. Surgeon General has estimated "Forty-one to sixty-five percent of individuals with a lifetime substance abuse disorder have also had a lifetime history of at least one mental disorder, and approximately fifty-one percent of individuals with one or more lifetime mental disorders have also had a history of at least one substance abuse disorder." These individuals appear not only in mental health and substance abuse treatment settings, but also in primary health care, correctional, homeless, protective service, and other social service settings. 29

38 Section II Treatment Implementation The stigma that is still associated with substance abuse disorders and mental disorders stands between many people with co-occurring disorders and successful treatment and recovery. Individuals with co-occurring disorders present a challenge to both clinicians and the treatment delivery system by the existence of two separate service systems, one for mental health services and another for substance abuse treatment. SAPTA encourages all its funded substance abuse treatment facilities to develop capacity to serve the less severe mentally ill and substance abuse dependent population. The concept of no wrong door treatment strategy allows those suffering from persistent mental illness and chronic substance abuse disorders to engage in seamless treatment for co-occurring issues. At the center of care delivery for the co-occurring diagnosed are the processes of continuous case management, care coordination of invested agencies, and stable housing. National trends regarding the population with co-occurring disorders clearly reflect a need for improved service delivery. It is a driving principle of current publicly supported Nevada providers that any person entering mental health care, substance abuse treatment, or primary care should be screened for mental disorders and substance abuse and then provided appropriate treatment. Over the last few years, programs have increased comprehensive evaluations, resulting in combined services and treatment planning for the cooccurring population. The Substance Abuse Prevention and Treatment Agency s (SAPTA) Co-occurring Disorders (CODs) Treatment project includes two Clark County programs (Community Counseling Centers Las Vegas (CCCLV) and Bridge Counseling) and three Washoe County programs (Quest Counseling, Bristlecone Family Resources, and Family Counseling Services of Northern Nevada). In SFY 2011, the SAPTA reassessed the project and modified the incorporated activities: Expanded services by partnering with Bridge Counseling Services to offer both adolescent and adult COD services. Continued to work with the Center for the Application of Substance Abuse Technologies to increase training offerings to clinicians providing treatment to COD clients, such as screening and assessment. Began the discussion on Recovery Oriented Systems of Care. Continued to provide technical support as needed. Clark County s COD Treatment Pilot Programs PILOT PROGRAMS Currently, CCCLV operates six sites within Southern Nevada Adult Mental Health Services (SNAMHS). In addition, CCCLV provides treatment to Solutions Recovery Inc s residential COD clientele and the residential clients who reside at Solutions and receives mental health treatment by SNAMHS. CCCLV continues their work with Family Court, to offer families coming into the system immediate services with the goal of keeping children with their parents. By providing extensive COD treatment, CCCLV has been able to more effectively address National Outcome Measures. To fill a much needed gap in services in FY 2011 Bridge Counseling and Associates was provided funds to treat adult and adolescent COD clients. Bridge has a diverse staff capable of meeting the specific needs of COD clients. 30

39 Section II Treatment Implementation Washoe County COD Treatment Pilot Programs The Quest COD program treats adolescent clients ranging in age from 13 to 18 years who meet placement criteria for ASAM Levels I and II.I. Recently Quest purchased a building that they hope will provide them the space to offer inpatient services and possibly a recovery high school. Since the last report, Quest has begun utilizing the modified mini to better capture COD clients. Quest continues to offer multi-dimensional family therapy, an evidence based practice for treating adolescent COD clients. In regards to staff, Quest has added a psychologist to its treatment team. The Modified Mini Screen is a set of 22 items derived from a structured psychiatric interview. It is designed to identify people who should have a mental health assessment. The Modified Mini Screen covers three categories of mental health problems: mood disorders anxiety disorders psychotic disorders. The Family Counseling Service COD program treats adult clients meeting ASAM Level I and II.I placement criteria. Level II.I outpatient services continued to be provided in conjunction with Northern Nevada Adult Mental Health Services (NNAMHS). Bristlecone Family Resources COD program treats adults meeting ASAM Level I and II.I placement criteria with co-occurring disorder diagnosis. Since the last report, Bristlecone has begun offering peer support and family groups focused on COD. In addition, Bristlecone adopted a two group format for all COD groups, a move the program reports as being beneficial to the clients and has improved outcomes. Bristlecone continues to work with various agencies in the greater Reno area in order to better treat clients. In order to improve the effectiveness of Nevada s COD programs, increase client access, and track status of expected project outcomes, SAPTA will continue to provide programs to provide TA in order to: Identify effective evidence based treatment curriculums that address the issues of the population being treated (ex. Adolescent clients). Improve communication between community providers in order to provide the COD client with a higher level of care and provide a foundation for future integration activities. Improve documentation practices in order to track National Outcomes Measures more efficiently. Develop a competent workforce that will have the ability to recognize individuals with COD issues and properly treat and provide suitable case management services for all COD clientele. In addition, SAPTA will continue to work in conjunction with MHDS agencies (Rural Clinics, SNAMHS, and NNAMHS) towards a true integration of services for the COD population. Future plans also include identifying a level of service within the Federal Block Grant that will assist the agency with providing treatment for this population. Marijuana Registry The Division of Mental Health and Developmental Services, Substance Abuse Prevention and Treatment Agency (SAPTA) accepted applications for substance abuse treatment services to include assessments with 31

40 Section II Treatment Implementation referrals or treatment to outpatient, intensive outpatient, residential levels of care and involvement with family recovery support services. Funding was provided through the Health Division s Marijuana Registry to increase access to substance abuse assessments and treatment services in Nevada for individuals involved with Nevada Child Welfare Services. SAPTA was seeking qualified facilities to provide services for a minimum of one hundred twenty (120) adult/ families with approximately $700,000 available. The request was designed to address compliance with the Nevada Revised Statute below: NRS 422A.370 Expedited application for treatment or services for certain persons. 1. If a person who is referred for treatment for mental health issues, treatment for substance abuse or any other treatment or service by an agency which provides child welfare services or by a court in a case involving a report of child abuse or neglect, the Division shall expedite the application of the person for such treatment or services to ensure that the person receives the treatment or services in a timely manner. 2. As used in this section, agency which provides child welfare services has the meaning ascribed to it in NRS 432B.030. (Added to NRS by 2009, 329) The Request for Qualifications (RFQ) application was open to certified non-profit treatment programs that may have an interest in responding to the following areas of service. To allow individuals and families referred by the child welfare agency to receive appointments for assessments and admission to the appropriate levels of substance abuse services on a priority basis under this State funding only. Early intervention services to provide access to participation in evidence-base programs and services to address the increased risk for intergenerational abuse and dependence on alcohol and other drugs. Evidence-based strategies to address women s experience of trauma (e.g. Seeking Safety; Helping Women Recover; Trauma Recovery and Empowerment Model, etc.) Family counseling to strengthen family functioning and assist with reunification of families when the children have been in out-of-home placements. The collection of data to enable SAPTA and Child Welfare to report quarterly on the progress of this project in a manner parallel to outcomes identified in the National Outcome Measures (NOM s) to the Nevada Legislation, Child Welfare Division and DHHS. Purchase levels of service identified as appropriate with this population, performance based, and a designed length of service to promote a successful outcome. Recovery Support Services within a community will be essential for serving this population. An established working relationship with public health, head start, local schools, and both juvenile and adult probation/parole is necessary. The submitted program unit costs are all inclusive for the level of service(s), as reimbursement will be based on per unit delivered. 32

41 Section II Treatment Implementation Staff providing the services must be qualified and trained in the delivery of evidence-base family services regarding substance related disorders. The following Performance Indicators were inserted to track successful outcomes. Reduce the time between contact by Child Welfare Services and the appointment scheduling with the treatment program. Reduce the time between the completion of the substance abuse assessment and admission into the appropriate level of treatment service or other determined services. Increase overall admissions to individuals needing treatment services referred through the Child Welfare Services. Seven treatment programs were awarded funding; three in Clark County, three in Washoe County and one in rural Nevada with a total scope of work exceeding 330 clients. FEE FOR SERVICE The Nevada Department of Administration Division of Internal Audits completed an audit report of the Substance Abuse Prevention and Treatment Agency (SAPTA) in September The findings and recommendations concluded that SAPTA should adopt either a fee-for-service or a performance-based reimbursement methodology. This would enhance SAPTA s ability to more effectively manage substance abuse treatment funds. The report also recommended SAPTA should require providers to report services funded by the grant, both federal and State funds. This would allow SAPTA to determine if providers are meeting the terms of the grant. Beginning in November 2011 with funding through the Health Division and in conjunction with the Division of Child and Family Services, SAPTA introduced a fee-for-service approach by funding seven (7) treatment programs. These programs will be paid based on their monthly utilization for services delivered. The 2012 Request for Application for treatment services statewide will introduce a fee-forservice payment and is planned to continue through June This Area is Intentionally Left Blank. 33

42 Section II Treatment Evaluation CLIENTS IN TREATMENT The Agency collects extensive information on clients admitted for treatment. Demographics, referral sources, utilization of treatment programs, reporting of capacity at or over 90%, waiting lists, discharge information, and the number of individuals waiting for treatment are all collected. Treatment admission data for SFY 2011 is as follows: Adult admissions by primary substance of abuse were: 39% for alcohol, 24% for methamphetamine, 12% for marijuana/hashish, 11% for heroin/morphine, 8% for prescription drugs, 5% for crack/cocaine, and <1% for all others. 43% of the adult populations served were in outpatient care, 24% were in detoxification care, 20% in residential treatment, 11% in intensive outpatient treatment and 2% in Opioid maintenance therapy. 64% of the adult population served were males and 36% were females, of which 2% were pregnant at admission. Most frequent referrals were from the criminal justice system (47%); followed by self, family or friends (28%); community referrals (11%); alcohol drug abuse care providers (5%); other health care providers (5%); Civil Protection Custody (3%); and school or employer (1%). 1,240 clients were placed on waiting lists and had to wait for admission an average of 19 days. Priority population clients received support services in the interim. ADOLESCENTS IN TREATMENT SAPTA treatment admission statistics for adolescents in SFY 2011 were: 1,183 adolescents were admitted for treatment, representing 10.6% of all SAPTA treatment admissions. Adolescent admissions by primary substance of abuse were: 69% for marijuana/hashish, 17% for alcohol, 5% for prescription drugs, 4% for methamphetamines, 1% for crack, 1% for heroin and 2% for all others. 75% of the adolescent population served were in outpatient care, 12% in intensive outpatient treatment, 7% in detoxification, and 6% in residential treatment. Most frequent adolescent referrals were from the criminal justice system (77%); by self, family or friends (11%); from healthcare providers or community services (5%); from Civil Protective Custody (3%); School (2%); and Alcohol or Drug Abuse Care Providers (2%). 72% of adolescent admissions were males, 28% were females of which 2% were pregnant. TREATMENT MAPS AND CHARTS On the next page is a map entitled, Provider Admissions for all Drugs SFY 2011 by Zip Code. This map illustrates where SAPTA clients resided when they were admitted into treatment. The rest of this section includes charts that compare various demographics of individuals that receive SAPTA funded treatment services. 34

43 Section II Treatment Evaluation Map 4. Provider Admissions for all Drugs in SFY 2011 by Zip Code 35

44 Chart 11. SAPTA Treatment Admissions, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 36

45 Chart 12. Adolescent Treatment Admissions, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 37

46 Section II Treatment Evaluation 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1, Adolescent 7, Total 2008 Adolescent 7,276 7,934 4,078 4,486 1,179 1, Total 2009 Adolescent 2009 Total 2010 Adolescent Males Females 7,257 3, Total 2011 Adolescent 7,291 3, Total Chart 13. Adolescent Treatment Admissions by Gender, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. 38

47 Chart 14. Admissions to Treatment by Race and Ethnicity, Nevada, SFY * *Admissions in Ethnicity may include a Race group. Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 80.0% 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 7,450 7,728 2,055 2,086 1,695 1,633 1,353 1, American Indian/ Alaskan Native Asian/ Pacific Islander Black or African American Caucasian Other/ Multi Race Unknown Hispanic 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 39

48 Chart 15. Admissions to Treatment by Referral Source, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescents numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 6,361 5,848 5,574 5,167 3,651 3,425 3,107 3,456 2,945 2,634 2,450 2, Clark Washoe Balance of State Areas Served 2008 Adolescent 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 40

49 Chart 16. Admissions to Treatment by Area of Residence, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescents numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 6,361 5,848 3,107 5,167 3,651 3,425 3,107 3,456 2,945 2,634 2,450 2, Clark Washoe Balance of State Areas Served 2008 Adolescent 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 41

50 Chart 17. Admissions to Treatment by Drug of Choice, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 50.0% 45.0% 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% 5,249 4,446 4, ,446 2,276 2,011 2,507 1,831 1,880 1, ,024 1, Drug of Choice 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 63 42

51 Chart 18. Pregnant Women and Injection Drug Users Admissions to Treatment, Nevada, SFY Historically adolescents were defined to include 18 year olds. As of 2010, adolescent numbers were revised to include clients who were 17 and under only. Section II Treatment Evaluation 18.0% 16.0% 1, % 12.0% 1,594 1,447 1, % 8.0% 6.0% 4.0% 2.0% 0.0% Pregnant at Admission Pregnant IDU at Admission All IDU at Admission 2008 Adolescent 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 43