Substance Abuse Prevention and Treatment Agency 2011 Annual Report

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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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

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

Table of Contents TABLE OF CONTENTS List of Charts... ii List of Tables... iii List of Maps... iii I. Agency Overview... 1 II. Treatment... 10 Assessment... 10 Capacity... 25 Planning... 26 Implementation... 28 Evaluation... 34 III. Prevention... 46 Assessment... 46 Capacity... 51 Planning... 54 Implementation... 56 Evaluation... 63 IV. Directories... 71 Treatment Directory 71 Prevention Directory...81 V. List of Acronyms... 89 i

Table of Contents TABLE OF CONTENTS LIST OF CHARTS Chart 1: SAPTA Revenue Sources, SFY 2007... 4 Chart 2: SAPTA Revenue Sources, SFY 2011... 4 Chart 3: SAPTA Expenditures, SFY 2011... 5 Chart 4: NOMs Admission Geographical Comparisons, SFY 2011... 9 Chart 5: NOMs Change from Admission to Discharge Geographical Comparisons, SFY 2011... 9 Chart 6: Nevada Methamphetamine Admissions by Primary Drug to SAPTA, SFY 2007-2011... 18 Chart 7: Nevada Meth and Heroin Admissions, by Primary, Secondary and Tertiary Use, SFY 2007 - SFY 2011... 22 Chart 8: Drug and Related Arrests and Alcohol Related Crimes, 2006-2010... 23 Chart 9: Drug Related Murders in Nevada, 2006-2010... 24 Chart 10: Health Insurance Coverage for Nevada Funded Programs, SFY 2011... 24 Chart 11: SAPTA Treatment Admissions, Nevada, SFY 2003-2011... 36 Chart 12: Adolescent Treatment Admissions, Nevada, SFY 2003-2011... 37 Chart 13: Adolescent Treatment Admissions by Gender, Nevada, SFY 2007-2011... 38 Chart 14: Admissions to Treatment by Race and Ethnicity, Nevada, SFY 2010-2011... 39 Chart 15: Admissions to Treatment by Referral Source, Nevada, SFY 2009-2011... 40 Chart 16: Admissions to Area of Residence, Nevada, SFY 2008-2011... 41 Chart 17: Admissions to Treatment by Drug of Choice, Nevada, SFY 2009-2011... 42 Chart 18: Pregnant Women and Injection Drug Users Admissions to Treatment, Nevada, SFY 2008-2011... 43 Chart 19: Admissions to Treatment by Level of Care, SFY 2009-2011... 44 Chart 20: Synar Noncompliance Rate for Nevada, FFY 2007-2012... 65 Chart 21: Prevention Participants by Area, Nevada, SFY 2007-2011... 66 Chart 22: Prevention Participants by Gender, Nevada, SFY 2007-2011... 67 Chart 23: Prevention Participants by Race and Ethnicity, Nevada, SFY 2010 and SFY 2011... 68 Chart 24: Prevention Participants by Adults and Adolescents, Nevada, SFY 2010 and SFY 2011.... 69 Chart 25: Prevention Participants by Age Group, Nevada, SFY 2011... 70 ii

Table of Contents (cont.) TABLE OF CONTENTS LIST OF TABLES Table 1: SAPTA Revenue Sources, SFY 2007 and SFY 2011... 3 Table 2: Substance Abuse Treatment and Prevention NOMs... 8 Table 3: Estimates of Need for Treatment in Nevada, 2011... 11 Table 4: Unmet Demand Estimate for Substance Abuse Treatment, 2011... 12 Table 5: YRBS Questions on Drinking, Drug use, and Suicide Related Behaviors... 13 Table 6: Admissions to SAPTA Funded Providers by Primary Drug of Choice, SFY 2011... 14 Table 7: Waiting List Trend Data, SFY 2007 - SFY 2011..... 25 Table 8: Prevention Participants Served.... 65 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... 16 Map 2: Perceptions of Great Risk of Having Five or More Drinks, 2008 and 2009 NSDUHs... 17 Map 3: Prescription Drug Abuse in SFY 2011 by Zip code.... 21 Map 4: Provider Admissions for all Drugs in SFY 2011 by Zip Code... 35 Map 5: Coalition Locations and Counties Served... 53 iii

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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 104-191 Health Insurance Portability and Accountability Act (HIPAA) of 1996 Public Health Service Act 2005 In accordance with NRS 458.025, 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

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 2010. 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

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 951,406 995,514 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 12-25 year olds. Grant ended September 2007. 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 2010. 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 26,303,472 2007 to 2011 Increase = 14% 3

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

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 $12.72 50% Primary Prevention $3.57 14% 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

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

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, https://bgaslegacy.feisystems.com/reports/nomssearch.aspx 7

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

Section I Chart 4. NOMs Admission Geographical Comparisons, SFY 2011 Agency Overview 100.0 90.0 80.0 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 35.5 31.7 28.7 Employed / In School 93.6 89.2 85.3 85.8 86.3 82.4 Clients Housed Arrest Free 40.2 70.5 58.4 Alcohol Abstinent 34.8 51.3 50.9 Drug Abstinent 35.2 31.8 32.8 Engaged in Social Support Activities Admission percents Nevada Western States United States Source: https://bgas.samhsa.gov/reports/nomsearch.aspx Chart 5. NOMs Change from Admission to Discharge Geographical Comparisons, SFY 2011 60.0 50.0 46.4 48.4 40.0 33.6 30.0 20.0 15.5 22.3 25.0 24.0 21.2 15.1 10.0 0.0 10.3 5.5 4.5 Employed / In School 3.7 3.3 2.5 Clients Housed 9.8 8.3 8.9 Arrest Free Alcohol Abstinent Drug Abstinent Engaged in Social Support Activities Change from Admission percent to Discharge percent. Nevada Western States United States Source: https://bgas.samhsa.gov/reports/nonsearch.aspx 9

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, 2012. 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, 2007. 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

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 2009. 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 2008-2009 (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 17 133,881 11,755 28,382 2,492 23,012 2,020 185,275 16,267 18 to 25 232,814 48,635 49,355 10,310 40,019 8,360 322,188 67,305 26 to 100 1,267,435 100,761 268,688 21,361 217,860 17,320 1,753,983 139,442 Total 1,634,130 161,151 346,425 34,163 280,891 27,700 2,261,446 223,014 Sources: 1) http://www.oas.samhsa.gov/2k9state/appb.htm 2) 2010 State Demographer estimates updated in 2008 http://nvdemography.org/wp-content/uploads/2011/05/nevada.pdf 3) Age range allocations taken from the U.S. Census Bureau Profile of General Population and Housing Characteristics:2010;2010 Demographic Profile Data http://nvdemography.org/wp-content/uploads/2011/05/ Nevada.pdf 11

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 16,496 825 Adults (18+) 2,076,171 181,000 31,761 149,239 7,462 Total Population 2,261,446 200,000 34,265 165,735 8,287 Sources: * State Demographers 2009 Population Estimates updated August 2008 ** Department of Health and Human Services, Substance Abuse and Mental Health Services Administration. 2007 and 2008 State Estimates of Substance Use, http:// www.oas.samhsa.gov/2k8state/agetabs.htm. 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, http://drugabuse.gov/marijbroch/teenpg9-10.html) 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

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: 2007-2009 Nevada Youth Risk Behavior Survey, State Comparative Data 13

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 2001. 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% 199 17% 4,092 36% 18 11% Methamphetamine/Other Amphetamine 2,391 24% 55 5% 2,446 22% 86 53% Marijuana/Hashish 1,192 12% 819 69% 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 10,007 100% 1,183 100% 11,190 100% 161 100% * Adolescents include those 12-17 years old. Less than one percent of the 161 pregnant clients admitted to treatment were adolescents. 14

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 2007. 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 2006-2010; National Highway Traffic Safety Administration (NHTSA)) Driving Under the Influence Adults in the US drank and drove approximately 112 million times in 2010. 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 21-34 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 811 395) 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

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 2009. 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 2008-2009. 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 12-17 the binge drinking rate was 8.49 percent and youth aged 18-25 the rate was 46.83. Nevada ranked in the second to lowest quintile in this age group at 46.83 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 2008-2009, 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

Section II Treatment Assessment binge drinking at the State level in 2008-2009. 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 2002. 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 39.52 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 2007-2008. 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 2009. 17

Percentage of Admissions Section II Treatment Assessment Chart 6. Nevada Methamphetamine Admissions to SAPTA by Primary Drug, SFY 2007 2011 50 40 30 20 Methamphetamine Admissions 34.9 26.5 20.2 20.4 21.9 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 2011. 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 2007 2008 2009 2010 2011 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 2010. Along the Southwest border, seizure amounts more than doubled between 2008 (2,221 kilograms) and 4,486 kilograms in 2010. 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, 2008-2009). 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

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 2006. 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 2006. 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 $164.91 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 2008-2009 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 2011. (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, 2010. The 30-day prevalence of use of cocaine in grades 8, 10, and 12 combined has increased 0.1percent between 2009 and 2010. (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 2009. 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 1995. Prescription Drug Monitoring Programs (PDMPs) allow physicians and pharmacists to log each filled prescription into a 19

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 2010. 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 2010. 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 2009. 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

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

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 2007 - SFY 2011 60 50 40 30 20 10 0 45.6 37.3 6.1 8.3 29.4 29.8 29.7 10.4 11.4 12.7 2007 2008 2009 2010 2011 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 10-24. 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, http:// pathwayscourses.samhsa.gov/suicide/suicide_references.htm#70.) 22

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, 2006 2010 25,000 20,000 15,000 10,000 5,000 0 2006 2007 2008 2009 2010 Drug Related Arrests - Adults Alcohol Related Crimes - Adults 23

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, 2006-2010. 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 12 10 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 2006 2007 2008 2009 2010 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 2011. 24

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 2008. To receive treatment services clients have had to wait 19 days once placed on a waiting list. Table 7. Waiting List Trend Data, SFY 2007-2011* 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 20 15 16 17 19 *Includes clients that waited 45 days or less. This Area is Intentionally Left Blank. 25

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 2015. 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

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

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 2012. 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 2011. 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 2012. 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

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

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

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

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

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 2009. 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 2015. This Area is Intentionally Left Blank. 33

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

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

Chart 11. SAPTA Treatment Admissions, Nevada, SFY 2003-2011 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

Chart 12. Adolescent Treatment Admissions, Nevada, SFY 2003 2011 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

Section II Treatment Evaluation 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% 1,079 613 2007 Adolescent 7,007 642 966 523 2007 Total 2008 Adolescent 7,276 7,934 4,078 4,486 1,179 1,171 605 517 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent Males Females 7,257 3,874 871 312 2010 Total 2011 Adolescent 7,291 3,899 2011 Total Chart 13. Adolescent Treatment Admissions by Gender, Nevada, SFY 2007-2011 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

Chart 14. Admissions to Treatment by Race and Ethnicity, Nevada, SFY 2010-2011* *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 1,244 608 625 352 300 386 398 401 419 32 29 188 21 17 161 99 103 13 93 11 124 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

Chart 15. Admissions to Treatment by Referral Source, Nevada, SFY 2009-2011 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 2,567 506 480 478 411 454 478 241 195 277 303 404 469 Clark Washoe Balance of State Areas Served 2008 Adolescent 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 40

Chart 16. Admissions to Treatment by Area of Residence, Nevada, SFY 2008-2011 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 2,567 506 480 478 411 454 478 241 195 277 303 404 469 Clark Washoe Balance of State Areas Served 2008 Adolescent 2008 Total 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 41

Chart 17. Admissions to Treatment by Drug of Choice, Nevada, SFY 2009-2011 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 4,092 929 322 278 199 745 713 723 538 2,446 2,276 2,011 2,507 1,831 1,880 1,148 892 1,024 1,044 686 715 819 98 86 10 12 5 29 62 62 30 17 17 48 52 55 30 23 26 Drug of Choice 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total 63 42

Chart 18. Pregnant Women and Injection Drug Users Admissions to Treatment, Nevada, SFY 2008-2011 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% 1,745 14.0% 12.0% 1,594 1,447 1,434 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% 267 198 165 161 13 62 9 6 3 0 44 30 0 28 14 12 1 0 30 6 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

Chart 19. Admissions to Treatment by Level of Care, Nevada, SFY 2009-2011 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% 5,228 5,235 45.0% 5,197 40.0% 35.0% 30.0% 3,607 25.0% 2,656 2,460 20.0% 2,251 2,084 1,851 15.0% 10.0% 5.0% 0.0% 1,194 1,210 1,196 863 892 735 80 130 207 169 68 79 148 202 80 67 144 1 1 0 2009 Adolescent 2009 Total 2010 Adolescent 2010 Total 2011 Adolescent 2011 Total Detoxification 0.6% 29.0% 0.6% 23.9% 0.7% 22.0% Residential 1.0% 18.1% 0.7% 16.6% 0.6% 18.6% Intensive Outpatient 1.7% 9.6% 1.3% 10.7% 1.3% 10.8% Outpatient 5.9% 41.8% 7.8% 47.0% 8.0% 46.8% Opioid Maintenance Therapy 0.0% 1.4% 0.0% 1.8% 0.0% 1.8% 201 44

Section II Treatment Evaluation TREATMENT HIGHLIGHTS Twenty-three non-profit private or governmental substance abuse treatment programs providing services at 70 sites were funded in State Fiscal Year 2011 with programs receiving approximately $13 million in financial support. Additionally, SAPTA certified another 45 treatment programs that were not funded. All funded programs must not discriminate based on ability to pay, race/ethnicity, gender or disability. Additionally, programs are required to provide services utilizing the SAPTA sliding fee scale. Providing a continuum of treatment services, SAPTA continued to support various substance abuse related services and treatment levels of care including: Comprehensive Evaluations, Civil Protective Custody, Detoxification, Residential, Intensive Outpatient, Outpatient, Transitional Housing, and Opioid Maintenance Therapy (OMT) that were delivered in conjunction with outpatient treatment levels of care. Services certified but not funded include Drug Court Services and Evaluation Centers. The Agency established a modality of care to respond to the geographic needs of citizens in remote areas of the state. Additionally, Telecare now provides licensed staff an opportunity to support substance abuse issues through the means of advanced technology. SAPTA continues to promote performance-based treatment outcomes by defining treatment measurements contained within all its sub-grant documents. For example, detoxification services have as a performance measure that 40% of all clients admitted will continue on in treatment. SAPTA, working with the Southern Nevada Health District, the Health Division s Public Health & Clinical Services, Carson City Health District, and the Northern Nevada HIV Outpatient Program Education and Services (HOPES) Clinic, continued to implement statewide standards regarding access to TB and HIV testing as well as counseling for clients in treatment. Provided a foundation for integrating Mental Health and Substance Abuse services, a crucial step in regards to Healthcare Reform. Provided a very critical service to Nevada as evident by the admission numbers for Co-occurring Disorders Treatment. Initially, SAPTA projected 240 clients would access COD services annually. Instead 635 clients were treated between the five programs in SFY 2010 and 592 in SFY 2011. Provided a stronger network of care. Currently, two of the five programs partner with Department of Mental Health and Developmental Services to provide treatment to individuals with mild to severe mental health conditions. Providing this service has enabled individuals to receive a continuum of care that will increase the likelihood of positive outcomes. SAPTA increased the amount of clients that abstained from using substances 30 days after discharge. 45

Section III Prevention Assessment PREVENTION OVERVIEW Prevention is defined as a proactive process of helping individuals, families, and communities to develop the resources needed to develop and maintain healthy lifestyles. (International Certification and Reciprocity Consortium) Prevention is broad based in the sense that it is intended to alleviate a wide range of at-risk behaviors including, but not limited to, alcohol, tobacco, and other drug abuse, crime and delinquency, violence, vandalism, mental health problems, family conflict, parenting problems, stress and burnout, child abuse, learning problems, school failure, school drop outs, teenage pregnancy, depression, and suicide. Why should we invest in prevention? "An ounce of prevention is worth a pound of cure." It is better to prevent a problem, rather than waiting to deal with the aftermath. In other words, making early investments in the positive development of children and youth costs far less than failing to prevent youth substance abuse and violence. It costs more than $45,000 per year to confine a young person in the juvenile justice system. In contrast, effective prevention saves money, as well as reduces the human toll caused by substance abuse and violence. Research shows that for every $1 spent on prevention, the savings to society can range from $2 to $20 (an average of about $10), depending on the cost of the prevention service. (SAMHSA, CSAP) SAPTA has established a system whereby the Agency purchases substance abuse prevention services through a coalition system that covers all 17 Nevada counties in a three year competitive cycle. Once coalitions are identified they must fund local providers to conduct direct service activities in at least three year competitive cycles. Coalition applications are reviewed by Agency staff and outside independent review panels. Funds are awarded on the basis of the Coalitions ability to provide the requested service. As stated in NRS 458.025, only agencies which have received SAPTA certification are eligible for funding and that includes coalitions and direct service providers. In addition to certification each agency has to meet the SAPTA Deeming Process criteria which includes proof of 501(c)3 status, sufficient infrastructure in place, an agreement to conduct program evaluation, and complete a template of a Coalition Request for Application (RFA) process. Coalitions must not conduct direct service activities, but can provide environmental strategies. Environmental strategies focus on changing aspects of the environment that contribute to the use of alcohol and other drugs. These include activities that decrease the social and health consequences of substance abuse such as limiting access to substances and changing social norms that are accepting and permissive of substance abuse. Changing public laws, policies and practices to create environments that decrease the probability of substance abuse are goals of environmental strategies. After awards are made, the Agency monitors compliance with the programmatic and fiscal terms of the sub-grants. Also, the Agency provides programs with technical assistance to ensure that appropriate services are provide. The primary Agency strategies are the coordination and implementation of all state and federal funding through planning and analysis of alcohol and drug abuse need. Elements of the Agency s prevention strategy are described below: Provide Nevadans access to quality substance abuse prevention services. Provide information regarding how many participants are being served as a result of Agency funding and the type of services provided. Develop an infrastructure to assist prevention providers in providing effective quality and quantity of services using the Five Steps of SAMHSA s Strategic Prevention Framework. (2005 Carnevale Associates LLC) 46

Section III Prevention Assessment Assessment Profile population needs, resources, and readiness to address needs and gaps; Capacity Mobilize and/or build capacity to address needs; Planning Develop a Comprehensive Strategic Plan Implementation Implement evidence-based prevention programs, policies, and practices; Evaluation Monitor, evaluate, sustain, and improve or replace those that fail Verify that state and federal funds are being used to purchase services that achieve state and federal goals. Require the assessment of priority risk and protective factors for individual communities. Require the assessment of individual communities in identifying target populations. Support evidence-based programs. These programs must be based on research or prior program findings that demonstrate the programs will prevent or reduce substance use by youth. Utilize CSAP s six strategies of substance abuse prevention, which include the following: Information Dissemination: This strategy provides awareness and knowledge of the nature and extent of substance use, abuse, and addiction and their effects on individuals, families, and communities. It also provides knowledge and awareness of available prevention programs and services. Information dissemination is characterized by one-way communication from the source to the audience, with limited contact between the two. Education: This strategy involves two-way communication and is distinguished from the information dissemination strategy by the fact that interaction between the educator/ facilitator and the participants is the basis of its activities. Activities under this strategy aim to affect critical life and social skills, including decision-making, refusal skills, critical analysis (e.g., of media messages), and systematic judgment abilities. Alternatives Activities: This strategy provides for the participation of target populations in activities that exclude substance use. The assumption is that constructive and healthy activities offset the attraction to or otherwise meet the needs usually filled by alcohol and drugs. Problem Identification and Referral: This strategy aims at identification of those who have indulged in illegal/age-inappropriate use of tobacco or alcohol and those individuals who have indulged in the first use of illicit drugs in order to assess if their behavior can be reversed through education. It should be noted, however, that this strategy does not include any activity designed to determine if a person is in need of treatment. Community-Based Process: This strategy aims to enhance the ability of the community to more effectively provide prevention and treatment services for substance abuse disorders. Activities in this strategy include organizing, 47

Section III Prevention Assessment planning, enhancing efficiency and effectiveness of services implementation, interagency collaboration, coalition building, and networking. Environmental Strategies: This strategy establishes or changes written and unwritten community standards, codes, and attitudes, thereby influencing incidence and prevalence of substance abuse in the general population. This strategy is divided into two subcategories to permit distinction between activities that center on legal and regulatory initiatives and those that relate to the service and action-oriented initiatives. (Federal Register, Volume,58, Number 60, March 31, 2993.) The SAPT BG required states to develop a 3-year plan for federal fiscal year (FFY) FFY 2011 FFY 2013. As part of the plan the states had to determine the priorities for both prevention and treatment. Nevada s prevention priorities, determined through the data gathering process, include: Enhance current strategic partnerships and develop new partnerships with behavior health agencies, including, but not limited to, adult and children s mental health agencies; primary care organizations; the State Division of Welfare; the Board of Pharmacy; public health, including maternal and child health; Education (ED); organizations representing special populations; and the Office of the Attorney General; Target substance abuse prevention in Native American communities among youth and in association with suicide; Develop and/or increase collaboration and partnership with the military; active service, veterans, reservists, National Guard, and families; Target alcohol, and drug use among women of child-bearing years and women currently pregnant; Prevent the onset of childhood and underage drinking and drug use, reduce the progression of substance abuse, and prevent the relapse of substance abuse of those in recovery; Research and develop a performance-based funding mechanism. THE STATE EPIDEMIOLOGICAL WORKGROUP (SEW) The Nevada SEW was created as part of the Nevada SPF SIG in October 2002 to collect and provide epidemiologic data to the State and its agencies in order to help reduce the use and abuse of alcohol, tobacco, and other drugs among Nevada s 12-25 year old population. The Workgroup is made up of a network of individuals who represent state agencies and organizations that use data related to substance abuse and its contributing factors. The original funding for the SEW ended in September 2010 and SAPTA applied for a separate grant to fund the Workgroup and its activities for up to four years. SAPTA was awarded the grant which began in November 2010 and it was renewed in November 2011. The vision of the SEW is to reduce the negative impact of substance abuse and related behaviors in Nevada s communities. The mission of the SEW is to act as an education resource for policy- and decision-makers by collecting, verifying, analyzing, and disseminating data for the purpose of helping statewide partners to reduce the negative impact of substance abuse and related problem behaviors. 48

Section III Prevention Assessment The following are the goals of the SEW: Recruit and retain SEW members who sustain the SEW and promote SEW mission and goals. Assess data needs of statewide partners in order to provide relevant data-related sources and services. Provide community outreach to statewide partners and other consumers of data to assist them in accessing data for their use in planning and demonstrating outcomes. Provide data, including trend data and highlights related to findings, along with input, recommendations, and interpretations as needed. Provide data related to risk factors, substance abuse related behaviors, and other related problem behaviors, including teen pregnancy, school dropout, violence, delinquency, depression and anxiety. Provide data across the lifespan, including those related to children, youth, young adults (in and out of higher education settings), adults (especially with regard to workforce-related norms and consumption patterns), and elderly populations. The following are the objectives of the SEW: Maximize all available alcohol, tobacco, and other drugs prevention resources. Remove state barriers to enhancing the delivery of effective local substance abuse prevention services. Develop shared responsibility among state and local governmental units. Increase the number of data-driven outcomes for substance abuse prevention. Promote the prevention of alcohol and other drug abuse. STATE EPIDEMIOLOGIC PROFILE In 2010, SAPTA received funding from SAHMSA to continue the work of the Statewide Epidemiologic workgroup. A requirement of the grant was that SAPTA produce an epidemiologic profile every year that described the epidemiology of substance abuse in Nevada. Information from the profile is used to guide the prevention programs in planning prevention interventions and education. Topics covered in the 2011 Epidemiologic Profile are alcohol dependence and abuse, heavy drinking, past month binge drinking, ARMF and Drinking Under the Influence (DUI), illicit drug use, methamphetamine use, suicide and information on mental health and substance abuse in Nevada. The 2011 version is available on the MHDS web site. CULTURAL COMPETENCY Cultural competence is the process of communicating with audiences from diverse geographic, ethnic, racial, cultural, economic, social, and linguistic backgrounds. Becoming culturally competent is a dynamic process that requires cultural knowledge and skill development at all service levels, including policymaking, administration, and practice. Cultural competence is a major component of the Strategic Prevention Framework (SPF) which is the model that SAPTA and its 13 funded coalitions use and relates to the incorporation of cultural competency within the SPF as follows: 49

Section III Prevention Assessment Assessment Assemble culturally competent groups of experts and stakeholders to analyze and interpret data. Understand the role of culture, race, ethnicity, and gender as they relate to assessment strategies and needs of populations. Capacity Building Understand community mobilization from a fiscal, human, and material resources perspective with culturally appropriate strategies. Create new fiscal, material, and human resources ensuring cultural representation (e.g., gender, age, language, disability). Implement a mechanism for providing continuing training and education to promote cultural competence, readiness, leadership and evaluation. Planning: Identify necessary program adaptations for defined populations and community environment. Implementation: Implement programs for defined populations and community environment. Evaluation: Use data collection methods that are culturally responsive and appropriate. This Area is Intentionally Left Blank. 50

Section III Prevention Capacity CENTER FOR SUBSTANCE ABUSE PREVENTION (CSAP) The CSAP provides national leadership in the Federal effort to prevent alcohol, tobacco, and other drug problems. To help Americans lead healthier and longer lives, CSAP promotes a structured, community-based approach to substance abuse prevention through the SPF. The SPF approach provides information and tools that can be used by States and communities to build an effective and sustainable prevention infrastructure, no matter the funding source. The SPF aims to promote youth development, reduce risk-taking behaviors, build assets and resilience, and prevent problem behaviors across the individual s life span. In SFY 2011, SAPTA funded approximately 73 primary prevention providers who are implementing substance abuse prevention programs to reduce and prevent substance use. Additionally, SAPTA funded and worked with 10 community based coalitions using CSAP s Strategic Prevention Framework Five Step Planning Model. These coalitions are responsible for the planning, coordination, and oversight of the 73 prevention programs and environmental strategies statewide. For SFY 2012, 13 coalitions and 67 direct service providers are funded that cover all 17 Nevada counties. Ten of the 13 coalitions are responsible for the planning, coordination, and oversight of 55 prevention programs and SAPTA provided oversight of the other 12 direct service providers in Clark County. The three new coalitions are in Clark County and were only funded for capacity building and environmental strategies during their first year as SAPTA funded coalitions. A map showing the areas served by the thirteen coalitions is shown on the page 54. SAMHSA has 8 Strategic Initiatives that were developed throughout FFY 2010. Strategic Initiative # 1 Prevention of Substance Abuse and Mental Illness, through the Center for Substance Abuse Prevention, the Center for Mental Health Services, and their partnering agencies, developed goals, objectives and action steps that states will use once the draft is approved. Below are the draft goals and objectives. The draft action steps with pertinent Performance measures, Goals, Objectives, and Action Steps can be found at http:// www.samhsa.gov/prevention. The states will be required to choose from and report on those measures in the future.. COALITION BUILDING AND STRATEGIC PREVENTION FRAMEWORK Community coalitions strive to include a broad representation of individuals and organizations from their communities. The Strategic Planning Framework (SPF) is a five-step process that assists communities, coalitions and agencies in identifying community problems, available resources, service gaps, and selecting interventions that address the unique needs of each community. The SPF process focuses on using data and building capacity within each community to impact the consequences of substance use-related matters. The SPF model is an evidence-based practice. It has been researched and evaluated. The SPF assists communities in using the data to identify needs as well as the strategies to impact those needs. The SPF is a public health, outcomes-based prevention approach that uses assessment and evaluation to continually move communities toward their goals of reducing substance abuse and its consequences. The communities of Nevada are using strong collaborations between the private sector, public health, academic partners, not-for-profit service providers, and other committed organizations to use the SPF to develop prevention expertise and infrastructure to sustain the process, and generate evidence to support replication of the process across the state. 51

Section III Prevention Capacity ADMINISTRATIVE PROGRAMS SAPTA used the SAPT BG to fund four administrative programs during SFY 2011. The four programs are listed and described below. Nevada Prevention Resource Center The Nevada Prevention Resource Center (NPRC) is the State Center for the Nevada Regional Alcohol and Drug Awareness Resource (RADAR) Network. The NPRC provides free current information on substance abuse prevention, treatment, and research, as well as materials in related fields such as mental health. Several SAPTA funded coalitions are RADAR satellite sites. Nevada Statewide Coalition Partnership The Nevada Statewide Coalition Partnership was awarded SAPT BG funds to implement a marijuana campaign that included a statewide educational conference, a social marketing campaign aimed at 14-18 year olds, and educating parents regarding marijuana using English and Spanish language materials. The Partnership also received State General Funds to implement a Methamphetamine Prevention Awareness campaign. Crisis Call Center Crisis Call Center s 24-hour crisis line often serves as the first point of contact for individuals who are seeking help, support, and information. Staff and volunteers are available 24/7/365 to help individuals discover the skills and resources that they uniquely possess and that allow them to develop solutions and maximize self-sufficiency. This hot-line is also a referral center for those in need of substance abuse information and treatment. The Crisis Call Center also handles 211 calls from Nevada residents. CASAT (Center for the Application of Substance Abuse Technologies) CASAT was awarded SAPT BG to coordinate all continuing education activities for SAPTA. The purpose is to improve substance prevention and treatment services by offering training and other TA to SAPTA Prevention and Treatment staff, prevention coalitions, and prevention and treatment direct service providers. Evidence-based practices in the field are the main emphasis of all education and training programs. CASAT has received SAPT BG funds to carry out the certification process for SAPTA s Prevention and Treatment programs. All prevention coalitions, as well as prevention and treatment direct service providers and administrative programs, must recertify every three years as required by SAMHSA. CASAT is aligned with the Nevada System of Higher Education; therefore SAPTA directly handles the certification process for all programs that are a part of that system. 52

Section III Prevention Capacity Map 5: Coalition Locations and Counties Served, SFY 2012 53

Section III Prevention Planning QUALITY IMPROVEMENT Plans continue in the creation of a Continuous Quality Improvement program with the purpose of developing a set of expectations for excellence in the SAPTA program. Guiding Principles for creating the structure of this Continuous Quality Improvement Program will incorporate SAMHSA s Strategic Prevention Framework Five -Step Process. MULTI-DISCIPLINARY PREVENTION ADVISORY COMMITTEE (MPAC) FORMERLY STATE INCENTIVE GRANT ADVISORY COMMITTEE (SAC) The MPAC formerly the State Incentive Grant Advisory Committee (SAC) was initially a requirement of the federally funded State Incentive Grant (SIG) project. The name was changed to the MPAC to reflect the diversity of disciplines working on Alcohol, Tobacco and Other Drug (ATOD) issues. The purpose of the Committee is to provide ongoing advice and guidance to the SAPTA projects in an effort to accomplish the following: Create a comprehensive statewide prevention strategy Maximize all available ATOD prevention resources Remove state barriers to enhancing the delivery of effective local substance abuse prevention services Develop shared responsibility among state and local governmental units Increase the number who receive prevention services Promote the prevention of alcohol and other drug abuse COLLABORATION In 2011, the agency, through an agreement with the Center for the Application of Substance Abuse Technologies (CASAT), conducted interactive webinars, on-line courses, seminars and video-taped courses covering evidenced-based fundamentals of substance abuse prevention programming, prevention theory, evidenced-based practices, program planning, workforce development, sustainability and the importance of culture in the successful implementation of prevention principals of effectiveness. Approximately 1,340 prevention specialists participated in the courses. SAPTA continues collaborating with CASAT in an effort to ensure substance abuse prevention education for all prevention professionals in the state. SAPTA continues to collaborate with the Center for the Application of Prevention Technologies, Western Regional Expert Teams (CAPT WEST RET) which provides TA through participation at the Statewide Epidemiological Workgroup (SEW), the Multi-disciplinary Advisory Committee (MPAC) as well as trainings which includes introduction to the Strategic Prevention Framework for all prevention professionals funded by SAPTA. Another of SAPTA s new collaborations includes the Nevada FASD Leadership Team headed by Dr. Ira Chasnoff, nationally renowned specialist in the area of FASD. Dr. Chasnoff and his team have implemented the 4P s Plus prevention program in Nevada addressing the importance of no exposure to tobacco, alcohol, and illicit drugs during pregnancy. 54

Section III Prevention Planning CENTER FOR THE APPLICATION OF PREVENTION TECHNOLOGIES (CAPT) The Center for the Application of Prevention Technologies continues to provide responsive, tailored, and outcomes focused training and TA to prevent and reduce substance abuse in Nevada. Funded by SAMHSA, the CAPT assists SAPTA in the selection and implementation of evidenced-based practices. The CAPT works with SAPTA by offering technical guidance and assistance in the overall program direction, management efficiency and consistency with a decentralized regional network system through Regional Expert Teams (RET). In addition to providing technical assistance and guidance to SAPTA, they also offer educational courses in prevention to SAPTA s stakeholders. Nevada is part of the CAPT West RET region which is housed at the University of Nevada Reno, but serves many eleven western states including Hawaii, plus six Pacific Island nations. Specifically, CAPT services are designed to strengthen the capacity of its grantees to effectively: Assess State- and community-level substance abuse problems and prevention needs Prioritize substance abuse problems, based on careful review and analysis of epidemiological data Mobilize prevention resources to support prevention activities Develop a strategic plan that links problems, intervening variables, and effective strategies Select evidence-based interventions that address identified needs and/or bolster innovative programs Implement evidence-based interventions, recognizing the need for fidelity of implementation Collect the process and outcome data needed to track the extent to which effective prevention strategies are being applied To meet these objectives, the CAPT provides a variety of services, including face-to-face training, distance learning, TA, networking opportunities, and the development of quality products to support training and TA. These services are informed by thorough and ongoing assessments of end-users and input from experts from across the prevention field. This Area is Intentionally Left Blank. 55

Section III Prevention Implementation SUBSTANCE ABUSE PREVENTION AND TREATMENT BLOCK GRANT (SAPT BG) The SAPT BG is the primary source of funding for substance abuse prevention in Nevada. This is a federal formula grant that is administered by SAMHSA. This federally legislated funding requires that a minimum 20% of the overall SAPT BG be set aside for prevention. While this grant is ongoing, it is dependent on the state applying yearly and reporting required performance data. The level of funding allocated to Nevada requires the state to maintain an average level of effort in funding prevention (and treatment) activities or the state s allocation will be reduced according to the level of state reduction in funding. SAPTA established a system whereby the Agency purchases substance abuse prevention services through a Statewide Coalition System. Coalitions are funded to provide environmental strategies, community-based strategies, information dissemination and through a Request for Application process allocate funds to nonprofit direct service or governmental providers that meet the identified community needs. Within this system, applicants are responsible for compliance with state and federal requirements with regards to receipt of funding. The Coalitions select direct service providers through a Request for Application process and are responsible for attaining service delivery projections that are established in their subgrant scope of work. Elements of the Agency s strategies are described below: Provide Nevadans access to quality substance abuse prevention services. Provide information regarding how many participants were served as a result of Agency funding and the type of services provided. Maintain and improve infrastructure to assist prevention providers in assuring effective quality and quantity of services. Verify that state and federal funds were used to purchase services that achieve state and federal goals. Require the assessment of priority risk and protective factors for individual communities. Enhance or expand collaboration with Agency funded substance abuse prevention coalitions. Require the assessment of individual communities in identifying target populations. Utilize CSAP s six strategies of substance abuse prevention which include: Information Dissemination, Prevention Education, Alternative Activities, Problem Identification, Community Based Process, and Environmental Strategies. Support and encourage the use of evidence-based programs for prevention services. In addition, the state must maintain a less than 20% noncompliance rate for the sales of tobacco to minors, according to the Synar amendment. States with over a 20% noncompliance rate are penalized in the amount of BG funding available for the FFY. For 2011, Nevada s non-compliance rate was 3.1%. 56

Section III Prevention Implementation STRATEGIC PREVENTION FRAMEWORK STATE PREVENTION ENHANCEMENT (SPE) GRANT With a broad, national scope, the SPE Program is designed to support States and Tribes in enhancing their infrastructures to reduce the impact of substance abuse. The SPF process is an integral part of SAMHSA s mission to reduce the impact of substance abuse and mental illness on America s communities. Through stronger, more strategically aligned substance abuse infrastructures, SPE States and Tribes will be better positioned to apply the SPF process to implement data-driven, evidence-based prevention programs, policies and practices in their communities. SPE funding will foster more responsive, interactive State and Tribal systems that can better address and adjust to the complexities of evolving health care initiatives and their fiscal implications for communities of high need. The purpose of the Nevada SPE project is to strengthen and reinforce the SPF process; extend the SPF model to better address prevention needs in high risk populations; and broaden the scope, use, and fidelity, of evidence-based programs. A Capacity Building/Infrastructure Enhancement Plan was the first of the SPE grant deliverables and was developed with input from a contracted facilitator, the SAPTA s Epidemiologist, and three working groups who represented SAPTA, members of the State Epidemiology Workgroup (SEW) and the Multidisciplinary Prevention Advisory Committee (MPAC). This Plan is made up four mini-plans that include the following: Data Collection, Analysis, and Reporting Plan; Coordination of Services Plan; TA and Training Plan; and Performance/Evaluation Plan. The Comprehensive Strategic Prevention Plan, the last grant deliverable, will be developed with input from a contracted grant coordinator, the strategic planning facilitator, the 10 established, three new coalitions and their partners, the SEW and the MPAC. The MPAC will serve as the Policy Consortium. Through regional meetings, a group process will provide a foundation for writing the final strategic plan. The plan will include an integrated data dissemination system with a data warehouse. This will enhance braiding of data sources allowing partners to easily upload and query data for multiple uses. The data warehouse enhancements will build an effective evaluation system rooted in process and outcome data. With a primary prevention focus, efforts will be made to: build emotional health, prevent or delay the onset of and mitigate complications from co-occurring substance abuse and mental illness (14,408 to be served); reduce the prevalence of alcohol dependence or abuse in adults and youth (178,409); prevent suicides and attempted suicides among populations at high risk; adolescents (14,571 attempts in 2009), elderly suicides (111); reduce nonmedical use of pain relievers in people 12 and older (142,547); and increase the perception of risk of Native Americans using marijuana (5,996). The SPE grant guidance also added two additional goals: Enhance State/Tribal workforce development and Enhance State/Tribal Policy development to support needed service system improvement. Enhance Nevada s Workforce Development Objective 1.1: Collaborate with CAPT West RET and coalitions to produce an updated plan that identifies, outlines, and addresses community coalition workforce development needs related to substance abuse prevention programs. Plan may include: 57

Section III Prevention Implementation Expanding or redefining the role of the current MPAC. Providing TA on the creation of the State SPE Policy Consortium. Providing TA in selecting evidenced-based strategies. Providing assistance in the development of an updated statewide strategic plan. Working with newly formed coalitions on creating Community Coalition Prevention Plan (CCPP) and logic models. Provide training through CASAT. Objective 1.2: Collaborate with Community Anti-Drug Coalitions of America (CADCA) to provide trainings for coalitions to build stronger, substance abuse infrastructures Enhance Nevada Policy Development to Support Needed Service System Improvements Objective 2.1: Establish an MPAC subcommittee that will identify strategies to address the following: Early identification of heavy users of alcohol or other drugs through simple screening questionnaires such as CAGE, which is used by primary health care providers, an internationally used assessment instrument for identifying problems with alcohol. Brief intervention services designed for early identification of behavioral health issues that are potential risk factors for substance abuse. Specific training for health care workers in early identification and brief intervention techniques. Objective 2.2: Hire a consultant to conduct a study to determine the cost benefit and effectiveness of substance abuse prevention programs as well as the method for measuring both. Objective 2.3: Study the feasibility of certifying prevention specialists in Nevada. STATEWIDE EPIDEMIOLOGY OUTCOMES WORKGROUP (SEOW) FUNDING SAPTA looks forward to working toward accomplishing all that is set forth within the four mini-plans, participating in the process of developing the Five-Year Strategic Plan, providing training and technical support to coalitions, direct service providers, community partners, and developing a data system that will provide data for use by all of our stakeholders and partners. In October, 2010, SAPTA applied for funding from SAMHSA to continue the work of the Statewide Epidemiology Workgroup (SEW), which was originally funded by the Strategic Prevention Framework grant. Funding was awarded for one year during which eight documents (deliverables) describing the work of the SEW were due. The purpose of each of the deliverables was to track the work of the SEW. The SEW was required to review and update its charter to formalize the structure and clarify its membership. An epidemiologic profile of the state and a community profile on a selected state population were required. SAPTA was required to develop an electronic on line data dissemination system to be used by coalition partners, legislators or people interested in substance abuse data on Nevada. The Year one deliverables were all competed, thus, SAPTA was awarded funding to continue the project in to a second year. Year two started in November, 2011 and SAPTA is currently working to complete the deliverables required for this round of funding. 58

Section III Prevention Implementation The SEW has benefited greatly as a result of these funds. The SEW membership was changed to include statewide members that have come to the group with new ideas, data and energy. Prevention efforts in the state will be enhanced and improved through the development of the data dissemination system, the epidemiologic and community profiles and the state/ community assessment. SFY 2011 SPF SIG AND COALITION ENVIRONMENTAL STRATEGIES The SPF SIG grant ended September 30, 2010. However all of the coalitions have been able to continue work on environmental strategies throughout SFY 2012 with State General Funds and Substance Abuse Prevention and Treatment (SAPT) Block Grant funds. Luz Community Development Coalition (Luz) Luz has worked with 9 organizations on strategies regarding No Use messages in their business practices. Luz engaged in conversations with 15 Officials in Clark County and provided information about alcohol outlet density in certain zip codes. The Te Necesitamos campaign ( a social norms advocacy message geared to the Latino community) reached 159,040 individuals on the television and 270,000 individuals on the radio. Luz paired eight special ATOD free events with information distribution to 126,000 individuals. Luz also held 15 other activities to distribute promotional materials. Luz participated in 36 community/health fairs and distributed information to about 18,000 individuals. Nye Communities Coalition (NCC) The I am one of Many campaign has produced two billboards in Pahrump with a minimum viewing of 800. Print ads were also placed in local newspaper with a readership of 4000 + for each issue. Monthly ATOD free nights were held with about 25 youth and adults attending regularly. Pahrump now implements server/seller training as part of the Fall Festival and the town is considering implementing this for other events such as July 4 th celebration. Compliance checks were conducted in Tonopah, Beatty, Lathrop Wells and Armargosa in collaboration with the Nye County Sheriff s Office. Join Together Northern Nevada (JTNN) JTNN and partners implemented a heroin awareness campaign across television and radio outlets to raise awareness related to substance abuse concerns and support resources. Approximately $100,000 of media time was purchased for $10,000. JTNN organized an A&E Intervention Townhall meeting to raise awareness related to substance abuse issues and access to treatment in Washoe County. The event was widely attended and has aired on the Arts & Entertainment Network (A&E). Our first MuHa - Musicians for Heroin Awareness fundraiser was successfully launched to raise money for the heroin awareness campaign. 59

Section III Prevention Implementation JTNN established a parent support group that now meets weekly to address the needs of parents with a child struggling with addiction. JTNN launched a Weed It Out 419 project with youth in collaboration with other coalitions to raise awareness about risks associated with marijuana use. Healthy Communities Coalition (HCC) Implemented Crisis text program through Crisis Line at Dayton Intermediate at Dayton Intermediate and Virginia City High: students can seek assistance for ATOD, mental health, violence, etc. related issues Coordinated two 2 day ASIST Suicide Prevention Trainings in Silver Springs in August. Held the FASD pack the track walk for Yerington High School and community Yerington Sept 11 Walk in Memory community suicide prevention walk (emphasis on alcohol connection) Partners Allied for community Excellence (PACE) Met with elected officials or their representatives a total of 11 times this fiscal year regarding public alcohol consumption. Ordinance passed implementing a 10 pm special event curfew for those 18 and younger Educate businesses on the risk of employee drug use and benefits of drug-free workplace Operation Street Smart / FASD training Ads on TV during peak times that will have the greatest impact on underage drinking and driving Partnership Of Community Resources (PCR ) Conduct compliance checks that target merchants who sell alcohol to minors Implement a social norm campaign to educate the community about the dangers of abusive drinking & drugs Party Dispersal checks at 13 known locations PCR will continue its positive relationship with Parent Organizations at the schools, attending Family Involvement Team (F.I.T.) meetings and back to school nights Placed pictures on statewide Facebook for WeedItOut419 marijuana campaign Stand Tall youth coalition activities. Statewide Native American Coalition (SNAC) Pyramid Lake Police Dept., Washoe Tribe Police Dept conducted Sobriety Checkpoints Training for Nevada Tribal Chiefs Police Association (NTCPA) regarding Alcohol, Meth, Marijuana Billboards were broadcast in 8-second spots in a 64-second rotation 60

Section III Prevention Implementation Hosted cultural events to engage American Indian in drug & alcohol prevention awareness activities. Develop a community assessment too for Marijuana and Tobacco/Survey Monkey Churchill Community Coalition (CCC) Hosted drug-free events during Alcohol Awareness Month Provided alcohol and DUI training to Fallon Naval Air Station personnel Provided ATOD brochures at community events Sent four community officials to the Marijuana Summit Frontier Community Coalition (FCC) Implemented I am One of Many campaign Conducted Enforcement of Underage Drinking Laws (EUDL) training Conducted server training programs Work with law enforcement to conduct sobriety checkpoints Partnership Carson City (PCC) Partnered with Carson City Sheriff s Department to conduct server training classes Conducted compliance checkpoints Implemented EUDL training sessions Hosted drug-free events for Hispanic population STATE PREVENTION INFRASTRUCTURE (SPI) FUNDING The purpose of the SPI funding is to continue local community-based prevention programming initiated under the federally funded State Incentive Grant that SAPTA had from SFY 2003 to the end of SFY 2007. To accomplish this, in SFY2011, the Nevada State Legislature included in the Division of Mental Health and Developmental Services budget, SAPTA s budget of approximately $2,497,828 to support substance abuse prevention coalition infrastructure and to implement at the local level evidence-based programs, practices, and strategies that address the prioritized substance abuse prevention needs of their communities. SPI has performance indicators as noted below: Number of persons served by coalition and program including age, gender, race, and ethnicity otal number of evidence-based programs and strategies implemented Fidelity of program implementation 30 day substance use, includes alcohol and other drugs Perceived risk and harm of substance use Age of first substance use 61

Section III Prevention Implementation Perception of disproval and attitude towards use Cost effectiveness, do program costs fall within the federally defined cost bands The purpose of Nevada s SPI is to reduce the use of Alcohol, Tobacco, or Other Drugs (ATODs) among Nevada s 12 to 25 year old youth through the development of a system for delivering prevention services through coordinating prevention services statewide and implementing prevention programs based on sound scientific research. Improving the ATOD prevention system has both long-term and short-term objectives. Statewide measures will indicate reductions in illicit drug use, marijuana use, and binge drinking among 12 to 25 year olds, and show a delay in the age of first use of marijuana and alcohol. The short-term changes (1 to 3 years) will be accomplished through three mechanisms on the local level: (1) enhancing local substance abuse prevention capacity, (2) leveraging existing prevention dollars from various sources, and (3) replacing ineffective ATOD prevention programming with evidence-based prevention programs. This vision is for local ATOD prevention coalitions to make funding decisions and monitor their effectiveness at a community level. METHAMPHETAMINE PREVENTION EDUCATION AND PUBLIC AWARENESS This funding was initially approved by the Nevada State Legislature in 2007 to provide prevention efforts at the community level statewide that were focused on reducing the incidence of methamphetamine use. Funding was greatly reduced in SFY 2011 to $525,932. These monies are currently allocated to ten SAPTA prevention certified and funded community coalitions. The coalitions collaborated on developing statewide prevention messages that are based on changing community and social norms around metham phetamine use. This campaign was initially called the Most of Us campaign and then transitioned into the I Am One of Many campaign in the second and third years of the project. This project seeks to inform the public that most people, young and old, in Nevada do not use methamphetamine and encourages the public to get involved in positive and pro-social activities including joining their local coalition. Messages have been developed and are appearing in a variety of venues from television commercials during primetime to advertising on buses and billboard; from local print media to comic books. In addition to the statewide campaign each local coalition has taken the messaging and adapted it to their communities particular substance abuse problems as identified through local data. Messages have also been culturally adapted for our Latino and Native American populations. They created local activities and messaging. Long term outcomes of the I Am One of Many campaign include increasing perception of harm of methamphetamine, increasing the age of initiation of alcohol and other drug use, and decreasing community normalization and acceptance of methamphetamine use. The coalitions are also implementing other environmental strategies and programs along with the media campaigns in their local service areas. 62

Section III Prevention Evaluation PREVENTION HIGHLIGHTS SAPTA continues to utilize SAMHSA s Strategic Prevention Framework (SPF) for all of its reporting and strives to apply it across all funding sources and Agency processes. SAPTA continues to follow its five year strategic plan in implementing a systematic approach to achieve effective substance abuse prevention results. The substance abuse strategic plan for prevention in Nevada is organized according to the five steps of the SPF model. SAPTA continues to use the IOM s Continuum of Care model to ensure that services are integrated and seamless between prevention, intervention, treatment, and recovery support. Universal direct, universal indirect, selective, and indicated prevention services are provided to appropriately identify target populations through the assessment of data and needs. SAPTA s data team and prevention staff have worked with the developer of NHIPPS to enhance the system in order to add prevention environmental strategy data. These enhancements will allow for the gathering of required prevention data not only for direct service prevention participants, but also for those people reached by Universal Direct and Indirect strategies. This will result in a database that can fully track fiscal, treatment, and prevention coalition and direct-service activities which will save time and increase capacity. SAPTA, as part of the SAPT Block Grant requirements, manages the Synar database. The federally required Synar report which tracks illegal sales of tobacco to minors shows that the noncompliance rate in Nevada for FFY 2012 is 3.1%. This is 16.9 points less than the 20% maximum set by the federal government for state non-compliance rates and up 2 points from 1.1 in FFY 2011. Prevention trainings are offered to Nevada s prevention providers through SAPTA collaboration with CSAP, CAPT West RET, CASAT, and other partners. During the 2011 fiscal year trainings were offered regionally to increase the overall use of evidence-based prevention programs, strategies, and practices in Nevada. In SFY 2011, the number of webinar trainings increased. Trainings included courses required for prevention specialist certification, as well as courses on topical issues. SAPTA implemented a statewide data project that resulted in the writing of state and local level data reports. The coalitions also implemented follow up assessments in order to compare results to the convenience survey that was implemented as part of the initial SPF SIG Data Project. SAPTA also awarded funding through a Request for Proposal process to Bach Harrison, LLC to develop a webbased data dissemination system in 2012. SAPTA was able to continue implementation of the SPI and Coalition Methamphetamine Prevention Education and Public Awareness projects as a result of continued funding from the Legislature and continued coalition advocacy. The methamphetamine funds were cut during the 2010 Special Session and those dollars were transferred to treatment for identified needs. SAPTA continues to work with community-based coalitions to develop local strategies and a statewide plan to address substance abuse prevention using data driven decision making and evidence-based approaches. SAPTA s coalition strategy also includes: using the coalitions to increase provider 63

Section III Prevention Evaluation capacity through a planning process, which includes data, training, evaluation, resource development, and other capacity development activities. SAPTA partnered with the Governor s Working Group on Substance Abuse in an effort to identify the impact of methamphetamine in Nevada. The Work Group includes representatives from the criminal justice system, the Nevada Legislature, treatment providers, media, education, and social and community service organizations. The coalitions methamphetamine prevention strategies address the recommendations identified in the report written by the Governor s Working Group on Substance Abuse. Methamphetamine use continues to decline in Nevada partly due to state funding. SAPTA is also a member of the Nevada Action Team working on the Rural Law Enforcement Methamphetamine Initiative that chose three implementation priorities to work on through June 2011. During the 2011 Legislative Session the working group s name and focus was changed to Substance Abuse Working Group and is within the Office of the Attorney General. SAPTA successfully initiated a Request for Qualifications (RFQ) for a one year limited special project. Since this RFQ included very limited administrative costs, it was only distributed to prevention coalitions already receiving SAPTA funding. The goals of the project were to implement a statewide marijuana campaign including a Marijuana Summit that was held in January 2011, a parent education segment and a youth awareness campaign called 419 Weed it Out. SAPTA received a Federal grant to continue the work of the Statewide Epidemiologic Workgroup. Participants from a variety of substance abuse, mental and behavioral health agencies, including tobacco prevention, domestic violence, suicide, and tribal health have been added. They are joined by several epidemiologists from the university, law enforcement, the coroner s office, the office of traffic safety and the CAPT. For SFY 2011, data reports on Adolescents and Substance Abuse, Women and Substance Abuse, Minorities and Substance Abuse in Nevada were produced using data from the Nevada Telephone Survey. The 2011 Epidemiologic Profile included data on alcohol and illicit drug use, data on suicide, veterans, prescription drug overdoses in Clark County, street drug overdoses in Clark County. Mental health data from the National Surveys on Drug Use and Health on major depressive episode and serious psychological distress, and data on co-occurring disorders was included in the Epidemiologic Profile. The SEW continuation project required a community profile that focused on Hispanics in Nevada and Substance Abuse. SAPTA successfully implemented a Request for Application process for Coalitions. Three new coalitions were chosen to receive funding in FY 2012 in addition to the existing 10 coalitions. SAPTA sub-granted with CASAT for The Safe and Drug Free Schools outreach project. The project centered on NIDA s Brain Power curriculum which was aligned to Nevada Education standards and 535 elementary and middle school principals were sent 1,612 kits for use during the school year. A webinar was conducted to introduce the materials and TA is provided to school personnel and 535 wire racks were also sent to the schools with basic substance abuse materials and will be continually supplied by the Nevada State Clearinghouse as needed. Pre and Post assessment instruments are also available for use. The Safe and Drug Free Schools funding ended June 2011. 64

Percent Noncompliance Section III Prevention Evaluation PREVENTION PARTICIPANTS SERVED The table below provides unduplicated participants in SAPTA funded prevention programs statewide and information on the number of items of literature distributed by the state clearinghouse system and coalitions. Table 8. Prevention Participants Served* Deliverable SFY 2009 SFY 2010 SFY 2011 Youth Adults Total Youth Adults Total Youth Adults Total Individuals Served 22,387 7,529 29,916 22,727 5,895 28,622 18,970 5,306 24,276 Lieterature Distributed 320,552 459,940 318,592 *The Individuals Served numbers represent all participants reported in the NHIPPS data system. Approximately 3,372 additional participants received direct services from agencies who did not report detailed information about the services delivered in the NHIPPS. SYNAR The Synar amendment was passed by Congress in 1992, and requires each state to enforce an effective law prohibiting the sale of tobacco products to minors less than eighteen years of age. The Synar regulation is administered by SAMHSA. States not enforcing youth tobacco laws could lose up to 40% of their SAPT Block Grant. The Synar rule entitled Substance Abuse Prevention and Treatment Block Grants: Sale and Distribution of Tobacco Products to Individuals Under 18 Years of Age, was released in 1996 and requires states to: Have in effect a law prohibiting any manufacturer, retailer, or distributor of tobacco products from selling or distributing such products to any individual under the age of 18. Enforce such laws in a manner that can reasonably be expected to reduce the extent to which tobacco products are available to individuals under the age of 18. Conduct annual random, unannounced inspections of retail outlets to ensure compliance with the law. These inspections are to be conducted in such a way as to provide a valid sample of outlets accessible to youth. Develop a strategy and timeframe for achieving an inspection failure rate of less than 20% ±3% of outlets accessible to youth. Chart 20. Synar Noncompliance Rate for Nevada, Submit an annual report that details the state s Federal Fiscal Years 2007 2012 activities to enforce its laws, the overall success achieved by the state during the previous fiscal year in reducing tobacco availability to youth, inspection methodology, methods used to identify outlets, and 20.0 plans for enforcing the law in the coming fiscal 15.0 year. 16.0 The Office of the Attorney General, Nevada DOJ conducts compliance checks on all retail outlets accessible to minors a minimum of twice per year. An analysis is conducted on a random sample of these facilities yearly for the Annual Synar Report. Chart 21 shown on the right shows the Synar Study noncompliance rate (sales to minors) based on that sample. 65 10.0 5.0 0.0 9.9 5.2 6.2 1.1 3.1 2007 2008 2009 2010 2011 2012

The following pages in the section displays charts that show various demographic characteristics of prevention participants. Chart 21. Prevention Participants by Area, Nevada, SFY 2007 - SFY 2011 Percentage of Participants Please note: Clark County s decrease in participants in SFY 2010 was due to a reorganization of coalition boundaries. Section III Prevention Evaluation 60.0 50.0 40.0 30.0 20.0 10.0 0.0 6,253 20,602 9,775 12,556 12,208 9,068 6,701 4,311 3,850 7,176 4.034 5,152 5,627 3,041 2007 2008 2009 2010 2011 Year Clark Washoe Balance of State 12,167 66

Chart 22. Prevention Participants, by Gender, Nevada, SFY 2007 - SFY 2011 Section III Prevention Evaluation 70% 60% 50% 40% 30% 20% 10% 0% 11,776 7,777 15,861 6,637 14,055 15,128 13,102 13,494 11,174 8,732 2007 2008 2009 2010 2011 Year Male Female 67

Chart 23. Prevention Participants by Race and Ethnicity, Nevada,, SFY 2010 and SFY 2011 Percentage of Participants Section III Prevention Evaluation 70% 60% 50% 40% 30% 20% 10% 0% 16,547 13,326 8,791 8,641 5,969 5,538 2,077 1,325 1,908 444 562 2,339 1,370 1,232 2010 Year 2011 Native American / Alaska Native Asian Black or African American Caucasian Multi-Racial Unknown/Other Latino or Hispanic 68

Chart 24. Prevention Participants by Adults and Adolescents, Nevada, SFY 2010 and SFY 2011 Section III Prevention Evaluation 35,000 30,000 25,000 20,000 15,000 10,000 5,000 0 29,916 28,622 7,529 5,895 24,276 20,508 5,306 14,414 5,627 5,063 22,387 22,727 18,970 14,881 9,351 2007 2008 2009 2010 2011 Number Participants Youth Participants Adult Participants 69

Section III Prevention Evaluation Chart 25: Prevention Participants by Age Group, Nevada, SFY 2011 15-17 22% 18-20 5% 21-24 2% 25-44 12% 45-64 3% 0-4 5-11 65+ 1% 0-4 2% 12-14 15-17 18-20 21-24 12-14 26% 5-11 27% 25-44 45-64 65+ 70

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LIST OF ACRONYMS... Page Number 1. A & E - Arts and Entertainment... 59 2. AOD Alcohol or Drug... 11 3. ARMVF Alcohol Related Motor Vehicle Fatalities... 49 4. ASAM - American Society of Addiction Medicine... 28 5. ASAM-PPC-2R - ASAM- Patient Placement Criteria - 2nd Revision... 28 6. ATOD Alcohol Tobacco or Other Drugs... 54 7. BAC Blood Alcohol Content... 15 8. BHIPS Behavioral Health Integrated Provider System... 5 9. CADCA - Community Anti-Drug Coalitions of America... 58 10. CAPT - Center for the Application of Prevention Technologies... 55 11. CAPT WEST RET - CAPT Western Regional Teams... 54 12. CASAT Center for Application of Substance Abuse Technology... 29 13. CCC Churchill Community Coalition... 61 14. CCCLV Community Counseling Center Las Vegas... 30 15. CCPP - Community Coalition Prevention Plan... 58 16. CDC Centers for Disease Control... 20 17. CFR Code of Federal Regulations... 1 18. COD Co-Occurring Disorder... 30 19. CPDs Controlled Prescription Drugs... 20 20. CSAP Center for Substance Abuse Prevention... 2 21. DCFS Division of Child & Family Services... 3 22. DCTSRD Division Criteria for Treating Substance Related Disorders... 2 23. DOJ Department of Justice... 18 24. DSM-IV Diagnostic & Statistical Manual of Mental Disorders... 2 25. DTO Drug Trafficking Organization... 18 26. DUI - Drinking Under the Influence... 49 27. EBPE Evidence-Based Practices Exchange... 28 28. EBTP - Evidence Based Treatment Practices... 29 29. ED - Education... 48 30. EHR Electronic Health Record... 5 31. EUDL - Enforcement of Underage Drinking Laws... 61 89

LIST OF ACRONYMS... Page Number 32. FASD - Fetal Alcohol Spectrum Disorder... 54 33. FBI-UCR Federal Bureau of Investigation, Uniform Crime Reporting Program... 8 34. FCC Frontier Communities Coalition... 61 35. FDA - Federal Drug Administration... 14 36. FFY Federal Fiscal Year... 48 37. F.I.T - Family Involvement Team... 60 38. GPPC - Gambling Patient Placement Criteria... 6 39. HCC Healthy Communities Coalition... 60 40. HIDTA High Intensity Drug Trafficking Area... 23 41. HIPAA Health Insurance Portability and Accountability... 1 42. HOPES HIV Outpatient Program, Education & Services... 45 43. HHS - Health and Human Services... 1 44. IOM - Institute of Medicine... 26 45. JTNN Join Together Northern Nevada... 59 46. LUZ - Luz Community Development Coalition... 59 47. MDE Major Depressive Episode... 15 48. MHDS Mental Health & Developmental Services... 1 49. MHPAEA Mental Health Parity & Addiction Equity Act... 2 50. MOE Maintenance of Effort... 3 51. MPAC Multi-disciplinary Prevention Advisory Committee... 54 52. MTF Monitoring the Future... 19 53. NAC Nevada Administrative Code... 1 54. NNAMHS - Northern Nevada Adult Mental Health Services... 31 55. NCC Nye Community Coalition... 59 56. NCES National Center for Education Statistics... 8 57. NHIPPS Nevada Health Information Provider Performance System... 5 58. NHTSA National Highway Traffic Safety Administration... 8 59. NIAAA - National Institute on Alcohol Abuse and Alcoholism... 52 60. NIDA National Institute on Drug Abuse... 2 61. NIMH - National Institute on Mental Health... 57 62. NOMs National Outcome Measures... 6 90

LIST OF ACRONYMS... Page Number 63. NPRC Nevada Prevention Resource Center... 52 64. NRS Nevada Revised Statutes... 1 65. NSDUH National Survey on Drug Use and Health... 7 66. N-SSATS National Survey of Substance Abuse Treatment Services... 12 67. NTCPA - Nevada Tribal Chiefs Police Association... 60 68. OMB Office of Management & Budget... 1 69. OMT Opioid Maintenance Therapy... 45 70. ONDCP - Office of National Drug Control Policy... 14 71. PACE Partners Allied for Community Excellence... 60 72. PCC Partnership Carson City... 61 73. PCR Partnership of Community Resources... 60 74. PDMPs Prescription Drug Monitoring Programs... 19 75. POAS Programs Operating & Access Standards... 2 76. PPCs - Prevention Prepared Communities... 52 77. RADAR Regional Alcohol & Drug Awareness Resource... 52 78. RET Regional Expert Teams... 55 79. RFA Request for Application... 46 80. RFQ Request for Qualifications... 32 81. SAC State Incentive Grant... 54 82. SAMHSA Substance Abuse and Mental Health Services Administration... 1 83. SAPT Substance Abuse Prevention & Treatment... 8 84. SAPT BG Substance Abuse Prevention & Treatment Block Grant... 1 85. SAPTA Substance Abuse Prevention & Treatment Agency... 1 86. SDFS Safe & Drug Free School... 3 87. SEOW - State Epidemiological Outcomes Workgroup... 58 88. SEW State Epidemiological Workgroup... 48 89. SFY State Fiscal Year... 3 90. SIG State Incentive Grant... 3 91. SNAC Statewide Native American Coalition... 53 92. SNAMHS - Southern Nevada Adult Mental Health Services... 30 91

LIST OF ACRONYMS... Page Number 93. SPE - State Prevention Enhancement... 6 94. SPF Strategic Prevention Framework... 50 95. SPF-SIG Strategic Prevention Framework-State Incentive Grant... 3 96. SPI State Prevention Infrastructure... 61 97. TA Technical Assistance... 1 98. TEDS - Treatment Episode Data Set... 28 99. YRBS Youth Risk Behavior Survey... 12 92

This Area is Intentionally Left Blank. This publication was supported through Grant Number B1 NVSAPT from the U. S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Substance Abuse Prevention and Treatment Block Grant. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the U. S. Department of Health and Human Services.