HEALTH CARE PROVIDERS

Screenings, Referrals, and Affordable Addiction Treatment Options: A Guide for Health Care Providers

Health care providers are often in the perfect position to help patients with substance use disorders, which encompass both dependence on and abuse of alcohol and illicit drugs.

Dependence on and abuse of alcohol and illicit drugs, which include nonmedical use of prescription-type drugs, are defined using the American Psychiatric Association's criteria specified in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Dependence reflects a more severe substance problem than abuse; individuals are classified with abuse of a particular substance only if they are not dependent on that substance.¹

Health care providers can not only identify the signs of alcohol or drug use, but also encourage the patient to start the journey toward recovery. By proactively identifying the symptoms of substance use disorders, health care providers can help patients begin the healing process.

These services are greatly needed. In 2003, more than 22 million Americans age 12 or older needed treatment for an alcohol or illicit drug problem.² As many as 63 percent of Americans say that addiction to alcohol or other drugs has had an impact on them at some point in their lives, whether it was the addiction of a friend or family member or another experience, such as their own addiction.³ People who have these disorders enter the medical system in a variety of ways:

• In 2002, 670,307 emergency department visits were related to drug abuse.⁴



• More than 72 medical conditions have risk factors that can be attributed to substance use. Many patients enter the medical system because of one of these conditions.⁵

Every patient visit with a physician or health care specialist is an opportunity to address these disorders and begin the pathway to healing. For health care providers to guide people into recovery, however, it is essential to recognize that alcoholism and drug dependence are medical conditions and public health problems for which effective treatments are available.⁶

In fact, a major study published in the Journal of the American Medical Association in 2000 found that treatments for substance use disorders are as effective as treatments for other chronic conditions, such as high blood pressure, asthma, and diabetes.⁷ Another study by the Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of Health and Human Services (HHS) found that treatment for substance use disorders improves mental and physical health, while boosting employment rates.⁸

Despite these benefits, many people do not receive the treatment they need. In 2003, as many as 20.3 million people with substance use disorders who needed treatment did not receive it. The reasons people said they did not receive treatment included:

• Not being ready to stop using alcohol or drugs (41.2 percent)



• Cost or insurance barriers (33.2 percent)



• Reasons related to stigma (19.6 percent)



• Not feeling the need for treatment (at the time) or feeling they could handle the problem without treatment (17.2 percent)⁹

These statistics can change if providers from all points on the health care spectrum–primary care physicians, dentists, obstetricians/gynecologists, psychiatrists, physician assistants, nurses, and others–increase their efforts to screen for substance use disorders. Health care providers are an integral part of screening and assessment; they can provide increased access to treatment for patients; and their advocacy for improved reimbursement through enhanced private insurance coverage can help make treatment more affordable.¹⁰

Health care providers' efforts to date have greatly increased access for many people nationwide, and their continued participation in training programs can further advance their skills in these efforts. For example, a training program in Alabama has increased awareness of the need for brief interventions by physicians and medical staff. Since its inception, the program has received more than 200 inquiries from physicians, and participants have begun training staff at local clinics and medical schools.¹¹

In addition, within the U.S. Department of Health and Human Services, the Health Resources and Services Administration (HRSA) has an interagency agreement with SAMHSA to address the need to improve the workforce in the substance abuse field through faculty development. The Interdisciplinary Faculty Development Program on Substance Abuse Education seeks to improve and expand health professional education in addressing substance use disorders.

Participating in programs like these is just one way that health care providers can promote recovery in their communities. Additionally, Physicians and Lawyers for National Drug Policy has provided materials to more than 1,000 physicians and medical students across the country who have responded to initiatives that call for greater access and private financing for treatment, and for increased collaboration and involvement in diagnosing and referring patients to appropriate treatment.

Assessment and Referral

People with substance use disorders need to be appropriately assessed, diagnosed, and referred to the appropriate treatment, regardless of where they enter the health care system. There is no wrong door to treatment for substance use disorders.¹²

Health care providers, therefore, play an extremely important role in identifying individuals with these disorders. More than two-thirds of people who have substance use disorders see a primary care or urgent care physician every six months. These visits give physicians multiple opportunities each year to recognize, diagnose, and prescribe treatment for people with these disorders. The need for alcohol and drug use screening at these visits is imperative for early diagnosis and intervention.¹³

Health care providers who refer people in need of alcohol or drug treatment often are more successful than others in getting these people into treatment. This is because of the stature of a physician or health care specialist.

Health care providers who treat certain types of people, such as those with mental disorders, have a particular responsibility to screen for substance use disorders. Often, alcohol and drug use are co-occurring disorders for people with mental illnesses.¹⁴

In 2003, about 4 million adults with a serious mental illness also were dependent on or abused alcohol or an illicit drug, yet among adults with these co-occurring disorders in 2003, only 47 percent received mental health treatment, and 11 percent received specialty substance use treatment. Only 7.5 percent received a combination of mental health and specialty substance use treatment. Specialty substance use treatment is offered at drug or alcohol rehabilitation facilities (inpatient or outpatient), hospitals (inpatient services only), and mental health cen-ters.¹⁵ These statistics highlight the need to better screen and assess people with co-occurring alcohol or drug use disorders and mental disorders. Several tools are available to help providers assess people with co-occurring disorders, including GAIN (Global Assessment of Individual Needs), an assessment tool developed as part of a SAMHSA-sponsored project.¹⁶

An estimated 4.7 million people suffer from both hidden disabilities and a co-existing substance use disorder.¹⁷ Hidden disabilities include deafness, cognitive impairment, arthritis, multiple sclerosis, attention deficit hyperactivity disorder, and learning disabilities, to name only a few.¹⁸ Those suffering from these conditions are at higher risks for developing substance use disorders– they have a two-fold to four-fold greater risk than the general population.¹⁹

The National Association on Alcohol, Drugs and Disabilities (NAADD) recently conducted a study that showed most alcohol and drug treatment programs do not accommodate the large number of people suffering from these disabilities. Over the years, this non-compliance with the Americans with Disabilities Act (ADA) has led to a large number of people with disabilities being denied access to treatment for substance use disorders. ²⁰ Acccess must be improved for people with disabilities and care must be sensitive to this population's special needs.²¹ For more information, there is a Substance Use Disorders and Disability brochure available through SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at http://ncadistore.samhsa.gov/catalog/ProductDetails.aspx?ProductID=16852.

Health care providers also are especially important in assessing older adults, whose needs are different from the general population. Older adults are often vulnerable to substance use disorders following major life changes, such as the death of a spouse, a divorce, or periods of prolonged illness. One of every 5 adults age 60 or older misuses alcohol and/or prescription drugs. Symptoms of older adults' disorders are often overlooked or misdiagnosed as depression, dementia, and other age-related health problems.²² SAMHSA's TIP 26: Substance Abuse Among Older Adults provides more information about the specific needs of this population; TIP 26 is available online at www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.48302.

For these reasons, health care providers should stay informed of all the substances or medications older patients are taking and look for signs of alcohol and drug use.²³ SAMHSA has developed a screening tool entitled Alcohol Use Among Older Adults: Pocket Screening Instruments for Health Care and Social Service Providers, which is designed to help health care providers identify the signs of abuse, intervene, and assist in obtaining treatment for older adults suffering from these disorders.²⁴ SAMHSA also conducts numerous initiatives that provide support services for older adults with substance use disorders.²⁵

Substance use disorders are a problem among adolescents, as well, and can isolate them from their peers, family, and community, making it difficult to lead a normal, healthy existence. This is true not only for those who are dependent on alcohol and drugs, but also for those with parental figures or siblings who have alcohol and drug problems. Preventing and overcoming these problems requires awareness, education, and dedicated support from family members as well as health care providers. It is estimated that half of American high school students drink alcohol, one-third binge drink, and one-fourth smoke marijuana.²⁶

To help combat this problem, a screening device–the CRAFFT test–was developed specifically for use among adolescents. CRAFFT is a verbal questionnaire that is named using a mnemonic of the first letters of key words in the test's six questions. CRAFFT is a valid means of screening adolescents for substance-related problems and disorders, which may be common in some general clinic populations.²⁷

While attention to specific populations is important, current recommendations state that health care providers should ask all their patients, regardless of age and reason for their visit, about their substance use history. Currently, 88 percent of physicians are asking new patients if they drink alcohol, but only 13 percent are using a formal alcohol screening tool.²⁸ Just as they inquire about other medical conditions, health care providers should ask patients questions about substance use. Additionally, physicians should seek the counsel of other physicians who are knowledgeable in addiction medicine when treating patients with a history of alcoholism or other addictive diseases.²⁹

There is evidence that training in the identification and diagnosis of substance use disorders can have a sustained effect on health care providers' ability to intervene with patients to guide them toward recovery. Five years after participating in a seminar on the detection of and brief intervention for people with a substance use disorder, more than 91 percent of participants–including physicians, nurses, physicians assistants, social workers, and psychologists–said they were still using techniques they had learned at the seminar.³⁰

Access to Treatment

Once people with substance use disorders are identified and referred to treatment, they have to overcome barriers to accessing appropriate treatment programs. These barriers are often caused by the stigma society has associated with substance use disorders; people often label these disorders as moral weaknesses rather than illnesses.

A national policy panel convened in 2002 by Join Together, a project of Boston University School of Public Health, addressed discrimination against people seeking treatment or recovery from substance use disorders.³¹ The panel was initiated in part by the results of a national poll commissioned by Faces & Voices of Recovery, which found that 20 percent of people in recovery and their family members cited fear of being fired or facing discrimination at work as barriers to accessing treatment services.³²

Providers who come in contact with people with substance use disorders are likely to see how this discrimination affects treatment. According to Carol Shapiro, director of a multi-service community-based program that works to support those living with addiction and their families, “People experience shame and stigma, which can severely impede the effectiveness of treatment and access to community-based resources. Researchers hint at this unexpected problem, but community-based treatment providers witness [them] directly.”³³

Of the 22.2 million people age 12 or older needing treatment for an alcohol or illicit drug problem in 2003, 20.3 million did not receive treatment.³⁴ The problem is especially acute for people in rural areas, women, Native Americans, and people with language or cultural differences.³⁵ Even among those who are “in treatment,” many may have no access to the most appropriate treatment for their condition or may face limits on the duration of treatment that inhibit its effectiveness.³⁶

Improving access to treatment includes improving the quality and the amount of care available. Frequency, duration, and intensity of treatment must all be considered, and services should be readily accessible to the community, with geographically convenient entry points.^37,38 Treatment should focus on the individual's needs and should respond to changes as the patient progresses through each stage of recovery.³⁹

In addition, treatment should meet the needs of people with co-occurring disorders, such as mental health issues. Treatment of both mental and substance use disorders can help prevent the exacerbation of health problems, according to SAMHSA's Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Health Disorders.⁴⁰

It is important to remember that people in need of treatment for substance use disorders do not fall exclusively within the purview of the “substance use disorder system.” They may appear in any of a variety of service systems, including primary health care, mental health, social service, justice, education, workplace and housing.

Because each of these avenues can provide a door to treatment, all health care providers (and other service providers) who come in contact with people experiencing alcohol or drug problems should be able to easily provide patients with access to treatment facilities in their community and encourage them on the road to healing.⁴¹ In fact, a 1998 Join Together National Policy Panel reported that education and training on the nature of addiction and recovery should be required for all health, mental health, social service and justice system professionals. If we are ever to fully integrate substance use disorders treatment into the health care system, such professionals must know how to intervene and refer people to appropriate treatment.⁴²

When treating anyone with a substance use disorder, health care providers must tailor the treatment, taking into account factors such as severity of substance use, presence of co-occurring disorders, age, level of maturity, cultural background, gender, and family and peer environment. For example, studies have shown that the most effective treatment for adolescent drug abuse is family-based treatment.⁴³ Once all factors have been assessed, the appropriate treatment and recovery services can be determined to meet the person's specific needs.⁴⁴

Various tools are available to help health care providers provide patients with access to treatment.

• An emerging body of research and clinical experience supports the use of the Screening, Brief Intervention and Referral to Treatment (SBIRT) approach for people who are experiencing problems related to the use of illicit drugs. SAMHSA's SBIRT program is a state discretionary grant program designed to assist states, territories, and tribes in expanding the continuum of care available for the treatment of substance use disorders. Its goals are to include screening, brief interventions, referrals, and brief treatment for persons at risk of dependence on alcohol or drugs by adding services in general medical and other community settings, such as community health centers. Other venues for providing these services are school-based health clinics and student assistance programs, occupational health clinics, hospitals, and emergency departments. The SBIRT program also aims to support clinically appropriate treatment services for nondependent substance users (i.e., persons without a substance abuse disorder diagnosis) as well as for dependent substance users (i.e., persons with a substance dependence disorder diagnosis). It also is designed to improve linkages among generalist community agencies performing SBIRT and specialist substance abuse treatment agencies, and to identify systems and policy changes needed to increase access to treatment in generalist and specialist settings.



• Seven awards were made in September 2003 to the governors of California and Illinois and the states of New Mexico, Pennsylvania, Washington, and Texas, and to the chair of the Cook Inlet Tribal Council, Inc. More information about the SBIRT approach, a SAMHSA program, can be found at http://ncadi.samhsa.gov/govpubs/BKD341.



• Another useful tool was identified in a research project, Ensuring Solutions to Alcohol Problems at The George Washington University Medical Center, and suggests 13 “active ingredients” to help health care providers effectively treat alcohol use disorders. This tool emphasizes early detection; a comprehensive assessment and individualized treatment plan; care management; individually delivered, proven professional interventions; “contracting” with individuals (actively involving a significant other to ensure that individuals are monitored to take their medication properly), social skills training; medications; specialized services for medical, psychiatric, employment, or family problems; continuing care; a strong bond with a therapist or counselor; long duration of treatment; participation in support groups; and strong patient motivation.^{45, 46, 47, 48}



• The American Society of Addiction Medicine (ASAM) also publishes patient placement criteria guidelines for placement of patients with substance use disorders. The ASAM Patient Placement Criteria-2R (second edition revised) provides two sets of guidelines to help physicians diagnose adults and adolescents who suffer from these disorders.⁴⁹

Because achieving recovery involves many elements–physical, mental, emotional, and/or spiritual– President Bush's Access to Recovery (ATR) grant program, administered by SAMHSA, empowers people to choose the providers and programs that best meet their needs by providing people seeking treatment with vouchers to pay for a range of effective, community-based treatment and recovery support services. It also expands access to care, including access to faith- and community-based programs, and increases substance abuse treatment capacity.

Another SAMHSA grant program, the Recovery Community Services Program (RCSP), provides additional support services for those seeking recovery from alcohol and drug use disorders. In RCSP grant projects, peer-to-peer recovery support services are provided to help people initiate and/or sustain recovery from substance use disorders. Some RCSP grant projects also offer support to family members of people needing, seeking, or in recovery. Peer support services are not treatment or post-treatment services provided by professionals, but rather support services from people who share the experiences of addiction and recovery. As mentioned above, peer-to-peer services help prevent relapse and promote long-term recovery, thereby reducing the strain on the overburdened treatment system.⁵⁰

Health Care Coverage

Private insurance is an important source of financing for substance abuse treatment.⁵¹ Yet cost or insurance problems were two barriers cited by more than 33 percent of people who needed but did not receive treatment and felt they needed treatment in 2003, according to the 2003 National Survey on Drug Use and Health.⁵²

In fact, a study published in the November/December 2004 issue of Health Affairs found that the use of formal substance abuse treatment among the privately insured population declined dramatically from 1992 to 2001. The authors concluded that this change may be due to the growth in managed care, which can have a dramatic effect on substance abuse treatment spending.⁵³

Currently, some private insurance plans do not adequately cover treatment for substance use disorders. They may not cover specific services, limit the number of services with annual or lifetime caps, or stipulate limited or no continuing care.⁵⁴

Insurance coverage for treatment can be limited to treatment provided by physicians, although nurses, pharmacists, and others who may not be treatment specialists are often involved. It may be beneficial for these additional front-line providers to be reimbursed by private insurers, because they are often in an optimal position to screen, recognize, diagnose, and treat these disorders.⁵⁵

According to the American Society of Addiction Medicine, investing in treatment and related services can help close serious gaps in treatment capacity and reduce associated health, economic, and social costs.⁵⁶ Addiction treatment benefits not only the individual and his or her family in the healing process, but also the public health, public safety, and the public purse.⁵⁷ To aid health care providers in offering needed treatment services, private health insurance plans may consider offering reimbursement for evidence-based practice improvements; capital improvements and reinvestment; and workforce recruitment, retention, and development.^{58, 59}

Reimbursement for treatment services can be beneficial. According to SAMHSA Administrator Charles Curie, as documented in a May 25, 2004, SAMHSA press release, treatment for substance use disorders “is a bargain compared to expenditures for jails, foster care for children, and health complications that often accompany addiction.” These services can help prevent more serious complications associated with these disorders.

Making a Difference: What Can I Do?

• Get the facts. Learn about the newest science-based treatment protocols and about the nature of substance use disorders. Increase your understanding of the recovery process. Refer to the resources listed at the end of this document for assistance in locating up-to-date information about substance use disorders for medical professionals.



• Examine your own perceptions. Even in the medical community, the perception remains that substance use disorders are a moral weakness, despite research that clearly establishes them as medical disorders.⁶⁰ This stigma compromises people's ability to get treatment. Well-trained and informed health care providers, using evidence-based diagnostic and therapeutic practices, can play a critical role in providing treatment to patients with substance use disorders.
  
  
• Employ screening instruments to help identify those in need of services. Make every effort to identify when an individual's health problems may have been worsened by an underlying problem with alcohol or drug use. Experts recommend that primary care clinicians “periodically and routinely screen all patients for substance use disorders.”⁶¹ In addition to questioning the individuals they serve, providers can use a variety of screening instruments, including:
  
  
  • CAGE (Cutting down, Annoyance by criticism, Guilty feeling, Eye openers)
  
  
  
  • CAGE-AID (CAGE Adapted to Include Drugs)
  
  
  
  • AUDIT (Alcohol Use Disorders Identification Test)
  
  
  
  • TWEAK (Tolerance, Worry, Eye opener, Amnesia, (K )cut down)
  
  
  
  • MAST (Michigan Alcohol Screening Test)
  
  
  
  • RAPS4 (Rapid Alcohol Problems Screen 4)⁶²
  
  
  These screening tools are described in depth in Treatment Improvement Protocol (TIP) Series #24, A Guide to Substance Abuse Services for Primary Care Clinicians (DHHS Publication No. (SMA) 97-3139). It can be ordered free of charge from SAMHSA's National Clearinghouse for Alcohol and Drug Information (NCADI) at 1-800-729-6686 or 1-800-487-4889 (TDD), or online at www.ncadi.samhsa.gov.



• Take a holistic approach to treating individuals. For treatment to be fully effective, health care providers must offer (or be able to refer people to) coordinated treatment for both mental disorders and substance use disorders.



• Recognize that “one size does not fit all.” Programs for treating substance use disorders are most effective if they are tailored to the needs of the patient, recognizing cultural backgrounds and special needs.

Making a Difference: How Can I Contribute to Recovery Month?

We encourage everyone in a health care profession to participate in National Alcohol and Drug Addiction Recovery Month (Recovery Month) this September. The theme for this year's Recovery Month is “Join the Voices for Recovery: Healing Lives, Families, and Communities.” Your voice is vital to the success of the 16th annual celebration of Recovery Month. Here are some ideas you may consider:

• Encourage others to take action. Please encourage fellow health care professionals to take advantage of training and continuing education opportunities so they are better equipped to identify patients with substance use disorders and can refer them to treatment. Support efforts to increase medical students' knowledge of substance use disorders, and offer to lead regular training sessions for volunteers and other staff members. Talk openly about the need for the medical community to overcome the stigma associated with substance use disorders.



• Examine your own workplace benefits. Objectively evaluate your own workplace benefits to see if there are equal resources for your employees when it comes to mental health services and treatment for substance use disorders. Ensure that you are providing adequate treatment services for family members as well as the primary insurance beneficiary.



• Participate in a community forum. Many cities around the nation will be hosting community forums during Recovery Month to talk about substance use disorders, discuss recovery-related topics, and solve identified problems. Consider becoming a forum participant. Your expertise and commitment will be invaluable. To find more information about local events in your community, visit the official Recovery Month Web site at www.recoverymonth.gov. (Click on the 2005 icon and look under events.) If no activities are scheduled, offer to help develop some. Community-based associations, foundations, local businesses, and faith-based organizations are some groups you can work with when organizing an event.



• Tell your own story, if you are comfortable doing so. If you are recovering from an alcohol or drug use disorder (or someone close to you is doing so), you can be a powerful voice for the effectiveness of treatment. As a respected member of your community, you may be able to affect benefit and service delivery decisions. You may want to consult your employee assistance program or human resources representative first to identify the most suitable and receptive audience for your disclosure. For maximum impact, if you have colleagues who also are in recovery, ask them if they would like to join you in sharing their stories of healing.

For additional Recovery Month materials, visit our Web site at www.recoverymonth.gov or call 1-800-662-HELP.

Provider Resources

Federal Agencies

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
This government agency provides information and resources on alcohol and drug use disorders and health insurance/Medicaid issues.
200 Independence Avenue SW
Washington, D. C. 20201
877-696-6775 (Toll-Free)
www.hhs.gov

HHS, Health Resources and Services Administration (HRSA)
The Health Resources and Services Administration's mission is to improve and expand access to quality health care for all.
Parklawn Building, 5600 Fishers Lane
Rockville, MD 20857
301-443-3376
www.hrsa.gov

HHS, National Institutes of Health (NIH)
The National Institutes of Health is the steward of medical and behavioral research for the nation. It is an agency under the U.S. Department of Health and Human Services.
9000 Rockville Pike
Bethesda, MD 20892
301-496-4000
www.nih.gov

HHS, NIH National Institute on Alcohol Abuse and Alcoholism (NIAAA)
This institute provides leadership in the national effort to reduce alcohol-related problems by conducting and supporting research in a wide range of scientific areas.
5635 Fishers Lane, MSC 9304
Bethesda, MD 20892-9304
301-443-3885
www.niaaa.nih.gov

HHS, NIH National Institute on Drug Abuse (NIDA)
This government institute supports more than 85 percent of the world's research on the health aspects of drug abuse and addiction and carries out a broad range of programs to ensure rapid dissemination of research information and its implementa­tion in policy and practice.
6001 Executive Boulevard Room 5213 MSC 9561
Bethesda, MD 20892-9561
301-443-1124
Telefax fact sheets: 888-NIH-NIDA (Voice) (Toll-Free) Or 888-TTY-NIDA (TTY) (Toll-Free)
www.nida.nih.gov

HHS, Substance Abuse and Mental Health Services Administration (SAMHSA)
This Federal agency improves the quality and availability of prevention, treatment, and rehabilitative services in order to reduce illness, death, disability, and cost to society resulting from alcohol and drug use disorders and mental illnesses.
1 Choke Cherry Road, 8th Floor
Rockville, MD 20857
240-276-2130 www.samhsa.gov

HHS, SAMHSA
Center for Substance Abuse Treatment (CSAT)
This government organization provides information on treatment programs, publications, funding opportunities, and resources and sponsors Recovery Month.
1 Choke Cherry Road,
5th Floor Rockville , MD 20857
240-276-2750
www.samhsa.gov/centers/csat/csat.html

HHS, SAMHSA
Substance Abuse Treatment Facility Locator
This is a searchable directory of alcohol and drug treatment programs.
www.findtreatment.samhsa.gov

Alcohol and Drug Services

American Medical Association (AMA) Office of Alcohol and Other Drug Abuse
This collaboration of the AMA and Robert Wood Johnson Foundation works to reduce underage alcohol use.
515 North State Street
Chicago, IL 60610
800-621-8335 (Toll-Free)
312-464-5000
www.ama-assn.org/ama/pub/category/3337.html

Association for Medical Education and Research in Substance Abuse (AMERSA)
This association offers training and materials for medical professionals and students and all primary health professional disciplines.
125 Whipple Street, Suite 300
Providence, RI 02908
401-349-0000
www.amersa.org

Institute for the Advancement of Human Behavior
This institute provides continuing medical education for mental health, chemical dependency, and alcohol and drug use disorder treatment providers in the United States and Canada.
4370 Alpine Road, Suite 209
Portola Valley, CA 94028
800-258-8411
www.iahb.org

International Nurses Society on Addictions
This society offers information and education for nurses concerning prevention, intervention, treatment, and management of alcohol and drug use disorders.
P.O. Box 10752
Raleigh, NC 27605
919-821-1292
www.intnsa.org

Johnson Institute
This national organization works to identify and eliminate barriers to recovery, while promoting the power and possibility of recovery by enhancing awareness, prevention, intervention, and treatment practices for alcohol and drug use disorders.
D.C. Office:
613 Second Street NE
Washington, D.C. 20002
202-662-7104
MN Office:
10001 Wayzata Boulevard
Minnetonka, MN 55305
952-582-2713
www.johnsoninstitute.org

Physicians and Lawyers for National Drug Policy
This organization conducts research and provides information to the public on drug use disorders, and works to put a new emphasis on the national drug policy by substantially refocusing the investment in the prevention and treatment of harmful drug use.
PLNDP National Project Office Center for Alcohol and Addiction Studies
Brown University
Box G-BH
Providence, RI 02912
401-444-1817
www.plndp.org

Mutual Support Groups

Al-Anon/Alateen
This group provides support for families and friends of alcoholics.
Al-Anon Family Group Headquarters, Inc.
1600 Corporate Landing Parkway
Virginia Beach, VA 23454-5617
757-563-1600
888-4AL-ANON (888-425-2666) (Toll-Free)
www.al-anon.alateen.org

Alcoholics Anonymous (AA)
AA offers a support group that provides sponsorship and a 12-step program for life without alcohol.
475 Riverside Drive, 11th Floor
New York, NY 10115
212-870-3107
www.aa.org

Narcotics Anonymous World Services
This is a non-profit fellowship society of men and women for whom drugs had become a major problem. Membership is open to all drug addicts, regardless of the particular drug or combination of drug used.
P.O. Box 9999
Van Nuys, CA 91409
818-773-9999
www.na.org

Psychiatry and Psychology

American Academy of Addiction Psychiatry
The Academy offers continuing education for alcohol and drug use disorder treatment professionals.
1010 Vermont Avenue NW, Suite 710
Washington, D.C. 20005
202-393-4419
www.aaap.org

American Psychiatric Association
This association offers mental health information for professionals, individuals, and families.
1000 Wilson Boulevard, Suite 1825
Arlington, VA 22209-3901
703-907-7300
888-357-7924 (Toll-Free)
www.psych.org

American Psychological Association
The American Psychological Association is the largest scientific and professional organization representing psychology in the United States. Its membership includes more than 150,000 researchers, educators, clinicians, consultants, and students.
750 First Street NE
Washington, D.C. 20002-4242
202-336-5500
202-336-6123 (TDD/TTY)
800-374-2721 (Toll-Free)
www.apa.org

American Society of Addiction Medicine (ASAM)
This society increases access to and quality of treatment, educates the medical arena and the public, and promotes research and prevention.
4601 North Park Avenue
Upper Arcade, Suite 101
Chevy Chase, MD 20815-4520
301-656-3920
www.asam.org

National Mental Health Association (NMHA)
This association is dedicated to promoting mental health, preventing mental disorders, and achieving victory over mental illness through advocacy, education, research, and service.
2001 North Beauregard Street, 12th Floor
Alexandria, VA 22311
703-684-7722
800-969-6642 (Toll-Free)
800-433-5959 (TTY)
www.nmha.org

Research

Addiction Technology Transfer Centers (ATTC)
These centers identify and promote opportunities for advancing addiction treatment research.
University of Missouri – Kansas City
5100 Rockhill Road
Kansas City, MO 64110-2499
816-482-1200
www.nattc.org

CompassPoint Addiction Foundation
This foundation performs research about the causes and nature of alcohol and drug use disorders.
7711 East Greenway Street, Suite 211
Scottsdale, AZ 85254
480-368-2688
www.addictionresearch.com

Harvard Medical School Division on Addictions
This center provides education and training to health care workers who treat alcohol and drug use disorders and to scientists who study them.
401 Park Drive, Second Floor East
Boston, MA 02115
617-432-0058
www.hms.harvard.edu/doa

National Center on Addiction and Substance Abuse at Columbia University (CASA)
This center conducts research on the economic and social costs of alcohol and drug use disorders.
633 Third Avenue, 19th Floor
New York, NY 10017
212-841-5200
www.casacolumbia.org

Treatment Providers

Alcoholism and Substance Abuse Providers of New York State
This non-profit membership association consists of coalitions, programs, and agencies throughout New York State that provide alcohol and drug use disorder prevention, treatment, and research.
1 Columbia Place, Suite 400
Albany, NY 12207-1006
518-426-3122
www.asapnys.org

American Association for Marriage and Family Therapy (AAMFT)
This association represents the professional interests of more than 23,000 marriage and family therapists throughout the United States, Canada, and abroad.
112 South Alfred Street
Alexandria, V A 22314-3061
703-838-9808
www.aamft.org

American Mental Health Counselors Association
This group enhances the profession of mental health counseling through licensing, advocacy, education, and professional development.
801 North Fairfax Street, Suite 304
Alexandria, V A 22314
703-548-6002
www.amhca.org

NAADAC, The Association for Addiction Professionals (National Association of Alcoholism and Drug Abuse Counselors)
This membership organization serves addiction professionals who specialize in addiction treatment, prevention, and intervention.
901 North Washington Street, Suite 600
Alexandria, VA 22314
800-548-0497
www.naadac.org

National Association of Addiction Treatment Providers
This association represents private alcohol and drug use disorder treatment programs throughout the United States.
313 West Liberty Street, Suite 129
Lancaster, PA 17603-2748
717-392-8480
www.naatp.org

National Association on Alcohol, Drugs and Disability, Inc. (NAADD)
This association promotes awareness and education about alcohol and drug use disor­ders among people with physical, sensory, cognitive, and developmental disabilities.
2165 Bunker Hill Drive
San Mateo, CA 94402-3801
650-578-8047
www.naadd.org

National Council for Community Behavioral Healthcare
The National Council is the only trade association representing the providers of mental health, substance abuse, and developmental disability services. Our members serve more than 4.5 million adults, children, and families each year and employ more than 250,000 staff.
12300 Twinbrook Parkway, Suite 320
Rockville, MD 20852
301-984-6200
www.nccbh.org

This list is not exhaustive of all available resources. Inclusion does not constitute endorsement by the U.S. Department of Health and Human Services, the Substance Abuse and Mental Health Services Administration, or its Center for Substance Abuse Treatment.

Sources

1 Results from the 2003 National Survey on Drug Use and Health: National Findings. DHHS Publication No. (SMA) 04-3964. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Office of Applied Studies, September 2004, p. 57.

2 ibid, p. 8.

3 Faces & Voices of Recovery Public Survey. Washington, D.C.: Peter D. Hart Research Associates, Inc., and Coldwater Corporation, May 4, 2004, p. 1.

4 Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates 1995-2002. DHHS Publication No. (SMA) 03-3780. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2003, Table 2.2.0.

5 Effective Treatment Saves Money. Substance Abuse in Brief. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, January 1999, para. 4.

6 Position Paper, Managed Care and Public Sector Agencies. Arlington, VA: National Association of Alcohol and Drug Abuse Counselors, 1990: NAADAC Web site: www.naadac.org/home.php, August 1999.

7 Kleber, H.D., O'Brien, C.P., Lewis, D.C., and McLellan, A.T. Drug dependence, a chronic medical illness: Implications for treatment, insurance, and outcomes evaluation. Journal of the American Medical Association, 284 (13), Chicago, IL: American Medical Association, October 4, 2000, p. 1689.

8 Dean R. Gerstein, et al. The National Treatment Improvement Evaluation Survey: Final Report. Chicago, IL: National Opinion Research Center, University of Chicago, March 1997, Table 3.

9 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 5.

10 Curley, B. “National Policy Panel Grapples with Treatment Quality.” Join Together Web site, February 18, 2003: www.jointogether.org/sa/news/features/print/0,1856,556670,00.html, para. 4. Accessed July 26, 2004.

11 ibid, para. 5.

12 Position Paper, Managed Care and Public Sector Agencies.

13 “Public Policy of ASAM: Screening for Addiction in Primary Care Settings.” American Society of Addiction Medicine Web site: www.asam.org/ppol/Screening for Addiction_Primary Care.htm, para. 3. Accessed August 19, 2004.

14 “AS/Healthy People 2010” slide presentation. OAS Web site: http://oas.samhsa.gov/mentalHealthHP2010/mentalHealth.cfm, slide 3. Accessed August 19, 2004.

15 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 6 and Appendix C.

16 Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, 2002, chapter 4, pp. 65, 66.

17 De Miranda, J. Treatment services offer limited access for people with disabilities. The Counselor, 1999: 24-25.

18 Fact sheet on alcohol, drugs, and disability. National Association on Alcohol, Drugs and Disability, Inc. 2001: 1-4.

19 De Miranda, J. Treatment services offer limited access for people with disabilities. The Counselor, 1999: 24-25.

20 ibid.

21 Fact sheet on alcohol, drugs, and disability. National Association on Alcohol, Drugs and Disability, Inc. 2001: 1-4.

22 Older adults and substance use disorders: A guide to recovery from misuse, dependency or addiction problems. DHHS Publication No. (SMA) 04-3942. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2004, para. 1, 2, and 7.

23 ibid.

24 Alcohol Use Among Older Adults: Pocket Screening Instruments for Health Care and Social Service Providers. DHHS Publication No. (SMA) 02-3621. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 2001, Brochure.

25 Substance Abuse and Mental Health Services Administration Matrix. “Older Adults.” May 2004, section entitled “Budget,” para. 4.

26 Centers for Disease Control and Prevention. Youth risk behavior surveillance–United States, 1999. MMWR Morb Mortal Wkly Rep.2000;49(SS-5): 1-96.

27 Knight, J., et al. Validity of the CRAFFT Substance Abuse Screening Test Among Adolescent Clinic Patients. Arch Pediatr Adolesc Med 156, June 2002, pp. 607-12.

28 Friedmann, P., et al. Screening and intervention for alcohol problems. A national survey of primary care physicians and psychiatrists. J Gen Intern Med February 2000, 15(2) pp. 84-91.

29 “Public Policy of ASAM.” American Society of Addiction Medicine Web site: www.asam.org/ppol/MEDICAL CARE IN RECOVERY 9-89.htm. Section entitled “Policy Recommendations,” number 4. Accessed August 19, 2004.

30 Naegle, M. Nursing education in the prevention and treatment of SUD. In Strategic Plan for Interdisciplinary Faculty Development: Arming the Nation's Health Professional Workforce for a New Approach to Substance Use Disorders (Mary Haack and Hoover Adger, Editors). Substance Abuse 2002, 23 (3): pp. 247-261.

31 “Ending Discrimination Against People With Alcohol and Drug Problems: Recommendations from a National Policy Panel.” www.jointogether.org/sa/action/dt/strategies/discrimination/policypanel/, para 2. Accessed September 22, 2004.

32 “The Face of Recovery.” Faces & Voices of Recovery Web site: http://facesandvoicesofrecovery.org/pdf/hart_research.pdf. p. 10. Accessed September 22, 2004.

33 Shapiro, C., Douglas, A. A Comprehensive Approach to Community-Based Drug Treatment. Providence, RI: Physician Leadership on National Drug Control Policy (now Physicians and Lawyers for National Drug Policy), November 1998.

34 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 5.

35 Treatment for Addiction: Advancing the Common Good. Boston, MA: Join Together Policy Panel, January 1998, p. 7.

36 Position Paper, Managed Care and Public Sector Agencies.

37 The National Drug Control Strategy. 1999. ONDCP 1999b. Washington, D.C.: Office of National Drug Control Policy.

38 Treatment for Addiction: Advancing the Common Good, p. 4.

39 Callahan, J.F. Report From the Executive Vice President: NIDA Report Upholds ASAM's Treatment Principles. Washington, D.C.: American Society of Addiction Medicine, 2000, p. 1.

40 Report to Congress on the Prevention and Treatment of Co-occurring Substance Abuse Disorders and Mental Disorders, chapter 4, p. ix.

41 Position Paper, Managed Care and Public Sector Agencies.

42 Treatment for Addiction: Advancing the Common Good, p. 3.

43 Rowe, C.L. and Liddle, H.A. Substance abuse. Journal of Marital and Family Therapy 29 (1), January 2003, pp. 97-120.

44 Adolescent Substance Abuse: A Public Health Priority. Providence, RI: Physician's Leadership on National Drug Policy, Center for Alcohol and Addiction Studies, Brown University, August 2002, p.23.

45 McLellan, A.T. 2002. Is addiction an illness–Can it be treated? Substance Abuse Journal of the Association for Medical Education and Research in Substance Abuse, 23 (3) (supplement), 2002, pp. 78-88.

46 Miller, W.R., Wilbourne, P.L. Mesa Grande: A methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 97, 2002, pp. 265-277.

47 Principles of Drug Addiction Treatment: A Research-Based Guide. NIH Publication No. 00-4180. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Drug Abuse, printed October 1999/reprinted July 2000.

48 Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH post-treatment drinking outcomes. Journal of Studies on Alcohol, 58, 1997, pp. 7-29.

49 “Patient Placement Criteria, Second Edition Revised.” www.asam.org/ppc/ppc2.htm, para. 4. Accessed July 29, 2004.

50 U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, Recovery Community Services Program Web site: http://rcsp.samhsa.go, sections entitled “ The Recovery Community Services Program,” “About the RCSP Program,” and “Peer Services: Peers Helping Peers.” Accessed November 16, 2004.

51 Mark T., Coffey R. The decline in receipt of substance abuse treatment by the privately insured, 1992-2001. Health Affairs (23)6, November/December 2004, pp. 157-162.

52 Results from the 2003 National Survey on Drug Use and Health: National Findings, p. 5.

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54 The National Drug Control Strategy. 1999. ONDCP 1999b. Washington, D.C.: Office of National Drug Control Policy.

55 Haack M.R. and Adger H. (editors). Strategic Plan for Interdisciplinary Faculty Development: Arming the Nation's Health Professional Workforce for a New Approach to Substance Use Disorders. Providence, RI: Association for Medical Education and Research in Substance Abuse (AMERSA), September 2002, p. 11.

56 Federal Funding for Addiction Prevention, Treatment, and Rehabilitation: Public Policy of ASAM. Washington, D.C.: American Society of Addiction Medicine, 2001, p. 1.

57 Estee J., Norlund D. J. Washington State Supplemental Security Income Cost Offset Pilot Project, 2000 Progress Report. Olympia, WA: Washington State Department of Social and Health Services, Management Services Administration, 2003.

58 Roebuck M.C., French M.T., McLellan A. T. DATStats: results from 85 studies using the Drug Abuse Treatment Cost Analysis Program (DATCAT). Journal of Substance Abuse Treatment 25, 2003, pp. 51-57.

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61 A Guide to Substance Abuse Services for Primary Care Physicians. Treatment Improvement Protocol (TIP) Series 24. DHHS Publication No. (SMA) 97-3139. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment, 1997, section entitled “Summary of Recommendations, Screening.”

62 Cherpitel, C.J. Screening for alcohol problems in the U.S. general population: Comparison of the CAGE, RAPS4, and RAPS4-QF by gender, ethnicity, and service utilization. Alcohol Clin Exp Res. 2002 Nov; 26(11):1686-91.

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