Citing the "almost incalculable" toll that alcohol and other drug addiction takes on society, a Join Together policy panel called on states to take a leadership role in addressing the need for more drug treatment and prevention by improving how services are organized, delivered, paid for, and measured.

The "Blueprint for the States" policy panel, led by former Massachusetts governor and presidential candidate Michael Dukakis, noted in its "Blueprint for the States: Policies to Improve the Ways States Organize and Deliver Alcohol and Drug Prevention and Treatment" report that states bear many of the costs of alcohol and other drug addiction, spending an estimated 13 percent of their budgets on addiction-related problems.

However, the report noted, "Less than four percent of this is spent on prevention and treatment, while more than 96 percent pays for the avoidable social and physical consequences that result from our failure to apply what we know about how to prevent and treat substance-use problems." These costs include child-welfare, prison, court, police, and Medicaid expenditures for treating medical problems related to addictive illnesses.

"It is of utmost importance that we keep hammering -- and I think the report does this -- that state budgets will actually be favorably impacted if the correct ... processes are put in place," said Pat George, a member of the Kansas House of Representatives and a policy panel member.

State Governments, Leaders 'Hold the Keys'

The report stressed that "state governments hold the keys to their own recovery from the financial and human waste caused by excessive alcohol and illicit-drug use.

"State policy, financing and regulatory authority can be effective tools," the panelists wrote. "We were struck by the consensus that emerged in our hearings about the many strategies that can be pursued at surprisingly low cost.

"We also found what is missing: leadership at the top and strategies that use the range of tools that states already have. This report is a blueprint for governors, legislative leaders and chief judges to adapt and use to gain control of the biggest single financial drain they face."

Dukakis said that the "one thing that struck me throughout our work was the fact that a lot of the interest and enthusiasm that we saw in the 1980s seems to have evaporated ... interest has moved on to other things, and the states are not doing the job we ought to be doing in this area ...

"I believe that prevention and education have to be at the top of the state priority list, beginning in the early elementary grades," added Dukakis. "I saw very little evidence in our hearings that that is happening in many states across the country."

On the other hand, "with an excellent leader, the ... recommendations are more likely to be adopted and sustained," noted panelist Katherine McQueen, assistant professor at Baylor College of Medicine and the University of Texas Health Science Center, and medical director for the Harris County Hospital District Screening, Brief Intervention, Referral, and Treatment (SBIRT) program. "There is a policy recommendation in here for everyone. This issue is a family issue, a financial issue, a public-safety issue, a workplace issue. No one person or legislator needs to embrace every word. I hope that leaders will see that this report is not about one political party or the other. This is about people and families and communities."

Panel Recommendations

The Blueprint panel recommended that states:

• develop a statewide strategy that includes all agencies affected by drug and alcohol problems
  
• increase accountability for all state agencies working on issues related to addiction
  
• educate lawmakers about the costs of alcohol and other drug addiction to improve their participation in policymaking
  
• train judges to address alcohol and other drug use among defendants and improve coordination with treatment services
  
• create a state alcohol and other drug policy advisory board, answerable to the governor and lawmakers, that includes representatives from the recovering community and civic leaders

Panel members also called for states to vest responsibility for implementing their statewide alcohol and other drug strategy in an entity "at the highest possible level in state government" and that reports directly to the governor.

"The strength of these recommendations is that they work together to outline a foundation that must be present to build and sustain a viable state system," said panelist Barbara Cimaglio, deputy commissioner for Alcohol and Drug Abuse Programs in the Vermont Department of Health. "While leadership is probably the most critical place to start, it takes a structure and resources to sustain a system over time."

Currently, few states have a drug strategy that is led by the governor and key lawmakers and crosses agency lines, the report noted. "To make matters worse, treatment and prevention agencies have been moved like checkerboard pieces in administrative reorganizations that have buried them far from the state's senior leadership," the panel noted. "We found these reorganizations often miss the mark, focusing on organizational efficiency at the cost of effective prevention and treatment."

"For too long, states have been saying you can live without this, and you can live without that," said panelist Tom McHale, a board member of Faces and Voices of Recovery and former employee-assistance representative for the United Auto Workers-General Motors Commercial Truck Center in Flint, Michigan. "States have been plucking programs and resources without giving thought to the consequences of their actions. Social policies have de-medicalized addiction and cannibalized the system for treating and preventing addiction."

Need for Coordination, Standards, and Outcome Measures Cited

The panel noted that funding for services directly and indirectly related to alcohol and other drug problems flows through the states at multiple points, and said that the goals of the state strategy should include identifying these funding streams and coordinating them. Panelists recommended that states expand Medicaid coverage for addiction treatment and prevention for high-risk children, require insurers to provide parity coverage for addictive illnesses, and consider raising alcohol excise taxes to pay for addiction services.

States also hold the key to improving the quality of addiction services delivered to residents; the panel recommended that states use their certification and licensing powers to establish minimum skill sets for addiction counselors and managers, improve treatment program capabilities, and set salary and payment rates "at levels that will attract and retain qualified providers."

These steps could improve treatment outcomes, which the panel said that states should track by creating a unified data system of programs that receive state funds. An annual report should be published that tracks the costs and consequences of alcohol and drug use as well as treatment and prevention outcomes, the panel recommended. "Pay more to providers that consistently achieve better results and less -- or nothing -- to providers that cannot achieve reasonable expectations," the report said.

"While leadership produces that initial visibility and support, measurement and accountability creates credibility and sustainable support for efficient and effective services," said panel member Ken Stark, director of the Washington state Mental Health Transformation Project and former director of the Washington Division of Alcohol and Substance Abuse. "Strong leadership and a focus on being data-driven will help prevent [addiction] issues from dropping off the radar screen."

To sustain focus on addiction issues, the panel called on community leaders and the recovery community to educate elected officials and work with policymakers on advisory boards, advocacy efforts, and drafting new laws and regulations.

The Blueprint for the State policy panel gathered public testimony during two 2006 public hearings, in Washington, D.C., and Santa Fe, N.M., as well as electronic submissions via the Join Together website. "I was surprised by the overall acknowledgment that certain aspects of the system need to be fixed," reflected panelist Karen Freeman-Wilson, CEO of the National Association of Drug Court Professionals. "Such open statements give hope that a solution can be reached in the foreseeable future. As we present our results, it is my hope that those who work in the state system will be motivated to advocate change from the ground up."

In addition to Dukakis, George, McQueen, Cimaglio, McHale, Stark and Wilson, members of the Blueprint for the States policy panel included Diana Bonta, vice president of public affairs for Kaiser Permanente's Southern California region; Sidney L. Gardner, president of Children and Family Futures, Inc.; Patricia Kempthorne, first lady of Idaho and co-chair of the Governor's Coordinating Council for Families and Children; and Paul Roman, Ph.D., distinguished research professor at the University of Georgia and director of the Center for Research on Behavioral Health and Human Services Delivery Institute for Behavioral Research.