State governors and lawmakers need to assert leadership to ensure that addiction treatment and prevention services are effective, coordinated, accountable, and delivered by trained staff, according to experts who testified at a pair of public hearings convened by Join Together.

Led by former Massachusetts governor and presidential candidate Michael Dukakis, the "Blueprint for the States: Policies to Improve the Way States Organize and Deliver Alcohol and Drug Prevention and Treatment" panel received testimony from dozens of field leaders during recent hearings in Santa Fe, N.M., and Washington, D.C. The testimony will help shape a set of key policy recommendations from the panel, which will be issued in June.

The hearings come as many states have dismantled their formerly independent substance-abuse agencies, moving responsibility for treatment and prevention into mental-health, public-health, or even child-welfare departments. At the same time, both states and providers are facing increased calls for accountability – notably from the federal government, the single largest funder of addiction treatment and prevention services.

Susan Gelber, co-author of a recent report on state substance-abuse agencies by the AVISA Group, told the panel that many state substance-abuse agencies are currently "too de minimis to compete … they tend to be stepchildren in reorganizations."

Today, just four states – Connecticut, New York, Ohio, and South Carolina – have a cabinet-level agency devoted specifically to substance abuse. "Half of the directors that were there when I started are no longer around," said Dave Wanser, executive director of the Texas Commission on Alcohol and Drug Abuse, once independent but now merged with the state health and mental-health departments.

Some testifiers, like California Department of Alcohol and Drug Programs director Kathryn Jett, said that a single state agency (SSA) for substance use disorders is required to coordinate services and programs. But Wanser, who is also president of the National Association of State Alcohol and Drug Abuse Directors (NASADAD), said that the merger of his agency had given the state a "true public-health viewpoint" on addiction that it previously lacked.

"There's no such thing as a single state agency (SSA); the concept doesn't work anymore," said Pamela Hyde, secretary of the New Mexico Human Services Department, who oversees an interagency Behavioral Health Collaborative that involves leaders inside and outside government in developing alcohol and other drug policy. "All agencies have to work together. We need a single state response, not a single state agency response."

Witnesses at the policy panel hearing repeatedly endorsed the concept of using permanent advisory groups, policy-review committees, and other methods to fuel cross-agency collaboration. Speakers noted that Medicaid and the criminal-justice systems are major funders of treatment services, for example, but often are not at the table for policy discussions – and rarely have their funding streams integrated with money flowing through the SSAs.

The AVISA report reinforced these points, noting that the "need for interagency collaboration is greater for substance-abuse agencies than for almost any other health or human services agency, because virtually every government agency has clients with overt or hidden substance-abuse disorders that complicate their lives and hence affect the other services' use, costs and effectiveness."

Gelber told the Join Together policy panel that state agencies also need the support – and ear – of the governor and/or legislature. "Without it, the agency drowns," she said, regardless of where the agency is housed.

"Location is a big part of authority," agreed Florida drug czar Jim McDonough. "I sit 50 feet from the governor. I don't see him very often, but people think I do."

Outcomes and Evaluation

The uneven landscape in state bureaucracies mirrors the uncertainty around another hot topic at the policy panel hearings: outcome evaluations and program accountability.

In recent years, the federal government has pushed states to develop a standard set of outcome measures for treatment and prevention, and some can see a day in the not-distant future where all federal funding – including the billion-dollar Substance Abuse Prevention and Treatment Block Grants – will be awarded based on conformity with performance measures. Already, the Substance Abuse and Mental Health Services Administration's (SAMHSA's) Strategic Prevention Framework Grants have been closely tied to the use of proven strategies and outcome measurements.

"It is past time for us to use prevention and treatment methods that are evaluation based," said addiction researcher William Miller, Ph.D., professor at the University of New Mexico. "We need to change reimbursement so that the treatment that gets reimbursed is what works."

States like New Mexico are moving in that direction, although Hyde's description of New Mexico's Behavioral Health Collaboration says a lot about the challenges: "Seventeen agencies have [common] outcome goals – success in school, reduced suicides, reduced law enforcement involvement – some of which we haven't figured out how to measure yet."

Some states, like Iowa, have worked through behavioral health managed-care carve-outs to provide incentives for adopting proven treatment strategies and measuring outcomes; others, like Delaware, have taken a more direct approach, paying a bonus to outpatient treatment providers who retain at least 85 percent of their patients; those who fail to do so get just 90 percent of the previous year's reimbursement rate. Adopted in 2003, the plan has trebled patient retention rates, with many programs adopting science-based treatment protocols to improve their effectiveness.

"We wanted to expand and enhance our statewide system, to introduce new and effective treatment methodologies and to assure that our contractors were using evidence-based practices to achieve the best possible results for clients," said Jack Kemp of the Delaware Division of Substance Abuse and Mental Health. "Other states can apply the same principles to the infrastructure of their particular jurisdictions. What we do directly with provider agencies, others can do through counties or cities or other intermediaries. "

"Delaware was tired of the therapy du jour," said Tom McLellan, Ph.D., director of the University of Pennsylvania Treatment Research Institute. "Addiction treatment is not an art form; it is amenable to scientific study … and should be bought and delivered with public goals and needs in mind."

A Level Playing Field for Prevention

States also have played a leading role in improving accountability in the prevention field; Colorado, for example, recently developed a set of uniform prevention outcome measures. Still, experts like Joe Weise, director of the Southwest Center for the Application of Prevention Technologies, said that workforce development and standards of care need to be improved. "Prevention is buried in state agencies," Weise said, citing the need to increase understanding of prevention as a public-health intervention that is well structured, cost-effective, and beneficial.

"As we speak about leadership, what does have to happen is that there has to be a stabilized infrastructure for prevention," said Beverly Watts Davis, special advisor to SAMHSA Administrator Charles Curie.

Harry Kressler, executive director of the Pima (Ariz.) Prevention Partnership, urged state policymakers to shift from measuring individual prevention outcomes to community-wide results. "The unit of analysis for prevention is best achieved by measuring changing community conditions within cultural contexts," said Kressler, who also warned that adopting lists of approved prevention programs "have greatly diminished innovation and flexibility in the field of prevention and community development."

Kressler said that the Synar Amendment, which holds states fiscally responsible for decreases in illicit tobacco sales to minors, could be a good accountability model for other types of prevention. "Since alcohol sales to minors in Arizona are estimated to account for 10 percent of all sales by the Arizona beverage industry, a similar amendment for holding states responsible for decreased alcohol sales to minors would likely generate similar, favorable outcomes," he said.

Training and Paying Providers

A number of witnesses told the policy panel that ensuring high-quality treatment and prevention would be impossible without better training and reimbursement of counselors. Training and licensing standards vary from state to state, and while governments have become the largest payer for treatment services, salaries for program staff remain pitifully low.

"Many of our addiction professionals across the USA can currently qualify for food stamps," said Cynthia Moreno Tuohy, executive director of NAADAC: The Association of Addiction Professionals. "This is not acceptable, especially if we want quality, competent, and long-term professionals."

Tuohy called on states to adopt higher cost-unit reimbursement rates for addiction treatment and prevention. "A percentage of this should be designated for staff salaries and benefits, in order to attract and retain qualified addiction professionals," she said.

Focus on Communities

Finally, witnesses urged the panel members to advise states not to overlook the constituencies for substance-abuse prevention and treatment services, including the recovery community and the population at large.

"Our number-one recommendation for this body is that states should adopt community mobilization as a primary strategy and support local coalitions to address what are at the core, local drug epidemics," said Gen. Arthur Dean, chairman and CEO of Community Anti-Drug Coalitions of America. "States should listen to communities. And when states support and value coalitions, they hear a groundswell of support echoed back at them."

Johnny Allem, president of the Johnston Institute, said that while the focus of national drug-control prevention seems to be on "vengeance and supply management" rather than health and healing, "this hearing brings hope for structural change, in part because the focus is on strategies at the state level."

Allem called for the "silos" represented by single state agencies to be dismantled, replaced by citizens' councils that would hold state health agencies accountable for treatment outcomes. "Government has placed responsibility for the health aspects of addiction disease in so-called single state agencies, but failed to support them with enough money or vital linkages," he said. "Even though these state agencies are often administered by the larger health system, there is little linkage with health education, screening, or treatments."

"Our efforts must begin with science, and the science that can be applied to public policy is expressed in this single sentence: Addiction recovery is a normal expectation when appropriate responses are applied in a timely manner," said Allem.

Government-funded programs provide most of the addiction treatment and prevention services in the U.S., and states are in the forefront of efforts to prevent and treat alcohol and drug problems. Who should lead this fight at the state level, how government entities and services can best be structured, and which state criminal-justice policies can serve as models for others are among the issues under consideration by the Blueprint for the States Policy Panel.

The panel will be accepting electronic submissions of testimony through March 1; to submit testimony, visit www.jointogether.org and click on the "Blueprint for the States" link.

The panel is chaired by Michael Dukakis, former governor of Massachusetts. Other panelists include:

• Diana Bontá, vice president of public affairs for Kaiser Permanente's Southern (California) Region;

• Barbara Cimaglio, deputy commissioner of the Vermont Division of Alcohol and Drug Abuse Programs;

• Judge Karen Freeman-Wilson (ret.), CEO of the National Association of Drug Court Professionals and chair of the Governor's Commission for a Drug-Free Indiana;

• Sidney L. Gardner, president of Children and Family Futures;

• Hon. Pat George, Kansas House Republican legislator;

• Patricia Kempthorne, First Lady of Idaho;

• Tom McHale, work and family representative for the United Auto Workers-General Motors Commercial Truck Center and board member of Faces and Voices of Recovery;

• Katie McQueen, assistant professor at the Baylor College of Medicine and University of Texas Health Science Center in Houston and medical director of the Harris County Hospital District's Screening, Brief Intervention, Referral and Treatment Program;

• Paul Roman, distinguished research professor at the University of Georgia and director of the Center for Research on Behavioral Health and Human Services Delivery's Institute for Behavioral Health Research; and

• Ken Stark, director of the Mental-Health Transformation Project and former director of the Washington Division of Alcohol and Substance Abuse.