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III. Discussion and Recommendations
The Substance Abuse Services System
Level of Attention, Funding, and Resources
The Task Force believes that adequate resources and funding are essential to the effectiveness of Maines substance abuse services system. Maine law (5 MRSA, chapter 521) requires an integrated approach to substance abuse and designates the Office of Substance Abuse (OSA) as the single administrative unit with responsibility for planning, developing, implementing, coordinating, and evaluating all of the States substance abuse prevention and treatment activities and services. The law specifies that other state agencies must cooperate fully with OSA and provides that OSA must report to the Legislature on an annual basis. In spite of these provisions, the Task Force finds that mechanisms are needed to ensure that substance abuse policies and issues receive an appropriate level of attention throughout the Executive Branch and at the Legislature.
The Task Force is concerned that in recent years OSA has experienced significant changes in its structure and position in Maine State Government. Previously, OSA was located in the Governors Office. Now it is in the Department of Mental Health, Mental Retardation, and Substance Abuse Services. Substance abuse issues also are under the jurisdiction of several other state agencies, including the Departments of Corrections, Education, Human Services, Public Safety, and Transportation.
Under the current structure of the Legislature, substance abuse issues are considered by several different joint standing committees, including Appropriations and Financial Affairs; Banking and Insurance, Criminal Justice, Education, Health and Human Services, Judiciary, Legal and Veterans' Affairs, Transportation, and others. The Joint Select Committee on Substance Abuse has provided an effective mechanism for addressing substance abuse issues in a coordinated fashion.
Need for Knowledge
Also essential to the effectiveness of Maines substance abuse services system is knowledge about substance abuse (including prevention) by those who come in contact with persons with alcohol, tobacco, and other drug problems. Educators, law enforcement personnel, medical care providers, mental health providers, and social workers all deal with the multifaceted issues of substance abuse. The Task Force believes that people receiving services from these professionals have a right to expect that all possible causes of their problems will be considered. Substance abuse issues need to be addressed by professionals who have knowledge about substance abuse prevention, indicators, treatment, and available services. Substance abuse training currently is not included in standard curricula for these professions. Professional regulatory boards need to consider substance abuse training as a condition of licensure or certification.
One way to enrich Maines knowledge base about substance abuse is to have Maines university system and colleges involved in substance abuse research. Maine is a unique laboratory for testing new approaches in prevention and treatment. It is small enough in population to make research projects manageable in their focus. Maines geographical issues mirror larger states with services to rural populationsonly on a more manageable level. The Task Force is interested in increasing the capacity of Maines university system and colleges to secure grants from the Substance Abuse and Mental Health Services Administration and other federal agencies to address barriers to services experienced by Maine people. University sponsorship often is required in order for Maine to receive certain federal substance abuse funds.
The Task Force believes that a strong consumer voice also is a key ingredient of an effective substance abuse services system. This voice includes current consumers of substance abuse services, recovering substance abusers, and family members. It needs to be a composite of the voices of people from the diverse groups affected by substance abuse. OSA already has created a formal mechanism (Quality Improvement Councils) for involving consumers in the planning and policy-making process. There also needs to be an independent consumer voice. Other New England states (Connecticut, Rhode Island, and Massachusetts) have promised public money to help develop this independent voice. The federal Center for Substance Abuse Treatment is committing $3,000,000 over each of the next three years toward the development of local education and advocacy groups run by and for recovering people. The Task Force supports efforts in Maine to strengthen the consumer voice.
1. Resources and Funding. Expand resources to fund substance abuse initiatives. Develop resources from all available sources including: reallocating state General Fund revenues; making changes in state tax policies; successfully applying for federal grants; building municipal support; and obtaining private sector grants and donations from businesses, foundations, and other philanthropic organizations.
2. Position of OSA. Implement mechanisms to ensure that OSA is appropriately positioned in State Government and that substance abuse issues receive an appropriate level of attention in both the Executive and Legislature Branches. Ensure full compliance with current Maine law that requires state agencies to cooperate with OSA. Ensure that all state agencies which spend funds on substance abuse services notify OSA at least annually about all expenditures of state, federal, and other dollars for these services. Require that OSA report directly to the Legislatures Joint Select Committee on Substance Abuse and/or other Joint Committees on the substance abuse services budget and the use of substance abuse resources, as well as the status of Maines substance abuse system.
3. Joint Select Committee. Continue to bring together representatives of the Legislatures policy committees into the Joint Select Committee on Substance Abuse, so they can examine substance abuse issues in a coordinated manner. The Task Force has identified a number of significant issues requiring further study, which the Joint Select Committee should examine:
4. Consumer Initiative. Support the development of an independent consumer initiative in Maine that can play an active role in the discussion and resolution of substance abuse issues.
Strategies and Services Embracing All Groups
Quality and Availability of Services
I found myself...with an opportunity to grow and change. It was important for me to realize that I was one of the lucky ones...I was one of 13 women in the State of Maine fortunate enough to be in the house at that time. I was sober and in an environment that supported my sobriety...The staff believed in me when I wanted to give up on myself. They loved me unconditionally ...This house has been my shelter from the chaotic life I was living. I was given the time to grow and another chance at life. Im filled with gratitude and love for this house...Now life is worth living! Resident graduating from a halfway house for women.
[I am] happier than I ever was...I dont obsess about alcohol, I dont wake up in the morning and wonder where Im gonna get my booze...They taught me to iron clothes. To feed myself. To be honest. To trust other people. To talk to people. They taught me to live. Graduate of a treatment program for youth.30
At [the halfway house], I learned how to cope, to grow, to share, to confront, to problem solve, to be responsible for myself and to others. I learned how to get a job and keep a job. I learned to be honest, I learned how to work my program and eventually to live my program...In the 13 years which have passed since I had my last drink/drug, I have returned to college and earned a bachelors and masters degree. I have a meaningful career. Friends have died drunk, sober, and even committed suicide. Others have continued in their struggle in and out of detoxes; in and out of psychiatric hospitals. Others have maintained sobriety and gone on to do excellent work in their respective careers... No matter what has happened, I have not needed to drink or drug. Graduations, weddings, funerals, super bowls, college, camping, 4th of July, New Years Eve, Christmas, etc. all sober every time. Its very possible and very much worth all of your effort, all of your tears, all of the pain. Former resident of a halfway house for women.
As the preceding statements attest, Maines substance abuse programs and services are not only important, but often are life-saving to the people trying to recover from alcoholism and other drug addiction. Unfortunately, there has been a decline in availability of these services. The lack of resources is a barrier for many Maine peopleparticularly those who are uninsured (the working poor). The key to improving availability is to increase or reallocate funding for substance abuse strategies and services.
Defining Continuum of Care
The Task Force reviewed Maines substance abuse prevention and treatment system in terms of its completeness and seamlessness, based on valuable input from diverse groups from throughout the State. The Task Force has defined "continuum of care" as a comprehensive network of prevention strategies, treatment modalities, and other services designed to meet the changing needs of the community and embracing all of its population groups, and has identified the continuums components, as illustrated on page 25. The components are described in greater detail in Attachment E.
Gaps in Continuum
The Task Force believes that Maines substance abuse services are effective for the people they help. The problem is that there are major service gaps in the continuum of care, which means that many people do not receive the care they need.
In 1997, 10,607 adults were admitted for treatment, while an estimated 75,600 needed treatment.31 Thus, an estimated 64,993 adults did not receive treatment. Programs throughout Maine have waiting lists, as illustrated in the following examples as of early November 1998:
Gaps in the continuum of care are the most alarming problems that exist in Maines substance abuse service system. The Task Force believes that a complete continuum is the foundation of an effective service system.
Continuum of Care: Definition and Components
A comprehensive network of prevention strategies, treatment modalities, and other services designed to meet the changing needs of the community and embracing all of its population groups.
Problem Identification & Referral
Driver Education & Evaluation Program Employee Assistance Programs
includes: Referral Services
Long Term Treatment
includes: Therapeutic Communities
includes: Individual Counseling
includes: Child Care
VI. CONTINUING CARE
Consumer Run Housing
Managed care has affected the methods, location, and duration of substance abuse services. In addition, changes in OSA's priorities over the past several years and legislative cuts in funding have contributed to abbreviated levels of inpatient treatment.
Inpatient stays are shorter (four to seven days), and most treatment now is provided on an outpatient basis (for example, day treatment, partial hospitalization, and group or individual therapy.) There often is a delay between the time an individual leaves one level of inpatient care and moves to the next, because there are no beds immediately available at the next level of inpatient care due to long waiting lists. For this individual, residential rehabilitation, extended shelter, and/or other supportive service is required so that treatment can be continued. Without the needed inpatient resource available, the individual who has begun treatment will not succeed in maintaining long-term recovery and will find it more difficult to achieve a healthy lifestyle.
Gaps for Children and Youth
The Maine Childrens Alliance has reported that prevention programs continue to be inadequate in size and scope. Adolescents, especially in rural areas, indicated the need for safe, drug-free places to socialize.32
Prevention programs in Maine are primarily aimed at children and youth. Effective prevention programming needs to look at the norms, values, and policies in place in communities, families and schools regarding alcohol and other drug use. Prevention needs to address adult and community behavior, as well as youth behavior. Without a serious attempt to change the norms and behaviors of the adult population, no long term impact is going to be made on youth regarding their use of alcohol or other drugs. Therefore, prevention programming needs to be expanded to include all age ranges and not just concentrate on youth.
As described on page 39, when youths enter the juvenile justice system, they are referred for an initial screening and then an assessment, depending on the severity of their use. The Task Force found that screening and assessment generally are not available for youth who are not part of the juvenile justice system. In order to determine the need for and level of treatment, screeningsusing a thorough assessment toolneed to be available to all identified youth in need, whether they are in the juvenile justice system, school, or a recreational facility. By increasing the access and availability of this early intervention, young people will receive referrals to appropriate counseling and treatment.
In Maine, 54 agencies are licensed to provide adolescent substance abuse outpatient treatment. However, there is only one OSA-funded long term treatment center located in southern Maine. Its twelve-bed capacity is inadequate to meet the needs of Maines adolescents who need long term treatment. Existing outpatient treatment capacity for adolescents also is limited. Finally, there is a lack of transitional housing opportunities. Without intensive support from their peers and the community at large, adolescents are likely to relapse into addiction.
Alcohol is such a devastating thing in our community. Ive carried a lot of caskets to the grave and its heartbreaking because most of them were preventable. Clayton Cleaves, Health Planner, Passamaquoddy Tribe at Pleasant Point33
In this report diversity is an inclusive term used to highlight the fact that there is no typical person who needs substance abuse services. The Task Force heard from representatives of many special population groups affected by substance abuse: adolescents (including alternative school students and at risk youth); elderly persons; gays and lesbians; homeless persons; methadone users; Native Americans; opiate addicts; persons who are deaf and hard of hearing; persons who have a dual diagnosis of substance abuse and mental illness; persons with mental retardation; and women.
The Task Force learned that there is not a complete continuum of care for the members of any of these groups and that they often are isolated from the rest of the community. This isolation has an impact on their tendency to abuse substances, as well as on their level of comfort in seeking treatment in the mainstream community.
Those who are members of special populations often are left out of the continuum of care completely. For example, a substance abuser who is deaf and seeking treatment often finds it difficult to find a safe place for treatment where s/he can be counseled by someone who is trained in substance abuse services and is a member of the deaf community or is culturally sensitive to that community.
The Task Force learned that there is a strong need for greater understanding of and respect for diversity. The substance abuse provider community needs to be more inclusive and responsive to the needs of people from diverse groups. The Task Force believes that diversity awareness is essential to effective services. Often substance abuse services are not well suited for the members of special population groups.
The Task Force has two primary concerns relating to Maines Medicaid Program. First, the State is not taking full advantage of Medicaid funding to support the costs of substance abuse services for Maines low income people. Second, the Task Force is concerned about how substance abuse will be addressed as part of managed care for Medicaid recipients. As Medicaid moves toward managed care, the use of research-based outcomes is important to the development of the substance abuse treatment system that will be available to the members of these plans. Research-based outcomes are useful in developing best practices regarding assessment of need for and appropriate type and length of treatment.
The problem is overwhelming. We see everything from parents who spend all their money on booze to parents who use alcohol to loosen their inhibitions and have sex with their children. Sandy Hodge, Supervisor, Maine Department of Human Services34
Be totally honest? Tell them how bad I messed up? DHS will never let me have my children home...I worried sick about how Id ever find a place to live or pay for stuff in storage. My children needed me. I had to find a way to talk to DHS. Resident of a halfway house for women.
Many children and adults involved in the Department of Human Services (DHS) protective systems, as well as their parents or guardians, have substance abuse problems. As the table on page 29 indicates, a number of those needing treatment are referred to substance abuse providers by DHS caseworkers.
However, those referred by DHS for substance abuse treatment are a small portion of those in need. Recent welfare reform legislation limits welfare payments for most recipients to five years. Of the approximately 16,000 people receiving Temporary Assistance to Needy Families (TANF), about 1,600 are in need of substance abuse services.
DHS has the statutory leverage to refer people into treatment, but existing enforcement mechanisms are not being utilized fully. OSA and substance abuse providers need to work with DHS and the Department of Attorney General to increase training for caseworkers and supervisors in order to increase their recognition of substance abuse, as well as their enforcement of and referrals to substance abuse treatment.
DHS Referrals to Substance Abuse Treatment
These numbers are unduplicated and include both primary substance users/abusers and other affected clients.
5. Assessment and Funding. Assess the extent to which substance abuse services within each component of the continuum of care are needed in each region of Maine. In order to ensure access to substance abuse strategies and services by diverse groups of Maine people, provide funding and other assistance, in proportion to population and geography, to support all components of the continuum of care in each region.
6. Youth Screening and Services. Increase access to and availability of substance abuse screening tools and assessments for youth. Establish one additional long term treatment facility for adolescents, as well as alternative services for youth (including but not limited to intensive outpatient treatment, family therapy, home-based family therapy, and gender-specific treatment). Increase the availability of transitional housing for youth. Make sure that all services are geographically accessible to all youth in need.
7. Staffing. Recruit and retain appropriate and adequate staffing throughout the continuum of care. Coordinate resources to help non-profit substance abuse service agencies retain competent staff and to prevent the migration of their staff to other private sector organizations.
8. Barriers and Support Services. Address barriers to treatment and ensure the existence and consistency of support services throughout Maine and throughout the continuum of care. Help substance abuse providers establish or link up with support services that meet the needs of the people they serve (for example, transportation, child care, and interpreter services). Develop a statewide model to provide guidance to substance abuse providers about how to secure support services, how to address the needs of special populations, and how to avoid stereotyping.
9. Reaching Special Population Groups. Institute action-oriented outreach programs that target isolated populations, in order to open avenues to treatment for population groups that are isolated from mainstream programs and services. In order for members of special population groups to access treatment from someone who shares their special needs and culture, target substance abuse education and training opportunities (for example, scholarships, internships, university-level courses, and training provided through OSA programs) to these groups.
10. Respect for and Training in Diversity. Develop and carry out a media campaign to encourage respect for diversity. Develop a standard curriculum that focuses on cultural diversity and make licensing of substance abuse providers contingent upon completion of this curriculum.
11. Medicaid. Maximize the use of Medicaid funding to support the costs of substance abuse services for Maines low income people. Design managed care for Medicaid recipients that is based on outcomes research and on the substance abuse treatment system developed by OSA.
12. Protection. Provide training for DHS caseworkers and supervisors, as well as for assistant attorneys general to improve their recognition of substance abuse, to make sure they understand confidentiality, and to underscore their responsibility to refer people for substance abuse treatment. Increase referrals to substance abuse treatment by DHS.
Publicly Intoxicated People at Risk
Legislation and Study Group
The 118th Legislature considered but did not enact legislation (LD 753) to allow law enforcement officers to take into custody persons who are publicly intoxicated if those persons refuse to be transported to a safer place. The primary impetus for the bill was a lawsuit against Westbrook involving a person who was publicly intoxicated, refused transport except to a coffee shop, and ultimately was injured fatally by an automobile.
At the Legislatures request, OSA formed a group of representatives from the Maine Sheriffs Association, Maine Chiefs of Police, Maine Hospital Association and Maine Association of Substance Abuse Providers (including persons in recovery and their families) to assess the magnitude of the problem. During the summer and fall of 1997, the group conducted an inventory of existing resources; carried out an assessment of the extent of the problem of public intoxication in Maine, and developed recommendations. Fifty-six (43% of all) sheriffs and chiefs of police responded to a survey developed by OSA.
Survey Results Concerning Adults
The survey revealed that for adults, public intoxication does not involve large numbers, but is widespread in both rural and urban areas. There were approximately 5,283 cases, of which 2,436 (46%) were repeat offenders. York, Cumberland, Kennebec, Somerset, Androscoggin, and Penobscot counties accounted for 80% of these reported incidents. Except for Androscoggin, they also accounted for the highest number of repeat offenders.
The survey revealed that the current service system cannot meet the needs of these people. Current treatment resources for publicly intoxicated adults include detoxification services, emergency shelter, and extended shelter. State funded detoxification programs/shelters are available in only Cumberland and Penobscot counties. Extended shelter is available only in Androscoggin, Cumberland, and York counties. There are 85 beds statewide for people who are indigent. The survey revealed that of the publicly intoxicated adults picked up by police over the course of a year, approximately 238 were transported to shelters or detoxification programs. Another 742 were transported to their homes and the rest were transported to hospitals, police stations, or elsewhere. While an additional 89 detoxification beds are available in Maine, they generally are available to clients who have a source of reimbursement (usually Medicaid, sometimes insurance)not to indigents.
Survey Results Concerning Adolescents
The survey indicated that approximately 1,833 juvenile offenses (of which 655 were repeat offenders) came to the attention of sheriffs and police due to public intoxication. Most were in Androscoggin, Cumberland and York counties. Approximately 64% of these cases were resolved by returning the juveniles to their parents or guardians. There are no shelters for intoxicated adolescents. In any event, adolescents require a different response than adults.
Involuntary Commitment Option
Prior to the late 1980s, there was an option in statute for the involuntary commitment of people whose substance abuse represented a danger to themselves. The statute was used infrequently, in part because the receiving facilitythe place to which to commit a personwas not defined. There have been several requests to reconsider this option. In 1991, model legislation was developed to create an involuntary commitment law for substance abusers who were a severe and imminent danger to themselves. Although the legislation had broad support, both in 1991 and again when it was reintroduced in 1994, it did not become law.
The Task Force believes that involuntary commitment is necessary for very small number of people to ensure that they receive needed substance abuse treatment. Narrowly crafted legislation is needed to allow the involuntary commitment of people who abuse alcohol or other drugs, who are a danger to themselves, and whose lives are at risk. The legislation also needs to protect the civil rights of substance abusers.
13. Involuntary Commitment. Enact legislation to allow the involuntary commitment of individuals in need of substance abuse services who are a danger to themselves and whose lives are at risk.
Why Do We Need Prevention?
Substance abuse is costly, harmful, and damaging to youth. Nationally, it is estimated that the direct monetary costs of alcohol and illicit drug use are approaching $200 billion and tobacco use is estimated to cost another $88 billion. As noted previously, the annual cost of substance abuse in Maine is estimated to be $1.2+ billion$916 for every man, woman, and child in Maine.35 This does not begin to account for the suffering and burden on those whose well-being is affected directly or indirectly by substance abuse.
Studies have shown that preventing problematic substance use can be an important component in helping reduce both the social and economic costs of substance abuse. Research suggests that for every dollar spent in preventing illicit drug use, there is a fifteen dollar savings in dealing with the consequences of drug use and addiction.
Risk Factors and Domains
With my father having left us when I was 7, and with most of my childhood blank, I can say that the biggest influence was that of being lost...What I learned I learned either from friends, the streets, my mother, other relatives (male), or occasional men in my mothers life. The end result of all that random education was that I was so screwed up I really didnt have any kind of grasp of what being a man was. Ive always wondered who I was, whether anything I thought or anything I held as values was me or a jumble of thoughts and emotions gained by osmosis from the environments and the people encountered from there to here. What part of me was me? Its been a deep hole to dig out from. At least though, Im starting to see a faint light...Ive got a long journey ahead. A young resident of a group home for men.
In the past, substance abuse prevention programs have focused primarily on children and youth. The issue of substance abuse prevention is complex and needs to be addressed on many fronts. Simply targeting children and youth for prevention programs will not adequately address the issue. Research has shown that effective prevention programming needs to target four domains: family, school, community, and individuals/peers.36 OSA has carefully analyzed the extent of risk factors for the use of alcohol, tobacco, and other drugs (ATOD) statewide37:
Healthy Conditions for Healthy Children and Youth
[Adults must help children] have a sense of power and purpose in their lives we must find ways to allow a kid to turn to the light. Michael Clifford, Director, Safe and Drug Free Schools, Portland38
Raising happy and healthy children and youth in Maine requires close collaboration among adults who create the conditions in which young people must live. Families, schools, communities and peers create a context in which children and youth thrive or fail on their way to maturity.
There are four requirements essential to the healthy development of children and youth:
Other conditions important to the healthy development of children and youth include:
Current legal and social conditions preclude meaningful youth participation in the legislative process. Unable to vote and lacking the resources to hire lobbyists, young people typically are passive recipients or targets of legislation. Leading prevention research recommends meaningful participation in community affairs as a strategy for increasing youth bonding to community values and raising self-esteem.39 Through schools and libraries, the means are now available for youth to be informed about legislation that affects them. Youth input on proposed legislation not only would offer legislators useful insights, but it also would help Maine youth develop citizenship skills.
Dropping out of school correlates with other negative outcomes including substance abuse and violence.40 Alternative schools and programs provide opportunities for students to complete school successfully and to break the cycles in their families and communities which engender substance abuse. Prevention interventions that focus on creating conditions for social bonding are beneficial to youths at the highest risk of drug abuse. Enhancing opportunities, skills, and rewards for positive social involvement increase the likelihood that these youths will become socially bonded to pro-social people and to pro-social courses of action.
Alternative schools and programs have demonstrated their effectiveness in providing opportunities for youth at-risk to break out of the cycle of failure and despair. A 1990 survey of Iowas alternative school graduates indicated that41:
An alternative school here in Maine has produced the following outcomes42:
Support for Communities
There are limited federal and state grants available for communities that want to develop substance abuse prevention programs. However, the Task Force finds that there is a need not just to maintain current levels of funding, but to expand opportunities for prevention education programs in traditional and alternative schools and in communities.
Along with additional grant funding for prevention programs, a revolving loan fund would be helpful, from which communities could borrow money at a low interest rate. Communities could use loans as start-up money for prevention initiatives. The amount of each loan could be capped and available on a first come, first served basis. As money is repaid, it would become available for other community programs. Communities would be expected to sustain programs on their own as they repaid their loans.
The Task Force believes one role of Maine State Government should be to continue to assist communities in their substance abuse related prevention efforts. At one time, responding to individual community requests for technical assistance, training, and community organizational issues was a function of OSAs Prevention Team. Due to several factors, including downsizing, current staffing does not allow for onsite consultation and technical assistance to all the communities that request such services. OSA should continue to be a leader in providing up to date, effective, and cutting edge information and technical assistance to Maine citizens and communities as they address substance abuse related prevention issues. OSA needs to redevelop a system of technical assistance to boost existing levels of community knowledge and experience and to help them plan and implement prevention efforts.
As evidenced by the turn out at the study circles throughout the state, there is great interest in addressing substance abuse related problems and issues. However, communities and individuals cannot do this alone. They need assistance in defining the nature of the problem in their particular community, effective strategies to deal with the issues, and appropriate methods of evaluating programs. A system of service delivery needs to be redeveloped to maintain and improve the quality of prevention programming to meet increasing demands within the state.
During October 1997, The Portland Newspapers ran a series of lead articles about alcoholism in Maine. Readers responded with many letters, calls, and requests for reprints. A coalition began to meet to plan a statewide response. Called Maine Communities Face Alcohol, the response provided an opportunity for communities to host one or more series of study circles, which were a group of people who met for a 4-week period to discuss the newspaper series. Each study circle had a trained facilitator whose job it was to keep the group on task and to make sure that meeting ideas were recorded. The goals of the study circles were to discuss the nature and extent of the problems within individual communities and then to develop action plans to address the problems.
There have been approximately 70 study circles. On October 4, 1998, there was a summit of people involved in the study groups to celebrate and develop next steps. The Task Force believes that the study circles have been an important and valuable community effort. They need modest continued financial support in order to continue and thrive.
Need for Inventory
At the same time, there needs to be an inventory of Maines prevention efforts and dollars. The Task Force believes that there is an interconnectedness of prevention across disciplines. For example, the elements of effectiveness for substance abuse prevention are the same as the elements for HIV prevention, violence prevention, crime prevention, and a host of other social problem and disease prevention. Several state agencies currently promote prevention activities. There is a need to: 1) identify the funding sources of all existing primary prevention efforts, including dollars allocated by public, non-profit, and private sources; 2) identify prevention efforts across all disciplines and all state agencies; and 3) determine how prevention programs can build networks, increase funding opportunities, and work together more effectively.
Nationally, there is an effort to develop standards to certify prevention specialists. This has occurred as the field of prevention has gained standing as a profession requiring specific skills, knowledge and abilities. The expansion of managed care demands that prevention program providers be qualified as a condition of reimbursement by insurance companies. The development of credentialing standards will enhance the credibility and professional stature of those working in the field of prevention.
Drinking by underage youth, and associated problems that arise as a result of that behavior, have not been addressed adequately on a unified, state level. Programs currently exist which could be implemented statewide in private and public universities, colleges and technical schools. A task force needs to be formed to assess existing programs and to recommend how to slow down the momentum of abusive drinking at the post-secondary level.
14. Youth Participation. Create opportunities for youth to participate in the development of legislation and policies that affect their lives.
15. Prevention Programs. Expand substance abuse prevention programs in traditional and alternative schools and communities statewide.
16. Revolving Loan Fund. Develop and maintain a revolving loan fund at OSA to assist communities with start up funds for substance abuse prevention.
17. Technical Assistance. Develop a system to ensure that technical assistance in program development, grant writing, and coalition building in relation to substance abuse issues is available to all Maine communities. See recommendation 3.
18. Study Circles. Develop funding partnerships with other public and private organizations to support the continuation of coalitions involved in efforts such as the study circles.
19. Public Awareness Campaign. Conduct a public information campaign to develop awareness of the devastating effects of alcohol and other drug abuse and to encourage individuals and communities to take action.
20. Inventory. Review the status and outcomes of primary prevention programs across Maine, how these programs are funded, and how they can collaborate to work more effectively and efficiently. See recommendation 3.
21. Prevention Specialists. Study the issues related to certification standards for prevention specialists in Maine. See recommendation 3.
22. Drinking by Post-Secondary Students. Establish a Task Force comprised of representatives from Maines public and private post-secondary schools with the mission to address underage and abusive drinking by students.
Services for Juvenile Offenders
Need for Substance Abuse Treatment
Many of Maine's juvenile offenders are substance abusers and need substance abuse treatment. The current treatment capacity cannot provide services to all of the juvenile offenders in need of treatment. In addition to the availability of a continuum of services and monitoring, substance abuse treatment providers with the clinical skills to work effectively with the juvenile offender substance abusing population are not generally available and easily accessible in the four Juvenile Corrections Regions of Maine.43
During the current fiscal year (beginning July 1, 1998), OSA and the Department of Corrections have committed to screening 2,000 juvenile offenders who remain in the community and 220 who are remanded to the Maine Youth Center. Based on previous screening results, 70%, or 1,550 of these adolescents, will need substance abuse treatment. In 1997, treatment providers served 962 adolescents in total. A third of these are already juvenile offenders. Even assuming that the treatment system's capacity is under used, an annual expansion of 460% in the number of adolescents needing substance abuse treatment is impossible to absorb with current resources.
Although the existing substance abuse treatment resources provided by OSA and the Department of Corrections at both the community and institutional levels are impressive and among the most innovative in the nation, these resources are not adequate to reduce substance abuse and its related criminal behavior by juvenile offenders.
Regional Treatment Networks
Fifty-four agencies are licensed to provide adolescent substance abuse treatment in Maine. Most of these agencies also serve adults. Existing capacity for all age groups at any given time, however, is used fully or almost fully. In response to the unmet need for treatment, OSA, the Department of Corrections, and community-based treatment providers have formed four regional networks to increase treatment capacity. The elements of these networks are as follows:
Elements of Regional Treatment Networks
1. Standardized substance abuse screening for treatment needs for all juveniles entering the system.
2. Centralized data collection and analysis.
3. A differentiated evaluation and treatment system based on three factors (treatment need, criminal risk, and responsiveness to treatment).
4. Improved communication between treatment providers and Department of Corrections juvenile caseworkers.
5. A cross-training program to establish research-based best practices.
6. A collaborative model for addressing identified groups in the treatment system.
Most treatment providers are part of the networks and these providers serve most of the offenders receiving community-based treatment. The networks provide treatment for community based juvenile offenders and continuing care for juvenile offenders released from the Maine Youth Center. During 1997, an average of 31% of network caseloads consisted of juvenile offenders. They report that they cannot increase capacity for juvenile offenders unless they significantly decrease capacity for other adolescents or adults.
There are three major issues of concern relating to the networks. First, there is inadequate treatment capacity to meet the substance abuse treatment needs of juvenile offenders. Second, within the networks there is no standardized evaluation and referral component to insure client matching with treatment services and to facilitate client access to treatment. Third, there are inadequate long-term residential therapeutic community resources (only one, in Hollis).
The Task Force identified a national model that has been bridging the gap between substance abuse and corrections for over twenty-five years (Treatment Alternative to Street Crime). This model provides for uniform evaluation of all juveniles identified by the screening system; client matching with the proper network treatment provider; and facilitation of access to treatment for the youth and family. This or other models could be modified to meet Maine's needs and could be an integral component in the existing treatment networks.
Maine Youth Center
For the youth at the Maine Youth Center, OSA is funding a differentiated substance abuse treatment program, designed as indicated on page 41. There are four major issues of concern related to this treatment program.
First, chronic substance abusers (about 20% of the Youth Centers population) are not provided the intensity of treatment necessary to address their substance abuse. Substance abuse is not considered a primary treatment issue. Second, there is inadequate transitional housing available for youth leaving the Youth Center designed to treat substance abuse as a primary issue. Third, existing transitional housing has inadequate substance abuse treatment services and often is not linked to the comprehensive network of providers. Fourth, additional treatment capacity will be needed when the northern Maine Youth Center opens.
Differentiated Substance Abuse Treatment Program
1. Screens for substance abuse in all youth admitted to the Youth Center.
2. Provides a full evaluation for those identified by the screening.
3. Assessments consider three factors critical to treatment placement (treatment need, criminal risk, and responsiveness to treatment).
4. Has developed a differentiated model that includes education and awareness programs, a brief intervention program, and an intensive treatment program for chronic users.
5. Is highly motivated and cognitive-behavioral in approach.
6. Provides for transition into community-based treatment networks.
23. Differentiated Program. Complete OSAs development of and fully implement the comprehensive differentiated program of evaluation and treatment for juvenile offenders who are substance abusers. Ensure that the program is carried out through the regional treatment networks and the southern and northern Maine Youth Centers.
24. Funding for the Networks. Provide stable, long term funding through OSA to the regional networks to increase differentiated treatment capacity to meet the unmet treatment needs of juvenile offenders who are substance abusers and living in the community. Cover the services of providers who are willing to participate in formal network operations and who specialize in the diagnosis and differential clinical treatment of juvenile offenders who abuse substances. Also use funding for:
25. Funding for the Institutions. Provide stable, long term funding through OSA to implement a differentiated therapeutic intervention program at the southern and northern Maine Youth Centers. Ensure that the program has differential content, duration, and intensity for addressing substance abuse clinically as a primary condition related to criminal behavior.
26. Juvenile Drug Court. Implement Juvenile Drug Court projects in each of the four Juvenile Corrections Regions through a collaborative process involving the Judicial Department, Department of Attorney General, District Attorneys, Department of Corrections, and OSA. Use the treatment capabilities of the regional treatment networks.
Services for Adult Offenders
Inadequate Substance Abuse Intervention
Its troubling, if not alarming, that in a state where 79% of the inmates have some connection to alcohol abuse, we dont offer them any treatment. Michael Cantara, York County District Attorney44
Maines adult prison population is not receiving adequate substance abuse intervention and treatment. Maines adult corrections system is in need of a comprehensive, differentiated substance abuse treatment program in combination with defined regional networks of providers having a specialty in working with the substance abusing adult offender. Maine's criminal justice system does not have a comprehensive strategy for ensuring that substance abusing or addicted offenders are compelled to undergo programs of treatment during their arrest and incarceration time. In addition, community-based substance abuse treatment is needed for adult offenders on probation.
Comprehensive Services Needed
The Task Force finds that there is a need for comprehensive substance abuse services for adult offenders who are substance abusers or addicts. At a minimum, these components are required:
Maine has only one Drug Court, which operates in Cumberland County under a federal grant. Known as Project Exodus, the Drug Court serves a corrections function, since program participants either are on probation or would be on probation if they were not legally participating in treatment pursuant to post-conviction bail.
27. Comprehensive Services. Provide stable, long term funding through OSA for a seamless, comprehensive adult offender substance abuse service which includes:
28. Assessment. Through collaboration involving OSA, the Maine Sheriffs Association, and the Department of Corrections, assess the need for substance abuse treatment for offenders serving sentences in county jails. Pay special attention to treatment for incarcerated OUI offenders. If necessary, develop best practices models for substance abuse treatment in county jails.
29. Drug Court. Continue the Drug Court pilot project for adult offenders in Cumberland County and expand it to three additional sites in Maine through a collaborative process involving the Judicial Department, Department of Attorney General, District Attorneys, Department of Corrections, and OSA. Use the treatment capabilities of the regional networks.
Operating Under the Influence
Until I got the OUI, I was able to keep up the appearance of being a successful attorney. After my arrest, I realized I was no different from the bum on the street with the same disease. John McElwee, recovering alcoholic and former Aroostook County District Attorney45
According to the Maine Secretary of State and the Maine State Police, operating under the influence is a significant problem. In 1996, 37.5% of all traffic fatalities in Maine involved alcohol. Maine drivers with a blood alcohol content of 0.15 or more are 200 times more likely to be involved in a fatal crash than the average non-drinking driver. Operating under the influence (OUI) of alcohol is most serious among drivers between 15 and 44 years of age. The use of alcohol by underage people while operating vehicles remains a problem within Maine. OUI minor administrative suspensions increased by 55.6% from 1995 to 1997 (from 531 to 826). It should be noted that the law changed from .02 blood alcohol content to zero tolerance and that there has been stricter enforcement with the new law.
The chronic drinker and driver and the driver who continues to drive following license suspension, create a serious threat to highway safety in Maine. Hard-core drunk drivers who are also repeat offenders, constitute a very small number of drivers, but account for a disproportionately large share of drunk driving problems. According to Maines Secretary of State, the severity of drunkenness and numbers of repeat offending drunken drivers appears to be increasing.
According to the U.S. Department of Justice, the use of illegal drugs is an increasing problem throughout Maine:
30. OUI Task Force. Create a Law Enforcement OUI Task Force, comprised of representatives of the Secretary of State, State Police, and county and local law enforcement agencies, to:
31. Young Driver Legislation. Require the Secretary of State and Bureau of Highway Safety to report to the legislative committees having jurisdiction over transportation and criminal justice matters by January 15 of each year on results and recommendations relating to the effectiveness of the Young Driver Legislation passed in 1998.
32. DEEP Legislation. Develop legislation to allow more flexibility in the design of the Driver Education and Evaluation Program, so that changes can be made when indicated by research, best practice, and evaluation.
33. Training. Make training in the use of the intoxilyzer machine, Horizontal Gaze Nystagmus, and advanced OUI recognition techniques a mandatory requirement of Basic Police Training.
34. Drug Enforcement Funding. Restore funding to the Maine Drug Enforcement Agency to the 1992 level of $1.72 million, to support the Agencys efforts on behalf of local communities.
35. Drug Flow Control. Direct the Maine State Police and Maine Drug Enforcement Agency to develop and execute a Joint Plan for Illicit Drug Flow Control, designed to provide Maine Law Enforcement Officers with training to enhance their skills in identifying and prosecuting offenders.
36. Training. Expand training at the Maine Criminal Justice Academy to focus on the recognition of drug trafficking, drug recognition, and expanding threats to law enforcement officers from the hazards of clandestine drug laboratories. Provide grant funds for local communities, so they can expand Drug Recognition Training for local law enforcement officers.
37. Tracking and Information. Enhance the capability of the Maine State Police to track and identify suspected and convicted drug offenders and to provide pertinent data to all local and county law enforcement agencies.
Private Sector Responses to Substance Abuse
One fourth of Maine adults who need substance abuse treatment do not have health insurance. Among those who needed treatment, 60.6% had private insurance coverage (though it is not known if substance abuse services are covered) and 12.3% had government-funded insurance (Medicare, Medicaid, and Veterans Administration benefits).46
Health insurance policies typically provide less coverage and benefits for substance abuse and mental illness than for physical conditions and illnesses. Recently, some states and the federal government have begun to require that mental health and/or substance abuse treatment have "parity" with treatment for other medical conditions. "Parity" means that mental health and/or substance abuse treatment must be covered by insurance companies in the same manner as other medical care.
Maine is one of twelve states that has enacted a "parity" law for mental illness. The law requires that group insurance coverage for groups of twenty or more persons provide benefits for biologically-based mental illnesses, like schizophrenia and major depressive disorder, under the same terms and conditions as physical illness. "Parity" is also necessary for substance abuse treatment so that health insurance companies provide substance abuse benefits in the same way that benefits are provided for physical conditions and illnesses. Currently, five states have "parity" laws for substance abuse treatment: Arizona, Maryland, Minnesota, North Carolina (for state employees only) and Vermont. The Task Force believes that Maine should be the sixth state to enact such a law.
A recent study conducted for the federal Substance Abuse and Mental Health Services Administration on the costs and effects of providing parity for mental health and/or substance abuse estimated that the average insurance premium increase for substance abuse parity only would be 0.2%. The premium increase for full parity for both mental health and substance abuse was estimated to be 3.6% on average.47
While current Maine law does not require "parity" for substance abuse treatment, the law does require a minimum level of benefits for alcoholism and drug dependency treatment to be provided in traditional fee-for-service group health insurance policies covering twenty-one or more persons. However, there is a deficiency in the law because it does not apply to the managed care plans of health maintenance organizations (HMOs).
Maine, like the rest of New England and the nation, has experienced a shift in health insurance coverage from traditional fee-for-service plans to managed care. More and more people in Maine are receiving their health insurance through HMOs. Statistics show that at the end of 1997, 21.25% of Maine's insured population was enrolled in managed care plans. Based on the higher percentage of HMO penetration in the other New England states, that number can be expected to increase to as much as 45% in the future.48
As more Maine people have become enrolled in managed care, the frustrations of both enrollees and health care providers have grown. Substance abuse service providers are often frustrated with the utilization review standards used by managed care plans and their application by utilization review case managers who frequently are not knowledgeable about substance abuse treatment issues. There is a need to revise these standards to reflect criteria that increase the chance of positive treatment outcomes and to reflect the "medical necessity" guidelines adopted by the American Society for Addiction Medicine.
Research has shown that length of stay in treatment is directly related to a positive treatment outcome49, but most managed care reviewers rarely approve treatment lengths supported by the research data. Those who review and approve substance abuse treatment for various managed care plans need training in substance abuse treatment.
Employee Assistance Programs
In 1997, there were 28 Maine employers with Employee Assistance Programs (EAPs) approved by OSA.50 The Task Force found that the quality of EAPs in Maine varies widely and that more needs to be done to encourage and support the development of EAPs that provide a variety of core technologies, rather than just counseling. The core technologies include consultation, training and assistance for managers, supervisors, and union stewards; confidential and timely assessment services for employees with personal concerns that may affect job performance; use of short-term intervention and counseling; referral services for treatment; benefits consultation to the employer with regard to mental health and substance addiction coverage; and identification of the effects of EAP services on the employer.
There have been instances where individuals and counseling agencies have held themselves out as EAPs without any EAP certification and without practicing any of the core technologies. Licensing is one method to ensure that there are quality EAPs throughout Maine. Currently, North Carolina and Tennessee have enacted laws to license EAP professionals, and legislation is under consideration in five other states. The license requirement is aimed at ensuring more consistent quality among EAPs.
The Task Force is concerned that the current Maine law and rules relating to EAPs and work place drug testing are too cumbersome and, as a result, may discourage the development of these policies and programs by some employers.
According to the state Bureau of Labor Standards, 122 employers out of a total of 147 with approved substance abuse testing policies conducted drug tests in 1997.51 A total of 13,097 tests were conducted, including 12,616 on job applicants (with 375 confirmed positive tests); 7 for probable cause (one positive test); and 474 employee random or arbitrary tests (with 16 positive tests). Of the 122 employers, 35 included alcohol as part of their test screening panel; 3,111 tests were screened for alcohol (with 8 were positive tests7 job applicants and 1 random.)
Many people believe that it is necessary and appropriate to test employees for alcohol as part of drug testing as a means of identifying employees in need of substance abuse services. Others are concerned about the legal and privacy issues related to testing for a legal substance, especially if employers are conducting random testing of employees with no other indication that job performance is impaired. The Task Force believes that more study is required.
38. Insurance Laws. Amend Maines health insurance laws to require parity benefits for substance abuse treatment under the same terms and conditions as benefits for physical conditions and illnesses. If the Legislature does not require parity benefits for substance abuse treatment, amend the current law mandating coverage for substance abuse treatment to require coverage in HMO plans and to require coverage in all individual and group insurance policies.
39. Utilization Review. Revise utilization review standards, based on the medical necessity guidelines adopted by the American Society for Addiction Medicine. Require training in substance abuse treatment for those who review and approve managed care plans.
40. Employee Assistance Programs. Improve the quality of EAPs by encouraging the development of programs that use the core technologies and by initiating state licensing for qualified and certified EAP professionals.
41. Streamlining. Encourage employer participation, by streamlining the statutory and regulatory provisions governing EAPs and drug testing policies. Amend 26 MRSA, chapter 7, subchapter III-A (Substance Abuse Testing) to increase its effectiveness so that more employers will develop fair, equitable, and responsible drug testing and EAP programs.
42. Screening for Alcohol. Examine the issues related to drug testing by employers, including screening for alcohol. See recommendation 3.