Co-occurring psychiatric and substance use disorders: What

1
Co-occurring psychiatric and substance use
disorders Whats the fuss?

• Richard A. Rawson Ph.D.
• UCLA Integrated Substance Abuse Programs
• San Diego, California
• October 2004

2
What are we talking about?
Co-Occurring Disorders
Dual Diagnosis
Dual Diagnosis
Depressed
Co-Occurring
Depressed
Mentally Ill
Mentally Ill
Anxious
Addict
DSM - IV
DSM - IV
Co Morbid
Co Morbid
Anxious
Addict
Traumatized
ICD - 10
ICD - 10
Traumatized
3
An oversimplified picture of the behavioral
healthcare service systems in the US

• Mental Health Services
• Leadership-psychiatrists
• Staffing-psychologists, social workers, nurses,
  MFTs
• Role of medications-Substantial
• Impact of behavioral therapies research-Substantia
  l
• Knowledge of substance use disorders and their
  treatment Minimal
• Role of self-help-Minimal

• Substance Abuse Services
• Leadership-A mixture of recovering
  addict/alcoholics, business people, professionals
• Staffing-paraprofessionals, with increasing role
  of professionals
• Role of medications and behavior
  therapies-Minimal
• Knowledge of psychiatric disorders-Minimal
• Role of self-help-Substantial

4
The prototype patients for the current service
delivery systems

• The mental health service system
• The uncomplicated schizophrenic
• The simple affective disordered individual
• The pure bi-polar patient

• The substance abuse service system
• The plain vanilla alcoholic
• The addict who uses only heroin
• The stimulant dependent individual w/o other
  psych diagnoses

5
Whats the Problem?

• Estimates of psychiatric co-morbidity among
  clinical populations in substance abuse treatment
  settings range from 20-80
• Estimates of substance use co-morbidity among
  clinical populations in mental health treatment
  settings range from 10-35
• Differences in incidence due to nature of
  population served (e.g. homeless vs. middle
  class), sophistication of psychiatric diagnostic
  methods used (psychiatrist or DSM checklist) and
  severity of diagnoses included (major depression
  vs. dysthymia).

6
Why are substance use disorders treated in
separate systems from other psychiatric disorders?

• How has the split occurred between substance use
  disorders and other psychiatric disorders?
• Before 1970 in the US, research and treatment for
  alcoholism and drug abuse were administered out
  of the National Institute of Mental Health.
• A number of factors prompted the separation of
  alcoholism/drug abuse into their own specialty
  areas, distinct and separate from general
  psychiatry.

7
Why are substance use disorders treated in
separate systems from other psychiatric disorders?

• A pervasive perception existed among the public
  and policymakers that the professional fields of
  psychiatry, psychology and medicine were
  extraordinarily unsuccessful in providing
  treatment to addicts and alcoholics and, that
  there was a tendency within much of organized
  psychiatry (and psychology) to avoid alcoholics
  and addicts as inherently untreatable
  individuals, incapable of insight.

8
Why are substance use disorders treated in
separate systems from other psychiatric disorders?

• Two major factors prompted the establishment of
  new institutes in early 1970s
• Sen. Harold Hughes promotion of treatment for
  employees with alcohol problems in the workplace
  was a major influence in the field of alcoholism.
  Health insurance began to include alcoholism
  treatment benefits, EAPs began and NIAAA was
  created.
• Huge increases in drug experimentation in late
  1960s and concerns about returning heroin
  addicted Vietnam Veterans, prompted public
  concern about drug abuse and prompted the
  creation of NIDA.

9
Why are substance use disorders treated in
separate systems from other psychiatric disorders?

• The result was
• National Institute of Mental Health (NIMH)
  responsible for research on and treatment of
  psychiatric disorders.
• National Institute on Alcoholism and Alcohol
  Abuse (NIAAA) responsible for research on and
  treatment for alcoholism and related issues.
• National Institute on Drug Abuse (NIDA)
  responsible for research on and treatment of
  illicit drug problems (and later nicotine).
• Each institute had its own experts, treatment
  systems, funding streams and each viewed the
  other as parochial, misinformed and naïve.
• Cooperation was uncommon.

10
Why are substance use disorders treated in
separate systems from other psychiatric disorders?

• Since early 1970s-
• Within treatment settings, alcoholism and drug
  abuse disorders are treated within the same
  treatment system hence, there are now
  essentially two service delivery systems
• 1. Alcoholism and Other Drug (AOD) system
• 2. Mental health system
• Psychiatry has formally incorporated the study
  and treatment of substance use disorders as part
  of psychiatry.

11
DSM and ICD The Bibles
12
Studies on Co-morbidity

• Most widely cited studies
• Epidemiologic Catchment Area (ECA) study
• National Comorbidity Study

13
ECA Study

• Epidemiologic Catchment Area (ECA) Study
• 20,291 interviews at 5 sites
• Data Collected 1980 1984
• DSM III Diagnoses

Regier, DA, et al. (1990). Comorbidity of Mental
Disorders with Alcohol and other Drug Abuse
Results From the Epidemiologic Catchment Area
(ECA) Study, JAMA, 264, 2511-2518
14
ECA DSM-III Diagnoses (rates per 100 people)
1 Month Lifetime
Any Alcohol, Drug or Mental Health Disorder 15.7 32.7
Any Mental 13.0 22.5
Alcohol Dependence 1.7 7.9
Drug Dependence 0.8 3.5
Regier, et al. (1990)
15
Lifetime Prevalence and Odds Ratios ECA Study
16
NC Study

• National Comorbidity Study
• 8,098 interviews across the country
• Data collected 1990 1992
• DSM-III-R Diagnoses

Merikangas, KR, et al. (1998). Comorbidity of
substance use disorders with mood and anxiety
disorders Results o the international consortium
in psychiatric epidemiology. Addictive Behavior,
23, 893-907.
17
NCS DSM-III Diagnoses

Merikangas, KR, et al. (1998)
18
NCS DSM-III Diagnoses
OR
Number of mental disorders
Merikangas, KR, et al. (1998)
19
Summary

• There is a problem
• We have documented it for a long time
• We need more information to figure out
• The current state of affairs
• What we do about it

20
Treatment of Co-occurring Disorders

• Treatment System Paradigms
• Independent, disconnected
• Sequential, disconnected
• Parallel, connected
• Integrated

21
Treatment of Co-occurring Disorders

• Independent, disconnected model
• Result of very different and somewhat
  antagonistic systems
• Contributed to by different funding streams
• Fragmented, inappropriate and ineffective care

22
Treatment of Co-occurring Disorders

• Sequential Model
• Treat SA Disorder, then MH disorder
• Treat MH Disorder, then SA disorder
• Urgency of needs often makes this approach
  inadequate
• Disorders are not completely independent
• Diagnoses are often unclear and complex

23
Treatment of Co-occurring Disorders

• Parallel Model
• Treat SA disorder in SA system, while
  concurrently treating MH disorder in MH system.
  Connect treatments with ongoing communication
• Easier said than done
• Languages, cultures, training differences between
  systems
• Compliance problems with patients

24
Treatment of Co-occurring Disorders

• Integrated Model
• Model with best conceptual rationale
• Treatment coordinated best
• Challenges
• Funding streams
• Staff integration
• Threatens existing system
• Short term cost increases (better long term cost
  outcomes).

25
Elements of an integrated model

• Staffing
• A true team approach including Psychiatrist
  (trained in addiction medicine/psychiatry)
  Nursing support Psychologist Social worker
  Marriage and family therapist Counselor with
  familiarity with self-help programs. (Others
  possible, vocational, recreational educational
  specialists).

26
Elements of an Integrated Model

• Preliminary assessment of mental health and
  substance use urgent conditions
• Suicidality
• Risk to self or others
• Withdrawal potential
• Medical risks associated with alcohol/drug use

27
Elements of an integrated model

• Diagnostic process that produces provisional
  diagnosis of psychiatric and substance use
  disorders using
• Urine and breath alcohol tests
• Review of signs and symptoms (psychiatric and
  substance use)
• Personal history timeline of symptom emergence
  (what started when)
• Family history of psychiatric/substance use
  disorders
• Psychiatric/substance use treatment history

28
Elements of an integrated model

• Initial treatment plan that includes (min- one
  day-max ten days)
• Choice of a treatment setting appropriate to
  initially stabilize medical conditions,
  psychiatric symptom and drug/alcohol withdrawal
  symptoms
• Initiation of medications to control urgent
  psychiatric symptoms (psychotic, severe anxiety,
  etc)
• Implementation of medication protocol appropriate
  for treating withdrawal syndrome(s)
• Ongoing assessment and monitoring for safety,
  stabilization and withdrawal

29
Elements of an integrated model

• Early stage treatment plan that includes ( min
  day 2-max day 14)
• Selection of treatment setting/housing with
  adequate supervision
• Completion of withdrawal medication
• Review of psychiatric medications
• Completion of assessment in all domains
  (psychology, family, educational, legal,
  vocational, recreational)
• Initiation of individual therapy and counseling
  (extensive use of motivational strategies and
  other techniques to reduce attrition)
• Introduction to behavioral skills group and
  educational groups
• Introduction to self help programs
• Urine testing and breath alcohol testing

30
Elements of an integrated model

• Intermediate treatment plan that includes (up to
  six weeks)
• Housing plan that addresses psychiatric and
  substance use needs
• Plan of ongoing medication for psychiatric and
  substance use treatment with strategies to
  enhance compliance
• Plan of individual and group therapies and
  psychoeducation with attention to both
  psychiatric and substance use needs
• Skills training for successful community
  participation and relapse prevention
• Family involvement in treatment processes
• Self-help program participation
• Process of monitoring treatment participation
  (attendance and goal attainment
• Urine and breath alcohol testing

31
Elements of an integrated model

• Extended treatment plan that includes (up to 6
  months)
• Housing plan
• Ongoing medication for psych and substance use
  treatment
• Plan of individual and group therapies and
  psychoeducation with attention to both
  psychiatric and substance use needs
• Ongoing participation in relapse prevention
  groups and appropriate behavioral skills groups
  and family involvement
• Initiation of new skill groups (e.g. education,
  vocational, recreational skills)
• Self help involvement and ongoing testing
• Monitoring attendance and goal attainment

32
Elements of an integrated model

• Ongoing plan of visits for review of
• Medication needs
• Individual therapies
• Support groups for psych and substance use
  conditions
• Self help involvement
• Instructions to family to recognize relapse to
  psych and substance use
• In short, a chronic care model is used to reduce
  relapse and if/when relapse (psychiatric or
  substance use) occurs, treatment intensity can be
  intensified.

33
Building integrated models

• Challenges of building an integrated model
• Cost of staffing
• Training of staff
• Resistance from existing system
• Providing comprehensive, integrated care with
  efficient protocols
• The most likely strategy for moving toward this
  system is in increments
• Psychiatrist attend at AOD centers
• Relapse prevention groups introduced to mental
  health centers
• Staff exchanges attending case conferences
  joint trainings
• Gradual shifting of funding

34
Treatment of Co-occurring Disorders Areas of
Promise

• Integration of SA treatment and treatment of
  affective disorders
• Depression
• Use of tricyclics and SSRIs produces excellent
  treatment response in SA patients with
  depression. Can be used with SA populations with
  minimal controversy.
• Good evidence of effectiveness with methadone
  patients, women with alcoholism and depression.

35
Treatment of Co-occurring Disorders Areas of
Promise

• Bipolar Disorder and SA Disorders
• Medications for BPD often essential to stabilize
  patients to allow SU treatment to be effective
• Challenges often occur in diagnosis
• Cocaine/methamphetamine use disorders often mimic
  BPD, medications for these disorders not yet with
  demonstrated efficacy and do not respond to
  medications for bipolar disorders

36
Treatment of Co-occurring Disorders Areas of
Promise

• Schizophrenia and SU Disorders
• Differential diagnosis with cocaine and
  methamphetamine psychosis can be difficult.
• Medication treatments frequently essential.
• Knowledge about medication side effects and the
  possibility that these side effects can trigger
  drug use is important.

37
Treatment of Co-occurring Disorders Areas of
Promise

• Understanding of neurobiological mechanisms and
  genetic foundations may provide key knowledge for
  both sets of disorders.
• Key issues in improving treatment effectiveness
• Training, training, training
• Increased contact between professionals from both
  systems
• Flexibility of funding streams
• Training, training, training

38
Treatment of Co-occurring Disorders Areas of
Controversy

• Should the treatment of SUDs be fully
  incorporated within the mental health
  system(e.g.Integrated Behavioral Health Agency)?
• If yes, will treatment protocols unique to
  substance abuse system be discarded?
• Will funding for SUDs be reduced?

39
Co-Occurring Disorders Center for Excellence
(COCE)

• Subcontractors Kick-Off Meeting
  
• February 13, 2004The CDM Group, Inc.
• Chevy Chase, Maryland
• Rose M. Urban, M.S.W., J.D., LCSW COCE
  Executive Project Director
  The CDM Group, Inc.

40
Co-Occurring Disorders -Advances in the Field

• Better definitions
• Treatment needs better understood
• Improved screening and assessment
• Improved systems and processes
• Evidence-based practices exist

41
Key COD Products and Technology Transfer
Initiatives

• CSATs National Treatment Plan, Changing the
  Conversation
• CSATs Substance Abuse Treatment for Persons with
  Co-Occurring Disorders TIP
• CMHSs Co-Occurring Disorders Integrated Dual
  Disorders Treatment Implementation Resource Kit
• SAMHSAs Report to Congress on the Prevention and
  Treatment of Co-Occurring Disorders and Mental
  Disorders
• SAMHSAs Strategies for Developing Treatment
  Programs for People with Co-Occurring Substance
  Abuse and Mental Disorders

42
Contributors to Knowledge Base

• Federal agencies
• Grantees (Including COSIG grantees)
• States
• Service providers
• Consumers
• Researchers
• Addiction Technology Transfer Centers (ATTCs)
• Centers for the Application of Prevention
  Technologies (CAPTs)
• National Mental Health Information Center (NMHIC)

43
SAMHSAS VISION FOR COD

• PROVIDE LEADERSHIP AND DIRECTION IN
• DEFINING AND TRANSFERRING THE LATEST
  EVIDENCE-BASED PRACTICES/ SYSTEMS, SERVICES,
  INFRASTRUCTURE
• TO ALL LEVELS OF THE COD SERVICE SYSTEM

44
OPERATIONALIZING THE VISIONSAMHSAS
CO-OCCURRING CENTER FOR EXCELLENCE (COCE)
45
COCE APPROACH

• COCE will
• Advance a unified substance abuse and mental
  health approach
• Address all levels of client disorder severity
  and
• Adapt solutions to the unique needs of each
  service recipient

46
What is the COCE?
CRITICAL INPUTS
COCE Analysis Integration Priorities
Mental Health, Substance Abuse, COD Research
SAMHSAs Mission Priorities
State/Local Experience Innovation
Federal Policy
COCE GOALS
WORK OF THE COCE
Consumer Needs And Perspectives
LEADERSHIP IN CLARIFYING Definitions Nosology Meas
urement Evidence Consensus-Based
Practices Unified Approach
State Policy
ACTIVITIES Training Technical Assistance Training
of Trainers Institutes Coordination with other
SAMHSA Centers
THE COD SERVICE SYSTEM
AGENDA SETTING Professional Education Practice
Improvement Research Policy Workforce Development
PRODUCTS Templates for Product Development Technic
al Reports Articles Literature Reviews Models of
Change Technology Transfer Principles and
Practices
RESOURCE TO SAMHSA Logistical/Operational Executio
n/Implementation Informational
47
Who is the COCE?
VISION LEADERSHIP
SAMHSA
CMHS
CSAT
CSAP
Insures accuracy and integrity of scientific and
clinical content
Plans and oversees COCE activities
Advises SAMHSA and COCE on planning and conduct
of COCE activities
CONTENT
IMPLEMENTATION
PLANNING, MANAGEMENT, ACCOUNTABILITY
EXPERT LEADERSHIP GROUP
SENIOR MANAGEMENT TEAM
STEERING COUNCIL
SENIOR FELLOWS e.g., Richard Ries, MD
FELLOWS
CONSULTANT AND SUBCONTRACTOR POOL
Advises and assists Expert Leaders in developing
overall COCE content
Conducts technical assistance, cross-training,
and assists in development of materials
Provides expert input on specific COD content
areas
48
The COCE Team

• Awarded as a 5-year contract to The CDM Group,
  Inc. (CDM) on September 29, 2003 in association
  with
• The National Development Research Institutes
  (NDRI)
• The Center for Behavioral Health, Justice
  Public Policy (CBHJPP) at The University of
  Maryland
• The National Opinion Research Center (NORC) at
  the University of Chicago

49
The COCE Senior Team

• Directed by CDM
• Rose M. Urban, J.D., M.S.W., Executive Project
  Director
• Jill G. Hensley, M.A., Project Director

50
The COCE Senior Team

• CDM
• Michael Klitzner, Ph.D. Senior Social Scientist
• William Reidy, Jr., M.S.W. TA/CT Specialist
• Sheldon Weinberg, Ph.D. TA/CT Specialist
• Robert OBrien, Ph.D. Evaluation Adviser

51
The COCE Senior Team

• NDRI
• Stan Sacks, Ph.D. Expert Adviser on
  Co-Occurring Disorders
• JoAnn Sacks, Ph.D. - Director of State Technical
  Assistance (TA)
• John Challis, B.A., B.S.W. Project Director
• CBHJPP, University of Maryland
• Fred Osher, M.D. Expert Medical Adviser on
  Co-Occurring Disorders
• NORC
• Sam Schildhaus, Ph.D. Director of the PPG Pilot
  Evaluation

52
Other COCE Subcontractors

• 52 other staff from key subcontractors
• Policy Research Associates, Inc. (PRA)
• National Addiction Technology Transfer Center
• Regional ATTCs (Northeast/IRETA, Northwest
  Frontier, and Pacific Southwest)
• National Center on Family Homelessness
• The George Washington University
• New England Research Institutes, Inc.
• Foundations Associates
• Potential Collaboration with
• National Association of State Mental Health
  Program Directors (NASMHPD)
• National Association of State Alcohol and Drug
  Abuse Directors (NASADAD)

53
The COCE Consultants

• 227 expert consultants with a range of expertise
  across disciplines, populations, and service
  settings, including
• Thomas Backer, Ph.D.
• Carlo DiClemente, Ph.D.
• Alan Marlatt, Ph.D.
• Tom McLellan, Ph.D.
• Richard K. Ries, M.D.
• Steven Schinke, Ph.D.
• Douglas M. Ziedonis, M.D.

54
Providing Guidance The COCE National Steering
Council

• National Association of State Mental Health
  Program Directors (NASMHPD) Andrew Hyman, J.D.
• National Association of State Alcohol and Drug
  Abuse Directors (NASADAD)
• State Associations of Addiction Services (SAAS)
• National Council of Community Behavioral Health
  (NCCBH) Jennifer Michaels, M.D.
• American Association of Addiction Psychiatry
  (AAAP) Richard Rosenthal, M.D.
• National Association of Alcohol and Drug Abuse
  Counselors (NAADAC)
• National Mental Health Association (NMHA)
• Research Community Richard Ries, M.D.
• Primary Care Community
• Consumer/Survivor/Recovery Community Michael
  Cartwright
• Homelessness Community Ellen Bassuk, M.D.
• Criminal Justice/Drug Court Community Joe
  Coccoza, Ph.D.
• Tribal/Rural Community Raymond Daw
• Trauma/Violence Prevention Community Lisa
  Najavits, Ph.D.

55
THE COCE AS A CENTER FOR EXCELLENCE

• COCE WILL
• Address the wide range of clinical,
  administrative and systems issues that impact the
  quality and accessibility of care for persons
  with COD
• Address the needs of a broad range of individuals
  and organizations including practitioners,
  researchers and scholars, policy makers,
  administrators, affected populations, and
  concerned citizens
• Have a multidisciplinary staff who have a common
  interest in COD and science-to-service
• Emphasize knowledge synthesis, research-to-practic
  e, and dissemination
• Model its message through the application of
  management, communications, and dissemination
  science in its own work
• Be responsive to the fields changing needs and
  priorities
• Take a long term view of system change and system
  improvement

56
THE COCE AS A CENTER FOR EXCELLENCE

• COCE IS COMMITTED TO
• Advancing a unified substance abuse and mental
  health approach
• Addressing all levels of client disorder
  severity and
• Adapting solutions to the unique needs of each
  service recipient
• THE FOUNDATIONS OF COCES WORK ARE
• Evidence-based treatment models and strategies
• Comprehensive and integrated services and systems
• Client/consumer focus and cultural competence
• Quality improvement process

57
TOOLS FOR EXCELLENCE
COCE Conceptual Framework
Services and Service Systems Infrastructure Special Populations
Prevention Principles of Care Children and Adolescents
Screening Legislation and Regulation Children of Individuals with COD
Assessment Standards (Federal, State, Other) Women
Treatment Planning Credentialing Gay, Lesbian, Bi-Sexual, Transgendered
Treatment Service Staff Development and Training Geriatric
Support Services System Coordination Supports Ethnic/ Linguistic Minorities
Service Integration Information Systems Homeless
System Integration Health Care Finance Criminal Justice Involved
Evaluation/Research Persons with Medical Comorbidity
Resources
Each category contains several subcategories,
allowing greater specificity
58
TOOLS FOR EXCELLENCE
COCE SCIENCE TO SERVICE PROCESS
SCIENCE-BASED COD PRINCIPLES
COCE Conceptual Framework
COD SCIENTIFIC BASE e.g.
POSITION PAPERS TECHNICAL REPORTS e.g.
PRODUCTS e.g.
Training
COD TIP
Definitions
Technical Assistance
OTHER TIPS
Screening Assessment Treatment Planning
Monographs
COD TOOL KIT
Curricula
Treatment Services
REPORT TO CONGRESS
Training and Workforce Development
Fact Sheets
NEW FREEDOM INITIATIVE
Etc.
Etc.
59
TOOLS FOR EXCELLENCE
THE COCE BRAIN TRUST
EXPERT LEADERSHIP GROUP Stan Sacks, Ph.D. Fred
Osher, M.D. Rose Urban, J.D., MSW
STEERING COUNCIL
SENIOR FELLOWS e.g., Richard Ries, M.D.
FELLOWS
60
COCEs Target Audiences

• States that have received Incentive Grants for
  Treatment of Persons with Co-Occurring Substance
  Related and Mental Disorders (COSIGs)
• States selected for the COD Policy Academy
• Selected Data Incentive Grant (DIG) States and
  State Data Infrastructure (SDI) Grants
• Sub-State entities including cities, counties,
  tribes and tribal organizations
• Providers (community-based, educational
  establishments, homelessness system, criminal
  justice, other social and public health)

61
The COCE Technology Transfer Approach
Technology Transfer
CRITICAL INPUTS

• Principles
• Relevance
• Credibility
• Clarity
• Feasibility
• Psychosocial factors

Mental Health, Substance Abuse, COD Research
SAMHSAs Mission Priorities
State/Local Experience Innovation
Federal Policy
Consumer Needs And Perspectives
State Policy

• Practices
• Matching goals to readiness
• Interpersonal strategies
• Organizational support
• Use of
• Translators
• Early adopters
• Champions
• Peer networking
• Follow-up and support

62
COCE Technology Transfer Mechanisms

• Provide technical assistance
• Provide training
• Prepare and distribute state-of-the-art materials
  on COD
• Analyze materials and develop taxonomies
• Design and manage a co-occurring disorders Web
  site
• Support regional and National meetings
• Develop and conduct a pilot evaluation of the
  co-occurring Performance Partnership Grant (PPG)
  measures
• Sustain technical assistance and cross-training
  through coordination with SAMHSAs existing TA/CT
  sources

63
Technical Assistance

• Individual and Group
• On-Site
• Off-Site
• Telephone
• Literature Reviews
• Networking
• Web sites
• General Information
• Materials, reports, etc.

64
COCE Technical Assistance Delivery Process
Post-Delivery Phase
Pre-Delivery Phase
Maintain Files To Inform Similar TA Events
On-Site
Off-Site
Off-Site COCE Staff and/or Consultant TA/CT
Provider(s) perform TA/CT activities Telephone L
it Reviews Networking Web site
Plan and Manage Logistics
Follow-up
Select TA/CT Providers
On-Site TA/CT Delivery
Field Requests and Assess Needs
Develop TA/CT Plan
Develop Consultation Plan
Evaluation and Reporting
COCE TA Coordinator Support
On Site Off-Site Both
65
Interim TA Plan

• Pilot of TA Plans and Procedures
• Federal Project Officer Reviews and Approves TA
  Plan Before Services are Provided
• Pilot Findings used to Refine Process for
  Full-Scale Rollout

66
Training

• Training of Trainers (TOT)
• Addiction Technology Transfer Centers (ATTCs)
• Centers for the Application of Prevention
  Technology (CAPTs)
• States
• Provider Organizations (e.g., NCCBH, SAAS)
• Cross-Training (CT)
• Curriculum Development

67
Materials Development and Analysis
CLINICAL CAPACITY BUILDING INFRASTRUCTURE DEVELOPMENT
Screening, Assessment, and Treatment Planning Financing Mechanisms
Treatment Services Certification and Licensure
Terminology, Nosology, Definitions System Integration
Training and Workforce Development Services Integration
Evaluation and Monitoring Information Sharing

• Position Papers
• Monographs
• Training Curricula
• Brochures
• Newsletter
• Fact Sheets
• Program Briefs

68
COCE Web Site

• Will be designed to
• Motivate exploration of COD
• Clarify users interests and concerns
• Guide users to relevant information and
• Provide users with support in understanding and
  using information.

69
Regional and National Meetings

• Annual National meeting
• Three regional meetings in year 1, four regional
  meetings in years 2-5
• Increase awareness of recent research
• Bridge the gaps between research, practice, and
  policy
• Form and sustain relationships among providers
  across constituencies
• Create peer networks
• Provide cross-training of providers

70
The COCE Contract Emphasizes Sustainability

• Early and substantive linkages with
• CSATs Addiction Technology Transfer Centers
  (ATTCs)
• CSAPs Centers for the Application of Prevention
  Technology (CAPTs) (6 regional centers)
• CMHSs National Mental Health Information Center
  (NMHIC)
• Development of sustainable systems of technology
  transfer
• Establishment of science-based practices as the
  norm
• Impact on agendas of knowledge producers to
  better meet the needs of a science-to-service
  model

71
Role of the Subcontractors

• Policy Research Associates (PRA) Criminal
  Justice Expertise
• National Center on Family Homelessness
  Homelessness Expertise
• George Washington University Treatment Systems
  Finance and Organization Cross-Systems
  Infrastructure Expertise
• New England Research Institutes, Inc. (NERI)
  Financial Strategy Development and Analysis
  Expertise
• Foundations Associates (FA) Consumer/Recovery
  Community Expertise

72
Role of the ATTCs
CURRENT PARTNERS CURRENT PARTNERS CURRENT PARTNERS CURRENT PARTNERS
National ATTC NE ATTC NW ATTC SW ATTC
Coordinate ATTC activities with COCE activities Logistical support for NE ATTC TOTs Plan for marketing dissemination of COCE products through ATTCs Convene an ATTC COD Workgroup to collaborate with COCE Work with COCE to design and implement a TOT for ATTCs Adapt COCE products and services to meet specific ATTC needs Assist in convening ATTC COD Workgroup Provide advice and planning concerning dissemination of COCE knowledge throughout the ATTC system inventory existing COD-related ATTC materials/databases assess these for suitability for COCE efforts and assist in revising for SAMHSA content clearance, if necessary Assist in convening ATTC COD Workgroup provide consultation to COCE staff on developing and/or revising curricula and training materials on COD for use by the ATTCs, particularly with respect to evaluating treatment outcomes
73
Role of the ATTCs
CURRENT ATTC PARTNERS
OTHER ATTCs
Motivate Orient Train
MAXIMUM IMPACT
THE COD FIELD
74
COCE Timetable

• Sep 29 Dec 30, 2003
• Conceptualize Approach and Develop Plans
• Initial COSIG Meeting December 15-17
• Jan 1 Mar 31, 2004
• Provide Interim TA
• Establish Coordination Mechanisms
• Convene National Steering Council
• Convene COSIG, DIG, and SDI Grants Involved in
  the PPG Pilot Evaluation
• April 1, 2004
• Full TA services
• Continued development of
• COCE infrastructure
• Linkages
• TIP
• Curricula
• Other materials
• Web site

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How to Request COCE Services

• Requests for services must be in writing
• Direct requests to
• samhsacoce_at_cdmgroup.com or
• COCE Phone Line 301-951-3369
• Questions?
• Jill Hensley, COCE Project Director
• 301-654-6740 (x 201)
• George Kanuck, Federal Project Officer
• 301-443-8642