Travis County Plan
— for —
Substance Use Disorders
September
Acknowledgements | i
Acknowledgements
is report would not have been possible without the
guidance and support of a variety of community leaders.
Many thanks to the following for the time, passion, and
commitment they brought to this planning process:
Leadership Team
David Evans, Austin Travis County Integral Care
Diana DiNitto, e University of Texas at Austin School of
Social Work
Joel Ferguson, e Council on Recovery
Raul Garcia, Travis County Sheri’s Oce, Austin
Recovery Oriented Systems of Care (ROSC) Initiative
Sherri Fleming, Travis County Health and Human Services
& Veterans Services
Stephanie Hayden, Austin/Travis County Health and
Human Services Department
Tracy Luno, Austin Independent School District
David Mahoney, Austin Police Department
Estela Medina, Travis County Juvenile Court
Sherwyn Patton, Life ANew
Eloise Sepeda, Austin Travis County Integral Care
Planning & Network Advisory Committee
Pete Valdez, Downtown Austin Community Court
Wendy Varnell, LifeWorks
Bill Wilson, Austin Travis County Integral Care
Kari Wolf, Seton Healthcare
Trish Young Brown, Central Health
Community Advisory Team
Robin Peyson, Communities for Recovery
Ana Almaguel, Travis County Health and Human Services
& Veterans Services
Jorge Alvarez, Austin Travis County Integral Care
Patricia Bouressa, Travis County Justice Planning
Sherry Blyth, Austin Travis County Integral Care
Drew Brooks, Faith Partners
Cynthia Corral, CommUnityCare
Joel Ferguson, e Council on Recovery
Louise Lynch, Austin Travis County Integral Care
Pat Malone, Austin ROSC Initiative
Kim McConnell, Travis County Adult Probation
Mary McDowell, People’s Community Clinic
Susan Millea, Children’s Optimal Health
Scurry Miller, LifeWorks
Beth O’Neal, Austin Travis County Integral Care
Lisa Owens, Central Health
Laura Peveto, Travis County Health and Human Services
& Veterans Services
Stephanie Rainbolt, LifeWorks
Terri Sabella, CommUnityCare
Gloria Souhami, Travis County Underage Drinking
Prevention Program
Danny Smith, Travis County Sheri’s Oce
Edna Staniszewski, Austin/Travis County Health and
Human Services Department
Jennifer Vocelka, SIMS Foundation
Brandon Wollerson, CommUnityCare
Ricardo Zavala, Austin Independent School District
Additional thanks goes to the individuals who helped
arrange focus groups and community meetings,
participants in the focus groups and survey, and to all
those who provided relevant data or helped us nd it.
Sta support for this project was provided by Ellen
Richards and Leela Rice, Austin Travis County Integral
Care. Process facilitation and report production was
completed by Woollard Nichols and Associates.
Contents | ii
Contents
Acknowledgements ............................................................................................................................ i
Introduction ....................................................................................................................................
Why Is is Issue Important? ............................................................................................................
Plan Focus ...................................................................................................................................
Plan Vision ................................................................................................................................
[ ] ....................................
Overview .....................................................................................................................................
Key Findings ................................................................................................................................
[ ] ...........................................
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[ ] ,
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[ ] , ,
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Conclusion ...................................................................................................................................
[ ] -
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Overview .....................................................................................................................................
Early prevention is essential. ........................................................................................................
Key Findings ................................................................................................................................
[ ] ,
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[ ] . ...........................................
[ ] ..................................................
[ ] .....................................................................
[ ]
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Conclusion ...................................................................................................................................
Contents | iii
[ ]
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Overview .....................................................................................................................................
Key Findings ................................................................................................................................
[ ] ..................................................
[ ] ..........................................
[ ] ...................................
[ ] ’ .....................
[ ] .............................
Conclusion ...................................................................................................................................
[ ] ’
............................................................................................
Overview .....................................................................................................................................
Key Findings ................................................................................................................................
[ ] . ..............................
[ ] O -
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[ ]
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Conclusion ...................................................................................................................................
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Introduction | 1
Introduction
Travis County faces signicant community challenges in addressing substance
use issues. Historically, while substance use is considered part of behavioral
health, it has often been overshadowed by mental health in both awareness
and funding. Substance use is one of the few health areas in which Travis
County has experienced a decline in some critical services for low-income
individuals, such as the loss of withdrawal management (commonly known as
detox) beds over the past several years. Also, despite the Aordable Care Act’s
promise of parity, substance use services are rarely compensated at a level that
fully reimburses for best practices, and employees specializing in the eld are
compensated at lower levels than other health professionals. ese situations
have occurred despite increased awareness of the comorbidity
i
of substance use
disorder with physical and mental illness, and a growing realization that failure
to invest in prevention and recovery results in later recourse to more expensive
solutions.
i e occurrence of two disorders or illnesses in the same person, also referred to as co-occurring
conditions or dual diagnosis.
35%
of
by
APD relate to alcohol
and/or drug abuse
8–15%
of
in
Travis County are
related to alcohol or
drugs
59%
of
in U.S.
admitted to using
drugs or alcohol in
the previous
months
34%
of
in
Travis County involve
alcohol
15%
of U.S. workers
report being
at least one
time during the
past year
60%
of
in
Travis County Jail
have substance abuse
problems
40%
of
victims in Texas have
a caregiver with an
alcohol or drug abuse
problem
25–50%
of
cases in
U.S. involve alcohol
Alcohol and Other Drugs Impact Our Community
Introduction | 2
Substance use impacts our community
systems in many ways. e
consequences of harmful substance
use are too often addressed in the most
costly settings, through the criminal
justice or emergency health systems,
rather than the public health system.
ere is room for optimism, however. e Substance
Abuse and Mental Health Services Administration
(SAMHSA) has identied four dimensions that serve both
as prevention tools and as supports for a life in recovery.
overcoming or managing disease(s) or
symptoms—for example, abstaining from use of alcohol,
illicit drugs, and non-prescribed medications if an
individual has an addiction problem—and, for everyone in
recovery, making informed, healthy choices that support
physical and emotional well-being
having a stable and safe place to live
participating in meaningful daily activities,
such as a job, school volunteerism, family caretaking, or
creative endeavors, and the independence, income, and
resources to engage in society
having relationships and social
networks that provide support, friendship, love, and hope
In Travis County, peer networks have increased their
capacity to provide prevention and recovery support.
Certication of sober houses, a new sober high school,
and the development of sober recreational activities are all
recent local advances. Prevention programs and treatment
centers are deploying evidence-based programming,
including trauma-informed care. e local criminal
justice system has developed a Reentry Court and is
examining assessment and treatment services within
the Travis County Correctional Facility and Probation
Department, and Life ANew is conducting reconciliation
circles. However, this is occurring in an environment of
increasing economic disparity, a growing population, and
a lack of resources to address critical needs related to
substance use disorder, especially for individuals at the
lower end of the income spectrum.
In September , the Community Advancement
Network (CAN) recognized that the community as a
whole was not focused on substance use and that certain
services, such as withdrawal management (detox), were
diminishing, so it convened local leaders to discuss
assessing and elevating the visibility of substance use
impacts in Travis County. Austin Travis County Integral
Care (Integral Care) agreed to lead the eort. Between
December and May , a leadership team and
community advisory team hosted a community forum,
met with local experts, reviewed data, conducted ve
focus groups, and administered surveys of individuals in
recovery and substance use disorders treatment providers
to create a community vision and short- and long-term
plans to address substance use.
Completed in May , the short-term plan
resulted in the following:
»
Development of a comprehensive resource guide for
substance use services in Travis County (created by the
Dell Children’s Medical Center of Central Texas and
maintained on Integral Care’s website)
»
An update to the desired continuum of mental health
care to include substance use, creating a behavioral
health continuum
»
Travis County’s allocation of , in one-time
funding for the continuation of the Family Drug
Treatment Court program and addition of ,
to the Substance Abuse Management Services
Organization (SAMSO) for treatment for women and
children.
Introduction | 3
High rates of substance use are costly
for our community.
An informed, educated and
supportive community that
understands the impact of substance
use disorders, communicates
community standards, and provides
relevant information.
Additional investment in evidence-
based prevention initiatives can save
money and lives.
Harmful substance use is prevented
at the earliest possible point.
Substance use disorders are treatable
chronic illnesses and we need to
develop this understanding within
our local community.
Integrated person-centered,
community-based, family-focused
recovery supports are readily
available.
Our community infrastructure
and investments are insucient to
address substance use disorders.
Infrastructure is in place to identify
opportunities to strengthen the
substance use disorder system, to
develop sustainable resources and to
monitor eectiveness.
Plan Focus
While this report addresses the impact of substance use
across the county, many of the recommendations are
focused on addressing those at or below of the
federal poverty level, which is generally the population for
whom public entities provide support.
Plan Vision
An engaged, informed, compassionate community that
prevents harmful substance use, provides ready access to a full
continuum of services and supports, and embraces a culture of
health, recovery, and resilience.
Plan Key Findings
Critical Issue [] | 4
Key Findings
[1]
Our community pays a high price for substance use
[2]
Substance use rates in Central Texas are consistently
higher than those in other parts of Texas and the
nation
[3]
Youth are using alcohol and marijuana throughout
Travis County
[4]
Individuals and families experience impacts to their
health, relationships, employment, and income related
to substance abuse
[5]
Family members, health care professionals, and other
key community members are not aware of the impact
of substance use disorders or of community resources
to address them
Immediate Action Steps
»
Establish a hub for substance use information and
referrals including a resource list of prevention
programs.
»
Educate health care professionals on identication
of substance use disorders, opportunities to
utilize Medication-Assisted Treatment (MAT), and
appropriate community referrals.
Additional Action Steps
»
Create and disseminate clear, consistent, culturally
relevant, eective community messages about
substance use disorder, its chronic nature, its impacts
and the opportunity for recovery, including inspiring
stories of individuals in recovery.
»
Engage and educate individuals, families, school
personnel and stakeholders in the legal system about
signs and symptoms of substance use disorder and
recovery services and supports.
[]
An informed, educated and supportive
community that understands the
impact of substance use disorders,
communicates community standards,
and provides relevant information.
1
[ ]
Overview
Substance use disorder impacts thousands of individuals in Travis County.
Locally, approximately , adults age or older (.), and approximately
, youth ages – years (.) have abused alcohol or illicit drugs in the
last year.
It is further estimated that , adults in Travis County (.) are
alcohol dependent and , adults (.) are dependent on illicit drugs and
will probably require some type of recovery support.
ese gures do not
include individuals who are dependent on prescription medication. In , the
Outreach, Screening, Assessment, and Referral Center (OSAR) for Texas Region
, the state-funded rst point of contact for any Texas resident seeking substance
abuse treatment services, screened , individuals from Travis County and
recommended for substance use treatment.
ii
Key Findings
[ ]
Our Community Pays a High Price
for Substance Use
Our community experiences substantial impacts from substance use disorder,
including increased costs to the legal and emergency systems and loss of
productivity in the workplace.
Assessing denitive costs of substance use disorder is challenging. For example,
an individual is charged with assault based on acts committed while intoxicated.
ough alcohol is a contributing factor, it is often not the primary charge listed in
the record, making accurate data collection dicult. Similarly, an individual can
present at the emergency room with a broken arm sustained as a result of falling
down while under the inuence of prescription drugs. ough the drugs led to the
injury, the medical record often does not reect this. In addition, local health care,
public safety and criminal justice systems are not currently focused on gathering
substance use data. erefore, identied cost estimates are conservative.
e Austin-Travis County Sobriety Center Working Group has attempted to
estimate some of the costs for responding to publicly intoxicated individuals in
Travis County. Sobriety centers are intended to enhance public health and public
safety by providing an alternative to the emergency room and jail for publically
intoxicated individuals to sober up and where appropriate, provide a safe
environment to initiate recovery. Many of the cost estimates below are cited from
the working group’s most recent progress report.
Public Safety
»
of all arrests by the Austin Police Department (APD) in were for
crimes related to alcohol and/or drug abuse.
»
In , APD reported , Driving While Intoxicated (DWI) oenses (a .
reduction from ) and , narcotics oenses (an . reduction from
).
ii OSAR typically screens four to ve Travis County residents a day, and they must arrive by about
6:00am in order to be seen as OSAR screenings are completed on a rst-come, rst-served basis. Prior-
ity is given to individuals who meet certain eligibility criteria.
SUBSTANCE ABUSE,
SUBSTANCE
DEPENDENCE AND
SUBSTANCE USE
DISORDER: WHAT’S
THE DIFFERENCE?
The fourth edition of the
Diagnostic and Statistical
Manual of Mental Disorders
(DSM-IV) included definitions of
substance abuse and substance
dependence. The distinction
between abuse and dependence
is based on the concept of abuse
as a mild or early phase and
dependence as the more severe
manifestation.
The current edition of the dsm,
the DSM-5, was released in
2013. It combines the DSM-IV
categories of substance abuse
and dependence into “substance
use disorders,” which are
measured on a continuum from
mild to severe. A disorder is
present when the recurrent use
of alcohol and/or drugs causes
clinically and functionally
significant impairment, such
as health problems, disability,
and failure to meet major
responsibilities at work, school,
or home. This revised definition
is intended to better capture
the range of symptoms that
individuals may experience
related to their substance use.
To adhere to current terminology,
this report utilizes substance use
disorder whenever possible.
However, because much of the
research cited in the report
was conducted prior to the
release of the DSM-5, the terms
substance abuse and substance
dependence will also appear.
sources: American Psychiatric
Association, SAMHSA.
Critical Issue [] | 5
»
e Travis County Sheri’s Oce estimates that on any
given day, of the , Travis County Jail residents
meet the criteria for substance abuse or dependence,
with approximately () solely meeting
dependency criteria.
»
of the individuals on probation in Travis County
are under supervision for a DWI, for possession
of drugs, and for the sale, delivery, or manufacture
of drugs.
It is estimated that of all Travis County
probationers have “diculty with alcohol” (term used
by the Travis County Community Supervision and
Corrections department; similar to dependence) and
are thought to have diculty with drugs.
»
In , , individuals in Travis County were charged
with , counts of public intoxication oenses.
»
Austin/Travis County Emergency Medical Services
(EMS) estimates that , transports in which alcohol
was included in the primary impression conducted
in took , hours of ambulance time, or
approximately workdays. Total charges billed to
patients for these transports were approximately .
million.
»
APD ocertime costs to arrest an individual for public
intoxication (PI) range from to per person.
Based on this data, the total cost of , PI bookings
in is estimated at , to ,.
»
Travis County Sheri’s Oce costs are . per
booking and . per jail bed day.
iii
In , there
were , bookings for PI that accounted for , jail
bedday hours (calculated hourly due to releases in less
than hours). erefore, the total estimated booking
costs were , and the total estimated jail bedday
costs were ,.
»
e City of Austin invests million annually in
the Downtown Austin Community Court (DACC).
Operating as a problem-solving and rehabilitative
court and providing referrals to supportive services for
oenders, the DACC adjudicates public order oenses
including PI committed within the downtown, East
Austin, and the West Campus areas. A majority of the
oenses adjudicated through DACC are committed by
defendants who are homeless, and a disproportionate
number of oenses are committed by a small number
of defendants who cycle through the criminal justice
system at a high cost to all community services
systems.
iii Based on data.
Health
»
Alcohol was detected in of trac fatalities that
occurred in Travis County in .
»
In , Austin/Travis County Emergency
Management Services (EMS) identied , patients
for whom alcohol or drug abuse was the primary
issue.
»
– of Austin suicides are related to alcohol or drug
abuse.
»
of U.S. pregnant teens admitted to using drugs
and alcohol in the previous months, a rate nearly
two times greater than non-pregnant teens.
»
Seton Healthcare Family estimated direct costs for the
individuals who accessed its emergency departments
within Travis County in Fiscal Year and who
might have met sobriety center criteria. Seton
estimates that , individuals may have met the
criteria
iv
in FY . e per-patient costs for those
individuals ranged from to (using mean and
median data), for a total direct cost of . million to
. million.
v
»
e Hospital Corporation of America/HCA (St. David’s
Hospital) estimated that it served , publically
intoxicated people in , but this number may
include some who would not qualify for admittance to
a sobriety center.
17
Workforce
»
Over of U.S. workers report being impaired by
alcohol at work at least one time during the past year,
including almost of workers reporting drinking
before work; of workers reporting drinking during
the workday; and of workers reporting being
hungover at work.
Workers with illicit drug and/or
heavy alcohol use have higher rates of job turnover
and absenteeism compared to those with no illicit drug
or heavy alcohol use.
iv Criteria were that the individual was publicly intoxicated, didn’t
have a medical diagnosis requiring an Emergency Department visit and
the arrest did not include charges for non-Public Intoxication-related
oenses, like assault or Driving Under the Inuence.
v e estimates do not include those patients who would likely be dis-
qualied based on a medical diagnosis that would warrant an emergency
department visit.
Critical Issue [] | 6
[ ]
Substance use rates in Central Texas are
consistently higher than those in other parts
of Texas and the nation.
e National Survey on Drug Use and Health (NSUDH) demonstrates that
Central Texas has consistently high rates of alcohol dependence.
e chart
below illustrates the rates of alcohol dependence for the U.S., Texas and the
-county Central Texas region. While rates of alcohol dependence in Central
Texas remain above the national and state averages, they have decreased in
recent years.
Rates of Alcohol Dependence, –
: National Survey on Drug Use and Health (NSUDH), . Central Texas is dened as Texas Re-
gion a and includes Travis, Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, & Williamson
counties. Chart data includes age and up.
e denition of dependence in the NSUDH is based on DSM-IV criteria.
Respondents were identied as having alcohol dependence if they met three or
more of the following criteria:
»
Spent a great deal of time over the period of a month getting, using, or
getting over the eects of alcohol;
»
Used alcohol more often than intended or was unable to keep set limits on
alcohol use;
»
Needed to use alcohol more than before to get desired eects or noticed
that the same amount of alcohol had less eect than before;
»
Unable to cut down or stop using alcohol when tried or wanted to;
»
Continued to use alcohol even though it was causing problems with
emotions, mental or physical health;
»
Alcohol use reduced or eliminated involvement or participation in
important activities; or
»
Experienced withdrawal symptoms (e.g. having trouble sleeping, cramps,
hands tremble).
Critical Issue [] | 7
Central Texas
Texas
US
2002–2004
2004–2006
2006–2008
2008–2010
2010–2012
Our region has a significantly higher binge drinking rate than
the United States and Texas.
e National Survey on Drug Use and Health (NSDUH) asks persons or
older to report on their binge alcohol use in the past days. Binge use is
dened as consuming ve or more drinks on the same occasion (at the same
time or within a couple of hours of each other) on at least day in the past
days. e rates for Central Texas far surpassed both national and Texas rates.
e City of Austin Community Health Assessment identied binge drinking as
an important area for the community to address.
Binge Alcohol Use in the Past Month
: National Survey on Drug Use and Health. Central Texas is dened as Texas Region 7a and
includes Travis, Bastrop, Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, & Williamson counties.
Similarly, the American Journal of Public Health estimated the prevalence
of drinking and binge drinking in every U.S. county from to and
reported that Travis County has the highest rate of overall drinking in the
state. At ., local drinking prevalence is more than eight percentage points
higher than the national average and percentage points higher than the
state average. ese numbers include anyone who has consumed one or more
alcoholic beverages in the past month.
Critical Issue [] | 8
15.9%
23.62%
27.47%
US
Texas
Central Texas
Regional Marijuana Use and Nonmedical Use of Pain Relievers
in Central Texas are Higher an in the Rest of the State
: National Survey on Drug Use and Health (Percentages, Annual Averages Based on , ,
and ). Central Texas is dened as Texas Region a and includes Travis, Bastrop, Blanco, Burnet,
Caldwell, Fayette, Hays, Lee, Llano, & Williamson counties.
Marijuana is the most commonly used illicit substance in
Travis County.
Approximately of individuals ages and older in Central Texas report
using marijuana in the last year. is is higher than the . reporting use
in the state as a whole and nationally. According to the Texas Department
of State Health Services, the number of individuals for whom marijuana
is the primary abused substance increased . between FY and FY
. More than half of new illicit drug users begin with marijuana. e next
most commonly used illicit drugs are prescription pain relievers, followed by
inhalants (most common among younger teens).
Marijuana was the primary
reason for of admissions to treatment programs in , compared with
in .
Marijuana also impacts our local criminal justice system: of
Austin Police Department possession arrests in were for marijuana.
Critical Issue [] | 9
9.39%
14.15%
Texas
Central Texas
4.45
5.23
Texas
Central Texas
Number of Adult Admissions to U.S. Substance Abuse
Treatment Programs by Primary Substance per Year
: Texas Department of State Health Services, Clinical Management for Behavioral Health Ser-
vices (CMBHS). . Behavioral Health Data Book: First Quarter .
Prescription painkillers are linked to increased overdoses and
increased use of heroin.
Nationally, people die of a drug overdose every day, with prescription
drugs tied to more than half of these deaths. According to national and local
reports, increased regulation of prescription painkillers intended to reduce
abuse is linked to increased rates of heroin use, which is often cheaper and
easier to purchase. A recent study identied heroin users as likely to be white
and to live in suburban or rural areas. e average age is . ree out of four
were rst introduced to opioids through prescription painkillers.
Although
the “high” produced by heroin was described by study participants as a
signicant factor in its selection, it was often used because it was more readily
accessible and much less expensive than prescription opioids.
In , the
Travis County Medical Examiner’s Oce identied prescription-related
deaths.
A survey of area substance use treatment providers conducted as
part of this assessment identied an increase in the number of individuals
requesting services related to heroin. In Texas, heroin was the primary drug of
abuse for of clients admitted to treatment in .
Synthetic marijuana usage has become more prevalent.
In November , April , and June , the Austin Police Department
responded to a rash of overdoses and health problems associated with
synthetic marijuana (commonly known as K or Spice), probably caused by
chemicals sprayed on the product. Synthetic marijuana is made from herbs
and chemicals and is designed to mimic the eects of marijuana. Travis County
substance use treatment providers state that this is a growing problem among
young people and individuals who are on probation or parole, as the drugs
are not detected in standard drug tests and there is a misconception that
the ingredients are all natural and the products are legal. In Texas, K/Spice
is considered a controlled substance. However, because synthetic marijuana
is produced under a variety of names and chemical compositions, it is often
dicult for law enforcement to take action.
e Number of U.S Heroin Users
Rose , over a Decade
Nearly in every , Americans
said they used heroin in the
previous year, a increase from
a decade ago with the bulk of the
increase among whites, according
to a new government report.
Experts think the increase was
driven by people switching from
opioid painkillers to cheaper heroin.
–
,
Critical Issue [] | 10
5,554
5,400
5,614
6,052
2,628
3,094
4,383
5,663
3,840
3,797
3,531
3,210
9,213
9,117
9,264
9,738
Alcohol
Cocaine
Marijuana
Methamphetamine
Opioid
Other
2011
2012
2013
2014
[ ]
Youth are using alcohol and marijuana
throughout Travis County
Nationally, the rates of American th, th, and th graders using alcohol
and drugs continued to show encouraging signs, including decreasing use
of alcohol, cigarettes, and prescription pain relievers; no increase in the use
of marijuana; decreasing use of inhalants and synthetic drugs, including
marijuana substitutes K/Spice and bath salts; and a general decline in the use
of illicit drugs over the last two decades.
e Austin Independent School District annually administers the Student
Substance Use and Safety Survey to a random, representative sample of middle
and high school students. e survey is used to track student knowledge,
attitudes, and self-reported behavior over time. Based on the – survey,
Children’s Optimal Health published the map in Figure below. e pie charts
represent data as reported at each campus, though they do not necessarily
reect activity occurring on campus.Data for other school districts in Central
Texas was not available.
High School Alcohol Use
»
In the – school year, of students reported never using alcohol
and reported use in the past month.
»
Among students reporting alcohol use in the past month, there was a
decrease from the prior year. ere was also a increase in students who
stated that they had never used alcohol.
»
High concentrations of students reporting recent alcohol use occur
throughout the area, especially among students living in the , ,
, , and zip codes.
High School Marijuana Use
When looking at high school marijuana use, the same survey found:
»
In the – school year, of students reported never using
marijuana and reported use in the past month.
»
Among students reporting marijuana use in the past month, there was no
change compared to students reporting in the prior year.
»
High concentrations of students reporting marijuana use occur throughout
the area, especially among students living in the , , , ,
, , , , and zip codes. e zip code,
which covers parts of East Austin, Del Valle and far East Travis County,
demonstrated high concentrations of self-reported alcohol and marijuana
use and warrants further focus.
EMS Treats More than 500
People After K Incidents:
“We’re seeing elevated temperatures.
We’re seeing seizures. We’re seeing
people having blackouts and we’ve
got some folks experiencing
violent behavior, very aggressive
tendencies. We’ve got some that
are experiencing paranoia and
anxiety,” said Chief Ernesto
Rodriguez with Austin Travis
County EMS.
– ,
Critical Issue [] | 11
Young Adult Drinking
Because Travis County has such a large number of young adults ages –,
it is important to understand the impact of drinking for this subpopulation.
Up-to-date research is limited in this area. e most recent and
comprehensive study of young adult drinking was published in , based
on the – NationalEpidemiologicSurveyonAlcoholandRelated
Conditions. It showed that people are likely to drink
most heavily in their late teens and early twenties. In –, about
of young adults reported drinking in the prior year. e authors concluded
that heavy episodic drinking and alcohol use had increased and are common
among all young adults, not just those attending college.
Alcohol use
increases risky behavior and the possibility of serious injury or death,
including trac fatalities.
[ ]
Individuals and families experience impacts
to their health, relationships, employment,
and income related to substance abuse.
Substance use disorder can result in legal challenges, place individuals in
unsafe situations, and, for those without family and community supports,
lead to homelessness. Substance abuse is correlated with increased risk for
teen pregnancy, HIV/AIDS, sexually transmitted diseases, physical ghts,
and suicide.
Eighteen percent of chronically homeless individuals in Travis
County are reported to have a substance use disorder, more than twice the
rate of the general population.
People who abuse alcohol and/or drugs
attempt to kill themselves nearly six times as frequently as people who don’t
abuse these substances.
Substance use also disrupts families. In Texas, . of victims of child
abuse have a caregiver who has an alcohol or drug abuse problem.
Children
in households in which substance abuse occurs lack stability, frequently
have challenges in school, and are at increased risk for abuse and neglect.
Children of substance-abusing parents also often take on inappropriate
roles, including increased responsibility based on the parents’ unavailability.
Drinking precedes acts of domestic violence in to of all cases. Chronic
use of alcohol is a better predicator of battering than acute intoxication, as
the highest rates of domestic abuse are found among moderate to heavy
drinkers, rather than the heaviest drinkers.
,
Often, the impact of ongoing
substance use can create unhealthy dynamics of denial and coping, as family
members feel angry, overwhelmed, and isolated, or deny that there is
a problem.
Critical Issue [] | 12
[ ]
Family members, health care professionals,
and other key community members are
not aware of the impact of substance use
disorders or of community resources to
address them.
A nationwide survey conducted by the National Center on Addiction and
Substance Abuse at Columbia University highlighted some troubling
ndings. For instance, more than of patients receiving treatment for
substance abuse reported that their primary care physician did not address
their substance use disorder. More than stated that their physician
missed the diagnosis of a substance use disorder, and only of primary
care physicians were involved in the decision to seek treatment.
e
survey indicated that less than of primary care physicians considered
themselves “very prepared to identify alcohol or drug dependence,” compared
with the more than who felt very comfortable diagnosing hypertension
and diabetes.
Similarly, many physicians are either not aware of, or are
not utilizing, Medication-Assisted Treatment (MAT). MAT involves the use
of medications, in combination with counseling and behavioral therapies,
for the treatment of substance use disorders. Research shows that when
treating certain substance use disorders, a combination of medication and
behavioral therapies is most successful. MAT is clinically driven, with a focus
on individualized patient care.
e responses of individuals in local focus groups echoed these ndings
regarding the need to educate doctors and family members about substance
use disorder. One participant described leaving a treatment facility and
visiting her family physician. She shared her anxiety about being out of a
safe environment and was immediately prescribed a potentially addictive
tranquillizer. She took it, since it was prescribed, even though she knew she
should not have. She quickly returned to abusing narcotics.
Other focus group participants discussed the frustration they feel when
family members do things to sabotage their recovery such as encourage
them to drink socially or cook with alcohol. A core sentiment among service
providers and individuals in recovery was the need for clear, consistent
community messages about harmful substance use and for a centralized
location for individuals to access current, trustworthy information on
substance use prevention and recovery. Due in part to the lack of ongoing
community focus on substance use, local leaders have not yet demanded a
policy-level concentration on substance use and its impacts.
Less than 20% of primary care
physicians surveyed considered
themselves “very prepared
to identify alcohol or drug
dependence.”
–
Critical Issue [] | 13
Conclusion
Substance use impacts thousands of local residents and exacts a high
community price, paid through increased demands on our health and public
safety systems. An educated, informed community can understand the
implications of those costs and identify solutions to achieve better outcomes.
Similarly, individuals, family members, and health professionals who are
knowledgeable about the signs, symptoms, and resources of substance use
disorder can play an important role in helping individuals seek help and
supporting those who are in recovery
•
Clear community messages regarding prevention and recovery supports
are present at multiple levels across the community.
•
e community is equipped with resources and tools to address
substance abuse and support recovery.
•
Individuals, families, and the community are aware of the impacts of
substance use and familiar with the concept of recovery-oriented care
and recovery support systems.
•
Individuals in recovery feel supported in the community.
A core sentiment among service
providers and individuals in recovery
was the need for clear, consistent
community messages about harmful
substance use and for a centralized
location for individuals to access
current, trustworthy information
on substance use prevention and
recovery.
Critical Issue [] | 14
Key Findings
[1]
Eective prevention messages and strategies exist, but
local eorts are diuse and uncoordinated and reach a
limited number of individuals
[2]
Prevention is most critical at times of transition
[3]
Harm reduction strategies work
[4]
ere is a lack of local investment in substance use
prevention strategies and messages
Immediate Action Steps
»
Invest in coordination and leveraging of existing
prevention programs through a collaboration such as
the Youth Substance Abuse Prevention Coalition.
»
Increase the overall investment in eective prevention
strategies so that they can be brought to scale.
Additional Action Steps
»
Create consistent community-focused messages that
underage substance use and harmful substance use are
dangerous and can result in death.
»
Target prevention at elementary and middle school
students.
»
Support harm reduction approaches such as
methadone, Housing First, and needle exchanges.
»
Identify young people who can inspire with their
recovery stories and nd platforms for stories to be
eectively shared.
»
Identify and implement eective technologies for
preventing harmful and underage substance use.
[]
Harmful substance use is prevented at
the earliest possible point.
2
[ ]
-
Critical Issue [] | 15
»
Increase the availability of appropriate activities for youth and adults that
do not involve alcohol or drugs.
»
Implement proven environmental, legal and regulatory strategies to reduce
substance use.
»
Support parents in communicating with their children about substance use
and seeking professional services when needed.
Overview
Prevention helps to discourage substance use before it results in costly and
life-threatening consequences. e Texas Department of State Health Services
and SAMHSA’s Center for Substance Abuse Prevention provide evidence-
based curricula and eective strategies to prevent harmful use and negative
consequences of alcohol, tobacco and other drugs.
Early prevention is essential
»
e average age of rst use of alcohol is and marijuana, .
»
Forty-seven percent of those who begin drinking before the age of later
develop alcohol dependence, compared with only of those who wait
until they are or older to start.
Research in drug use and addiction has
found similar results.
»
More than of adults with substance use disorders started using before
; half of them began before age .
e Drug Danger Zone: Most Illicit Drug Use Starts in the
Teenage Years
: SAMSHA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use
and Health, 2011 and 2012.
PREVENTION
DEFINITIONS
Universal prevention strategies
are designed to reach a very large
audience. A universal prevention
program is provided to everyone
in a given population, such as a
school or community.
Selective prevention strategies
target subgroups of the general
population that are determined
to be at risk for substance abuse.
Targeted individuals or groups
are recruited to participate in
the prevention effort.
Indicated prevention inter-
ventions identify individuals
who are experiencing early
signs of substance use disorder
and related problem behaviors
and target them with special
programs.
sour ce: Texas Department of
State Health Services
Critical Issue [] | 16
12–13
14–15
16–17
18–20
21–25
26 or Older
Percentage of Past-Year Initiates
Among Those Who Have Never Used
Age Group
0
5
10
15
2.9%
8%
11.2%
10.4%
4.5%
0.3%
Key Findings
[ ]
Effective prevention messages and strategies
exist, but local efforts are diffuse and
uncoordinated and reach a limited number of
individuals
During the planning process, eight Travis County organizations were identied
as focusing specically on prevention.
vi
Most of these have been providing
evidence-based prevention programming for many years. e Youth Substance
Abuse Prevention Coalition was formed in to assist in coordinating these
programs.
e following are some of the local strengths and challenges identied by a
focus group of Travis County substance use prevention providers:
Strengths
»
History, consistency, and continuity of programming
»
Collaboration between partners and common referrals
»
School Health Advisory Councils in the Austin, Manor, and Del Valle
Independent School Districts include substance use in their review of
health issues
»
Many schools oer Project Graduation events (alcohol- and drug-free
alternative graduation parties)
»
Travis County constables and the Austin Police Department participate in
community outreach
Challenges
Travis County lacks a central agency or
location that coordinates prevention programming, messaging, and education
Providers
are not using the same clearly dened community messages about preventing
harmful substance use
Few resources exist to expand evidence-
based prevention programs
e majority of prevention programs target
individuals, despite acknowledgement that education and support of families
is critical to success
Providers report that the stigma around substance use disorder
continues, making messaging challenging
vi Organizations included Aware, Awake, Alive; Phoenix House; LifeWorks, Travis County Under-
age Drinking Program; Austin Travis County Integral Care; the Travis County Underage Drinking
Prevention Coalition; the YWCA of Greater Austin; and the Workers’ Assistance Program.
Critical Issue [] | 17
Our
community needs to ensure that eective prevention programming is available
for our increasingly diverse population
Each organization presents similar messages about underage substance
use, but there is a lack of coordination on a core message and social norms.
Underage substance use and harmful substance abuse are not clearly dened or
visible in the community. For example, in the focus group, several participants
mentioned the relatively common practice of parents allowing teenagers to
drink in their homes as drinking is “inevitable.” One consequence of the lack of
coordination is that multiple agencies that provide prevention programming
approach the same organizations or schools to implement programming.
is results in duplicated eort on the part of prevention organizations and
frustration on the part of school or program administrators who have to sort
through multiple requests and determine which programs best meet their
needs. Prevention providers expressed a willingness to work together but
indicated that they lack the infrastructure to do so.
[ ]
Prevention is most critical at times of
transition.
A National Institute of Drug Abuse report stated that the risk of substance
abuse increases greatly during times of transition. For an adult, these
transitions could include a divorce or loss of a job; for youth and teenagers,
risky times include moving, changing schools, and other disruptions to
normal routines. In early adolescence, when children advance from elementary
through middle school, they face new and challenging social and academic
situations. Children are often exposed to cigarettes and alcohol for the rst
time during this period. When they enter high school, teens may encounter
greater availability of drugs, drug use by older teens, and social activities
at which drugs are used.
is information should inform local prevention
eorts and assist in identifying critical areas for targeting programming and
messaging. Based on the average age of rst use, prevention programming
would be most eective in late elementary or early middle school.
PREVENTION
PRINCIPLES
Principle 1 Prevention programs
should enhance protective
factors and reverse or reduce
risk factors.
Principle 2 Prevention programs
should address all forms of drug
abuse, alone or in combination,
including the underage use of
legal drugs (e.g., tobacco or
alcohol); the use of illegal drugs
(e.g., marijuana or heroin);
and the inappropriate use of
legally obtained substances
(e.g., inhalants), prescription
medications, or over-the-
counter drugs.
Principle 3 Prevention programs
should address the type of drug
abuse problem in the local
community, target modifiable
risk factors, and strengthen
identified protective factors.
Principle 4 Prevention programs
should be tailored to address
risks specific to population or
audience characteristics, such
as age, gender, and ethnicity, to
improve program effectiveness.
source: The National Institute on
Drug Abuse (NIDA)
Critical Issue [] | 18
[ ]
Effective prevention strategies are available.
More than years of research has examined the characteristics of eective
prevention programs. One shared component is a focus on risk and protective
factors that inuence harmful substance use.
Protective factors are characteristics that decrease an individual’s risk for
developing a substance use disorder.
ey include:
»
Strong and positive family bonds
»
Parental involvement in children’s lives and monitoring of activities and
peers
»
Clear rules of conduct that are consistently enforced
»
Success in school performance
»
Strong bonds with institutions, such as school and religious organizations
»
Adoption of conventional norms about drug use
Risk factors increase the likelihood of substance abuse problems and include:
»
Chaotic home environments, particularly those in which parents abuse
substances or suer from mental illness
»
Ineective parenting, especially of children with dicult temperaments or
conduct disorders
»
Lack of parent-child attachments and nurturing
»
Inappropriately shy or aggressive behavior in the classroom
»
Failure in school performance
»
Poor social coping skills
»
Aliations with peers displaying deviant behaviors
»
Perceptions of approval of drug-using behaviors in family, work, school,
peer, and community environments
Travis County providers use a variety of evidence-based programs, such as
the Botvin’s Life Skills Training (Phoenix House), Curriculum-Based Support
Group (LifeWorks), Strengthening Families (Integral Care), and Positive Action
(YWCA of Greater Austin). However, their reach is not widespread and they
often approach the same schools and organizations to provide programming,
generally targeting a limited number of low-income students. As the earlier
Children’s Optimal Health map demonstrated, the use of alcohol is widespread
and is actually more prevalent in the more auent western side of Travis
County. ese programs also are often delivered in English and may not be
linguistically or culturally appropriate for the increasingly diverse youth
population of Travis County. An investment in coordination, a focus on family
engagement and times of transition, an increase in recreational opportunities,
and an increase in the overall scale of such programming can provide a
substantial return on community investment.
Critical Issue [] | 19
[ ]
Harm Reduction Strategies Work.
Harm reduction strategies are policies and programs
that reduce the adverse health, social and economic
consequences of substance use to individuals, drug
users, their families and their communities. A
study identied the following promising harm reduction
strategies:
-
() Methadone is a long standing treatment to
address opioid dependence. It consistently performs
better at retaining people in treatment and reducing
heroin use than do various drug-free alternative
treatments. Buprenorphine is used similarly. Naltrexone
is used to address alcohol dependence.
Studies of needle exchange
programs have provided promising evidence of positive
impacts. Needle exchange is intended to reduce
transmittal of HIV and other blood-borne pathogens
among individuals who use injectable drugs.
Motivational
Interviewing (MI) is a way of talking with clients that
minimizes resistance and increases the probability that
change will occur.
Evidence from several meta-analyses
demonstrates that MI is to more eective than no
treatment and is generally equal to other more expensive
treatments for a variety of problems ranging from
substance use disorder to reducing risky behaviors and
increasing client engagement in treatment.
e U.S. Department of Justice has
identied several community strategies, many of which
are in place in Travis County, as promising practices for
preventing or decreasing substance use.
ey include:
»
e central gure in this
strategy is the community police ocer, whose
mission is to maintain direct contact with the citizens
of a small, dened area. is ocer serves as liaison
between the community and the police.
»
- Problem-oriented
policing compels ocers to think creatively to nd
solutions to persistent crime problems within a
community. Problem-oriented police ocers are
trained to uncover patterns of crime, to identify
solutions, and to nd the resources needed to address
problems. e focus shifts away from the limited
perspective oered by crime statistics to broader
questions about the root causes of crime.
»
Many communities
have “hot spots,” of crime and drug use within
otherwise low-risk areas. It is estimated that of
locations generate about of crimes. Locally, Life
ANew began a restorative justice initiative focusing
on one of these “hot spots” at th and Chicon. e
initiative was very successful, expanding its reach
and providing a case study in the eectiveness of the
combination of a restorative justice approach and
reducing drug availability.
»
Alternatives to
incarceration are designed to stop the revolving door
of drug abuse and crime by using the coercive power
of the court to engage drug abusing oenders in
treatment. e criminal justice and substance abuse
treatment systems work together to provide oenders
with the services they need while still holding them
accountable for their crimes. Locally, the Travis County
drug court and the Downtown Austin Community
Court use the combined eorts of the justice system,
treatment professionals, and social services entities
to intervene and break the cycle of substance abuse,
addiction, and crime.
»
e Travis County Underage
Drinking Prevention Program, Travis County Sheri’s
Oce and other community partners work to create
a safe and healthy environment for the youth of
our community by reducing underage access to
alcohol. Travis County has an active “secret shopper”
program designed to reduce underage alcohol sales
by employing young people who have been trained
by police to attempt to purchase alcohol illegally
from retailers. Sale of alcoholic beverages to a minor
is a Class A misdemeanor, punishable by a ne up
to ,, connement up to a year in jail, or both.
Additional penalties for businesses are determined by
the Texas Alcoholic Beverage Commission.
»
e Austin Police Chief
reported , DWI oenses in . e Center for
Problem-Oriented Policing lists considerations
for eective strategies to lower DWI incidences,
which include: Reducing the legal limit for drinking
while driving, conducting and publicizing sobriety
checkpoints, training police ocers to spot impaired
drivers, requiring convicted drunk drivers to install
Critical Issue [] | 20
electronic ignition locks on their vehicles, and
requiring convicted drunk drivers to complete alcohol
assessment, counseling, and/or treatment programs.
Many of these strategies are currently used by the
Austin Police Department and the Travis County
Sheri’s Oce.
»
Programs and community messages
promoting the use of alternative transportation
options can be eective in curbing drunk driving. ATX
Safe Streets works to address this issue, and buses run
after midnight from the entertainment district to the
University of Texas campus area. ere are also local
businesses that will drive an impaired individual’s car
home, and parking spaces that allow people to leave
their cars overnight. A study on public transit
in Washington D.C. found that for each late night
hour bus service was extended, ridership increased by
, DWIs decreased , and fatal accidents involving
intoxicated drivers were reduced by .
[ ]
ere is a lack of local investment
in substance use prevention
strategies and messages.
Travis County allocates , for substance abuse
prevention to Youth Advocacy at the Workers Assistance
Program. Other local programs focusing their eorts
specically on substance use prevention are primarily
funded privately or through grants from the Texas
Department of State Health Services. e local Substance
Abuse Managed Services Organization (SAMSO) does not
provide any funding for prevention.
Conclusion
Research has demonstrated that harmful substance
use among adults can be successfully mitigated, and
that drinking and drug use are less likely to become
problematic if delayed until after age . Our community
is implementing eective prevention programs and
strategies; but there is not a clear community message
that underage substance use is illegal and dangerous
and that harmful adult use is unacceptable. Investment
focused on prevention is limited, especially from local
sources. With a fairly minimal investment, we now
have the opportunity to increase coordination among
prevention programs and bring together community
stakeholders to agree upon and promulgate consistent
messages on substance use prevention.
•
Underage drinking and drug use, binge drinking and
harmful adult substance use decrease.
•
Coordination among area substance abuse
prevention programs increases.
•
ere are clear community social norms that
underage substance use is illegal and harmful adult
use is unacceptable.
•
Local institutions support increased investment
in effective prevention principles, practices and
programs.
•
Prevention programs are targeted at critical times of
transition (e.g. moving from elementary to middle
school, divorce, etc.)
•
Evidence-based harm reduction strategies are
in place.
•
Our community has effective regulations and
enforcement of the consequences of substance use,
including underage drinking and DWI.
Critical Issue [] | 21
Key Findings
[1]
Substance use disorders are chronic illnesses
[2]
Recovery is possible through a variety of pathways
[3]
Early access to supports is vital to successful recovery
[4]
Addressing trauma is critical to many people’s paths of recovery
[5]
Family members should be integrated into recovery eorts
Immediate Action Steps
»
Educate healthcare and public safety system navigators on substance use
resources.
»
Educate, employ, and integrate peer coaches.
»
Increase access to withdrawal management (detox).
»
Expand access to recovery supports early in recovery and maintain them for
at least one year.
Additional Action Steps
»
Increase access to education and programming on trauma-informed care.
»
Integrate substance use screening, assessment, treatment and linkages to
recovery supports within the mental health and physical health system of
care.
»
Utilize a person-centered funding approach.
»
Create a mechanism to improve system navigation.
»
Provide support and education for the families of individuals engaged in
recovery.
»
Increase the availability of appropriate activities for youth and adults that
do not involve alcohol or drugs.
»
Create services that that accommodate a variety of schedules (e.g.,
weekends, evenings).
[]
Integrated, person-
centered, community-
based, family-focused
recovery supports are
readily available.
3
[ ]
Critical Issue [] | 22
»
Ensure that psychiatric support services and medication are available
as individuals transition from treatment to home or community-based
settings.
»
Explore use of technology to support recovery, including online courses,
and access to counselors via videoconferencing.
»
Ensure that substance use disorder treatment curricula are relevant,
person-centered, culturally appropriate, up-to-date, and evidence-based.
Overview
Individuals enter recovery through various avenues. Today, many individuals
enter the recovery system as a result of criminal justice involvement, rather
than through the healthcare system. is is the least eective way to address
what is a signicant public health problem. Shifting to a person-centered,
community-based public health approach will require education, stakeholder
engagement and realignment of resources. ese changes will also be necessary
to help people in our community gain access to more eective pathways to
recovery.
Key Findings
[ ]
Substance use disorders are chronic illnesses.
Chronic diseases such as diabetes, hypertension, and asthma are often
characterized by relapse (recurrence of symptoms) and require lifelong
vigilance to achieve and maintain recovery. is is also true of substance use
disorders. Characteristics of substance use disorders consistent with those of
other chronic diseases include:
»
A tendency to run in families;
»
An onset and course inuenced by environmental contributions like early
physical or sexual abuse, exposure to violence, stress and drug availability;
»
e ability to respond to appropriate treatment, which may include long-
term lifestyle modication;
»
Similar rates of relapse; and
»
Eective treatments are available, but there is no known cure.
Studies have shown that to of the predisposition to addiction can
be attributed to genetics. Complex interactions between genes and the
environment also impact the likelihood of addiction, with protective factors
like resiliency and the ability to deal with stress in opposition to risk factors
like peers who use alcohol or drugs.
Relapse rates for substance use disorders
are similar to those of diabetes, hypertension, and asthma. As with other
chronic illnesses, relapse should be seen as a trigger for a new intervention,
rather than an indication of failure.
“Recovery is a process of change
through which individuals
improve their health and
wellness, live a self-directed
life, and strive to reach their full
potential.”
–SAMHSA
Recovery Supports Recovery
supports are those services and
programs that provide critical
assistance to individuals seeking
to recover from substance use
disorder (such as peer support,
sober housing, and mental
health counseling)
Recovery
• Emerges from hope
• Is person-driven
• Occurs via many pathways
• Is holistic
• Is supported by peers
and allies
• Is supported through
relationships and social
networks
• Is culturally-based and
influenced
• Is supported by
addressing trauma
• Involves individual, family,
and community strengths
and responsibility
• Is based on respect
so u r c e : SAMHSA’s 10 Guiding
Principles of Recovery
“Drug abuse is an illness. It is a
health problem, not a criminal
justice problem.”
– ,
,
Critical Issue [] | 23
Relapse Rates are Similar for Drug Addiction & Other Chronic
Diseases
: McLellan et al., 2000; National Institute on Drug Abuse
[ ]
Recovery is possible through a variety of
pathways.
SAMHSA’s denition of recovery has expanded over the last few years, moving
away from a focus on abstinence to emphasize improvements in health and
wellness and reduction of harmful consequences. e current denition of
recovery is a process of change through which individuals improve their health
and wellness, live a self-directed life, and strive to reach their full potential.
rough the Recovery Support Strategic Initiative, SAMHSA has identied four
key dimensions that support a life in recovery:
Overcoming or managing one’s disease(s) or symptoms—for
example, abstaining from use of alcohol, illicit drugs, and non-
prescribed medications if one has an addiction problem—and
for everyone in recovery, making informed, healthy choices
that support physical and emotional wellbeing
A stable and safe place to live
Meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and
the independence, income and resources to participate in
society
Relationships and social networks that provide
support, friendship, love, and hope
Drug Addiction
Type I Diabetes
Hypertension
Asthma
40–60%
30–50%
50–70%
50–70%
Critical Issue [] | 24
For many individuals with a substance use disorder, achieving recovery can be
a long process. An analysis of a longitudinal study of people receiving publicly
funded treatment found a median time of years from rst to last use, and a
median time of years from rst treatment episode to last use.
e authors
also found that achieving recovery often took signicantly longer for:
»
Males
»
People who started using before age (particularly those starting under
the age of )
»
People who had participated in treatment three or more times
»
People with high mental distress
Recovery is indicated by either sobriety or reduced substance use (depending
on the severity of the disorder), and increased quality of life. Abstinence from
the use of alcohol, illicit drugs, and non-prescribed medications is often the
goal for those with severe substance use disorders. e likelihood of success
increases as time passes. If an individual can maintain sobriety for ve years,
he or she is much more likely to maintain long-term recovery.
Extended Abstinence is Predictive of Sustained Recovery
: Dennis et al, Evaluation Review, 2007; National Institute on Drug Abuse
“e initial catalyst [for my
recovery] was a narcotics
task force that knocked down
my front door. Two weeks
later I caught more felonies
for possession. I nally got a
plea bargain for jail time and
treatment. I found myself in jail
on Easter stripped down naked,
they skipped my breakfast, in
an 8x8 padded room on suicide
watch with no clothes, and I was
hungry. And that was it.”
—
Critical Issue [] | 25
1–3 years
1–12 months
3–5 years
5+ years
66%
0
50
100
36%
86%
86%
Percentage Sustaining Abstinent
Through Year 8
Duration of Abstinence at Year 7
Recovery Triggers
Focus group participants identied both intrinsic and extrinsic factors that
triggered their recovery process, including the following:
Internal Factors
»
Isolation
»
Personal loss of control (harmed self or someone else, destroyed property)
»
Acknowledgement that life was going nowhere
»
Physical and mental health concerns
»
Fear of death or harm
External Factors
»
Family and children
»
Criminal Justice involvement
»
Child Protective Services involvement
»
Support from a caring individual
»
Seeing someone else stuck in or dead from a lifestyle centered around
alcohol and/or drug use
Perceptions of Recovery
e widespread perception that individuals don’t recover is dicult to
overcome. Stakeholders in the planning process agreed that it would be
helpful for individuals in long-term recovery to become more visible and share
their stories in order to give hope and inspiration to others. Every individual is
unique and each has his or her own strengths, goals, culture, and preferences
that will impact the path to recovery. Traditional perceptions are that when
individuals go into recovery they follow a predictable path:
Traditionally Perceived Pathway to Recovery
In , SAMSHA’s Center for Substance Abuse Treatment conducted focus
groups and interviews to gain greater insight into the process of recovery. e
report identied multiple recovery pathways, including:
»
without treatment or a formal support system
»
including -Step groups such as Alcoholics
Anonymous, Women for Sobriety and SMART Recovery
»
- including groups such as Celebrate Recovery or
religious practices, such as attending church
»
including rituals specic to individuals’ cultures
One Recovery Path
“My pathway to recovery began
after a court order to a treatment
program after my children were
removed from my care by CPS. I
entered into a thirty-day inpatient
substance use treatment program.
Upon graduation, I entered a
transitional living program, where
it was mandatory to attend three
to four weekly 12-Step community
groups and attain employment.
Plus, I had a counselor who helped
me explore spiritual matters and
counseled me about past traumas.
After a year of sobriety, I was
reunited with my children and
we got an apartment of our own.
I continued to work the 12-Step
program and continued full time
employment to provide for my
family. At three years of sobriety, I
went back to college to obtain my
undergraduate degree. Currently, I
am almost 8-and-a-half years sober
and I credit residential treatment,
the 12-Step program, family and
social support, vitamin therapy,
yoga, meditation, acupuncture,
and several other similar pathways
for my personal recovery journey
of wellness and wholeness. In two
weeks I will graduate with my
master’s degree in social work.”
—
Critical Issue [] | 26
»
starting with arrest and incarceration
that leads to treatment
»
including
residential treatment, therapeutic communities, and halfway houses
»
including yoga, breath work, and
traditional Chinese medicine, such as acupuncture, herbal medicine,
and Qigong
»
including art, music, and volunteering
While some participants used just one of the pathways, the majority
used two or more, both concurrently and sequentially, on their road
to recovery. e primary lesson that emerged was the importance of
enabling access to the right pathway or pathways to help an individual
nd his or her own best route to recovery.
[ ]
Early access to supports is vital to successful
recovery.
Substance use disorders are chronic illnesses that usually require
intervention and are prone to relapse. For individuals beginning recovery,
it is critical that recovery supports are introduced early in the process
and that these supports remain available for at least a year to increase
the likelihood of success. Based on a survey of more than individuals
in recovery in Travis County, of respondents had been arrested at
least once and had been incarcerated at least once during their active
addiction. Forty percent of respondents had a DWI charge, had
damaged property, frequently missed school or work, and had
frequent emergency room visits while active in their addiction. Dealing
with the consequences of substance use often can feel overwhelming
to individuals as they enter recovery. Many must attend probation or
parole meetings, address health issues, repair relationships with families,
address child custody issues, and overcome disrupted education and
job histories.
Because of this often complex history, many individuals need person-
alized supports as they enter recovery and begin to rebuild their lives.
Recovery supports are services and programs that provide critical
assistance to individuals as they seek to achieve long-term recovery,
including:
»
Peer recovery programs
»
Safe, aordable, sober housing
»
Employment or volunteer activities
»
Mental health counseling, psychiatric medication and support
»
Physical health services
»
Support for family members
»
Faith or spiritual home
“ere was a police ocer who
had seen me on the streets for
a while. Instead of arresting
me, he told me he was going
to call me every day until I got
help. He did, and this simple act
of kindness led me to getting
treatment. Just knowing that
someone believed things could be
better made all the dierence.”
—
Based on a survey of more than
individuals in recovery in Travis
County, of respondents had been
arrested at least once and had
been incarcerated at least once during
their active addiction. Forty percent
of respondents had a DWI charge,
had damaged property,
frequently missed school or work, and
had frequent emergency room
visits while active in their addiction.
Critical Issue [] | 27
»
Opportunities for recreation without drugs or alcohol
»
Stress reduction activities such as meditation
»
Physical exercise
To address the consequences of their substance use, individuals in early
recovery need to have a sense of stability and their basic needs for sustenance,
housing, work, and emotional health must be met in order to continue on a
recovery path.
Safe, Affordable, Sober Housing
e number one concern for focus group participants was nding safe,
aordable housing that oers an environment conducive to recovery. For many
individuals this means nding a new housing option, as the place they lived
previously is associated with alcohol or drug use and may still have individuals
living there who will not support recovery. Recovery residences oer an option
to address this. According to the National Association of Recovery Residences
(NARR), these provide sober, safe, and healthy living environments that
promote recovery from alcohol and other drug use and associated problems.
Recovery residences are divided into levels of support based on the type of
housing and the intensity and duration of support oered. Services range from
peer-to-peer recovery support to medical and counseling services. In recent
years, NARR has created a certication process administered in Texas through
the Texas Recovery Oriented Housing Network.
Peer Recovery Support Services
Peer support has proven eective for both adults and adolescents. As used in
SAMHSA’s Recovery Community Services Program, the term “peer” refers to
individuals who share the experiences of addiction and recovery, either directly
or as family members or signicant others. SAMHSA has identied four types
of support that can be provided through peer relationships:
Demonstrate empathy, caring, and
concern to reduce isolation and
bolster a person’s self-esteem and
condence
Peer mentoring, peer-led support
groups
Share knowledge and information
and/or provide life or vocational skills
training
Parenting classes, job readiness
training, wellness seminars
Provide concrete assistance to help
others accomplish tasks
Child care, transportation, help
accessing community health and
social services
Facilitate contacts with other people
to promote learning of social and
recreational skills, create community,
and acquire a sense of belonging
Recovery centers, sports league
participation, alcohol- and drug-free
socialization opportunities
New Travis County court aims to
help oenders with drug abuse
issues
e new re-entry court which
launcthed in December [2014],
aims to help people with the
longest rap sheets and highest risk
of falling back into the criminal
justice system, requiring them to
attend biweekly meetings at the
courthouse after completing the
intensive Substance Abuse Felony
Punishment Facility program while
in prison.
– -
Critical Issue [] | 28
In recent years, as evidence of the eectiveness of peer coaching and peer
supports has grown, so has credentialing for recovery coaches, with curricula
and funding from the Texas Department of State Health Services. In Travis
County, an array of organizations provide peer training, supervision, and
support, including Communities for Recovery, Via Hope, SoberHood, and
Teen and Family Services Austin. Despite these eorts, building further
infrastructure for the supervision and ongoing training of peer coaches
is important to ensure quality services and ready access. Many peer
organizations are now connecting with more formal systems of care. However,
increasing connections with the criminal justice and traditional treatment
systems should be explored.
Employment Support
After housing and peer support, access to steady employment was identied
as the next most critical recovery support. Individuals in focus groups and
surveys stated that a core element of recovery is having a routine. Work
provides both a regular place to be and a means to meet basic needs. Many
individuals stated that their alcohol and drug use had interfered with their
education and work history and indicated that they would need support to nd
and maintain a job paying a living wage.
Mental Health Counseling & Psychiatric Medication/Support
Persons diagnosed with mood or anxiety disorders are about twice as likely to
also suer from substance use disorder when compared with respondents in
general. Similarly, persons diagnosed with drug disorders are roughly twice as
likely to also suer from mood and anxiety disorders.
A recent clinic-based
study of substance abusers found that had at least one co-occurring
mental disorder.
About half of people with schizophrenia or bipolar disorder
have a co-occurring substance use disorder.
Because of the comorbidity,
individuals in early recovery often need access to mental health counseling and,
in many cases, psychiatric medication. In the local focus groups and survey,
one of the challenges many individuals in recovery reported facing was timely
access to mental health and medication support.
Medication-Assisted Treatment (MAT)
e Substance Abuse and Mental Health Services Administration (SAMHSA)
denes MAT as “the use of medications, in combination with counseling and
behavioral therapies, to provide a whole-patient approach to the treatment of
substance use disorders.” Medications utilized in MAT include: Methodone,
Buprenorphine, Naloxone, Zubsolv, Subotex, and Suboxone, which are all
used for the treatment of opioid dependence, and Disulram, Naltrexone, and
Acamprosate Calcium, which can be used to treat alcohol dependence.
Family Support
Focus group participants identied family as an essential part of the recovery
process. Given the strain on familial relationships resulting from substance
use, many need to reconnect with family and repair their relationships. e
quality of familial relationships impacts individuals’ ability to maintain
recovery. Focus group participants also expressed a desire to have access to
family counseling sessions during and after treatment.
Critical Issue [] | 29
Spirituality
Spirituality looks dierent for each person. It may be associated with specic
religious beliefs, or may represent a broader, nondenominational interest
in the spiritual. A majority of local focus group participants referenced
spirituality as a bedrock of their recovery. While for many this was related to a
-Step recovery program, for others it was based on a religious aliation or a
desire for a spiritual path.
Other Supports
Many focus group participants stated that meditation and yoga are useful
in helping with focus and relaxation. Boredom was frequently mentioned
as one of the factors leading to destructive alcohol or drug use, so access to
sober recreational activities is important. In Austin, a variety of organizations
organize sober activities for adults and youth, including the Sober Recreation
Committee of Austin, which has a Facebook page to promote sober events;
Recovery Alliance of Austin, which provides educational opportunities and
support services; and Recovery People, which organizes and mobilizes people
in recovery.
[ ]
Addressing trauma is critical to many people’s
paths of recovery.
In the National Survey of Adolescents, teens that had experienced physical or
sexual abuse or assault were three times more likely to report past or current
substance abuse than those without a history of such trauma.
In surveys of
adolescents receiving treatment for substance use disorder, more than
had a history of trauma exposure.
SAMHSA has recognized trauma-informed
care as a best practice for addressing substance use disorders, stating that a
“program, organization, or system that is trauma-informed:
»
Realizes the widespread impact of trauma and understands potential paths
for recovery;
»
Recognizes the signs and symptoms of trauma in clients, families, sta, and
others involved with the system;
»
Responds by fully integrating knowledge about trauma into policies,
procedures, and practices; and
»
Seeks to actively resist re-traumatization.”
In Travis County, the Trauma Informed Care Consortium of Central Texas
brings together professional organizations to address the trauma needs of
children and families. Traditionally, the coalition has addressed the impact of
adverse childhood experiences in children, but it is now expanding to address
trauma among adults. Many local treatment centers are also incorporating
trauma-informed care into their programming.
In surveys of adolescents receiving
treatment for substance use disorder,
more than had a history of
trauma exposure.
Critical Issue [] | 30
[ ]
Family members should be
integrated into recovery efforts.
Substance use disorder negatively impacts the entire
family. For true recovery and healing to occur, everyone
needs to receive help. Family members and friends of
individuals with a substance use disorder often lack
accurate information about the issue. ey struggle
to know how to address the problem and may fear
confrontation or estrangement. Family therapy oered in
the course of treatment for substance use disorder creates
an opportunity for family members to understand the
disease and their own issues and improve communication.
Treating the whole family is essential to healing and
recovery.
A growing body of research on the eectiveness of family
therapy is demonstrating that diverse approaches can
address multiple challenges. Family therapy in substance
abuse treatment has two main purposes. First, it seeks
to use the family’s strengths and resources to help nd or
develop ways to live without substances of abuse. Second,
it ameliorates the impact of chemical dependency on both
the individual and the family. Frequently, marshaling the
family’s strengths requires the provision of basic support
for individuals with substance use disorder as well as
for their families.
Similarly, behavioral therapy has led
to increased rates of abstinence from substance use and
decreased the incidences of separation and divorce.
While many Travis County treatment centers incorporate
family therapy into their programs, stakeholders agree
that more emphasis should be placed on addressing family
issues.
Conclusion
Recovery is a process that requires intervention and
ongoing support. Individuals who don’t have their basic
needs met for housing, income, and personal support
are more likely to relapse and engage in destructive
behaviors. Individuals, families, and communities all
bear responsibility for supporting recovery. Individuals
have a personal responsibility for self-care and recovery
and should be supported in speaking for themselves.
Families and signicant others have responsibilities to
support their loved ones, especially children and youth in
recovery. Communities have responsibilities to provide
opportunities and resources to address discrimination
and to foster social inclusion and recovery. Individuals
in recovery also have a social responsibility and should be
supported in joining with peers to speak collectively about
their strengths, needs, desires, and aspirations.
•
Substance use disorders are primarily treated in
health care settings, rather than the criminal justice
system, reducing criminal justice costs.
•
ere is increased coordination and collaboration
between the formal and informal recovery systems
of care.
•
Recovery supports such as housing, employment,
mental health care, and peer support are readily
available.
•
Prevention and treatment are integrated into the
primary care and mental health systems, creating a
holistic system.
•
Trauma-informed care is integrated into the
recovery system.
•
Family members of individuals with substance
use disorders have timely access to supports and
services.
Critical Issue [] | 31
Key Findings
[1]
Our community has limited access to treatment
resources
[2]
Our system of care is not suciently person-centered
and lacks coordination and integration
[3]
Our community lacks the ability to measure progress
in addressing substance use disorder
[4]
Specic subpopulations lack access to treatment
appropriate for their needs
[5]
Current funding is inadequate to support and sustain a
quality system and workforce
Immediate Action Steps
»
Create or identify an existing group of community
leaders to oversee plan implementation and system
integration.
»
Create a capacity and gap analysis to develop a
roadmap for the investment of new funds in an
integrated recovery system, with attributes including
deliberate linkages between formal and informal
systems; a transition from acute to community-based
care; and opportunities to increase the overall capacity
of the prevention and recovery systems.
[]
Infrastructure is in place to identify
opportunities to strengthen the
substance use disorder system, to
develop sustainable resources and to
monitor effectiveness.
4
[ ]
’
Critical Issue [ ] | 32
Additional Action Steps
»
Align substance use screening, assessment, treatment and linkages to
recovery supports with the mental health and physical health systems of
care.
»
Ensure that psychiatric support and medication is available at times of
transition from a treatment setting.
»
Increase the capacity, aordability, and quality of recovery supports such as
sober housing, peer support, employment, and recreational activities.
»
Provide current substance use disorder data that is easy for the public
health system, the media, and policymakers to access.
»
Create consistent measurements of progress in impacting substance use,
including using quality of life indicators.
»
Coordinate data sharing across health systems.
»
Create “warm hand-os” between dierent pieces of the recovery system.
»
Strengthen workforce capacity and ensure sta are caring, competent,
and qualied, can relate to individuals in recovery, and have manageable
caseloads.
»
Ensure that medication assistance benet coverage under public and
private insurance includes access to medications proven eective in
addressing substance use disorders, including Medication-Assisted
Treatment.
»
Identify and coordinate state and federal funding requests to enhance the
capacity for local substance use prevention and recovery supports and
services.
Overview
Travis County’s continuum of care for substance use disorder is fragmented
and under-resourced. Our community currently lacks an oversight group
of community leaders focused on increasing resources, reducing the impact
of substance use disorder, and integrating the system to increase positive
outcomes. In addition, the current funding structure is based on a model that
does not generally cover program costs and that keeps substance use disorder
professionals at the low end of healthcare pay scales.
Critical Issue [ ] | 33
Key Findings
[ ]
Our community has limited access
to treatment resources.
e Substance Use Inventory for Travis County released in demonstrated
that there are a variety of outpatient and residential treatment centers in
Travis County. However, demand outstrips the supply, especially for low-
income access to treatment. e - National Survey on Drug Use and
Health identied the Central Texas region as having the highest percentage
of individuals who are in need of but not receiving alcohol abuse treatment in
the state. Local providers also report that since Travis County has a relative
richness of resources, individuals from around the region access services here,
reducing the number of slots available for local residents.
Texans 12 or Older Needing But Not Receiving Treatment for
Alcohol Use in the Past Year
: 2010-2012 National Survey on Drug Use and Health. Texas Region 7a includes Travis, Bastrop,
Blanco, Burnet, Caldwell, Fayette, Hays, Lee, Llano, & Williamson counties
Critical Issue [ ] | 34
[ ]
Our system of care is not sufficiently
person-centered and lacks coordination and
integration.
Focus group participants and survey respondents reported diculty locating
and navigating prevention and recovery resources. Screening, assessment, and
recovery supports for substance use disorders are not consistently integrated
into existing healthcare systems. In addition, the agencies and organizations
that frequently address substance use disorders (i.e., schools, hospitals, jails,
treatment centers and ongoing recovery supports) often oer referrals, but
do not directly connect individuals to other providers, resulting in poorly
coordinated transitions. Similarly, health records are not well integrated and
substance use providers often do not coordinate with primary or mental health
clinicians.
Focus group responses to key questions about the current
system of recovery:
»
Longer length of connection (beyond days) – after-care
»
Person-centered approach
»
Opportunity to connect and share experiences with peers
»
Caring, competent, experienced counseling sta who have personal
experience with substance use
»
Positive reinforcement
»
Sober atmosphere
»
Individual readiness and willingness to participate
»
Cognitive behavioral therapy with curriculum that supports making
good choices
»
Meditation, yoga, exercise
»
-Step programs
»
Access to alternatives to -Step programs
»
Gender-specic programming
»
Co-ed programming to discuss relationships and parenting
»
Focus on value systems/principles
»
Accountability
»
Mental health services and medications
»
Connection to peer support and community resources
»
Addresses basic needs (food, housing, employment)
Critical Issue [ ] | 35
’
»
System navigation
»
Appropriate individualized screening that identies the right level of
care
»
Safe places to wait for services
»
Interim supports, including housing, while trying to access treatment
»
Detox
»
Funding to pay for classes/treatment
»
Convenient locations
»
Spanish-speaking sta
»
Connection & integration between treatment resources and ancillary
recovery supports (housing, jobs, peer support, etc.)
»
Sucient numbers of qualied sta with training in mental health
»
Access to psychiatric medication
»
Individualized treatment
»
Limited safe, condential, one-on-one counseling
»
Relevant, updated curriculum materials appropriate for dierent
education levels
»
Family counseling
»
Earlier focus on access to housing and employment
»
Access to peer specialists and recovery coaches
»
Co-ed point of view to learn about relationships/parenting (probation)
»
Recovery success stories
-
»
Family counseling support
»
Housing & employment support
»
Sober housing for women with children
»
Access to peer specialists and recovery coaches
»
Ability to connect with peer support while on probation
»
Advocacy & funding for recovery supports
»
Access to medication
»
Access to meditation, yoga, exercise
»
Access to low-cost exercise options and supports
»
Access and education about technology supports (recovery apps, online
courses, updated videos)
»
Medication-Assisted Treatment
| 36
e community advisory team echoed many of the focus groups’ sentiments.
ey also noted the system issues below as well as a lack of focus on substance
use issues at the larger, community level:
. One of this assessment’s
ndings is a lack of connection between the dierent systems impacting
the lives of individuals dealing with substance use disorder. If an individual
tries to access treatment or recovery support, it is often challenging to nd
information. When a person does nd information, it generally consists of a
referral that simply lists the name and phone number of an organization. e
same process occurs when a person is leaving a treatment facility. For the
most part, information is not regularly exchanged between the professionals
engaged in the individual’s life, such as a primary care physician or existing
caseworker. Individuals entering a recovery system are usually in the midst of
a chaotic situation, and are often involved with multiple other systems, such
as child welfare or criminal justice. Under these circumstances, it is extremely
challenging to navigate the dierent systems, identify the best places for
support, and make informed decisions.
. In order to receive
state-funded treatment, individuals are required to go through regional
Outreach, Screening, Assessment, and Referral centers (OSARs). e OSAR
for Central Texas is Bluebonnet Trails Community Services, located in Round
Rock in Williamson County. It serves the thirty counties of Region . However,
assessments are often performed in other parts of the system, including
primary care settings. SAMHSA has identied many screening tools that can
be used in these settings,
vii
but currently no tool is consistently used across
health systems, and many primary care providers are not comfortable with
addressing substance use or asking screening questions. In the criminal justice
system, the Travis County Correctional Complex is in the process of reviewing
its substance use screening tools and incorporating them earlier in the intake
process. e Travis County Probation Department has an extensive screening
and assessment process in place.
. While a great deal of progress has been made in integrating
health records, full integration has not yet occurred and there are often still
barriers, real or perceived, to entering behavioral health information into
physical health records. One key barrier is the concern that sharing data will
violate the Health Insurance Portability and Accountability Act (HIPAA) and
other privacy laws. is can be overcome with training about how to share data
within HIPAA’s strictures. Full records integration and information-sharing
would allow for better prescription tracking, reducing an individual’s ability to
go to multiple physicians to obtain prescriptions that lend themselves to abuse.
It would also help health care professionals diagnose substance use disorder
more quickly based on a pattern of behavior, increasing timely and appropriate
care delivery.
vii A full list can be used at http://www.integration.samhsa.gov/clinical-practice/screen-
ing-tools#drugs.
Critical Issue [ ] | 37
Currently no tool is consistently
used across health systems, and
many primary care providers are
not comfortable with addressing
substance use or asking screening
questions.
. While
best practices call for individualized services, the reality is that funding
restrictions limit service exibility for many providers. Most treatment and
recovery providers are paid to perform certain functions and are limited in the
amount of additional services they can provide.
[ ]
Our community lacks the ability to measure
progress in addressing substance use disorder.
Two local community assessment reports mention substance use. e
Community Advancement Network monitors substance use rates through
its dashboard. e City of Austin’s Community Health Assessment mentions
high rates of binge drinking. However, no current group creates a report card
specically focused on substance use and its impact. Developing one requires
that we identify agreed-upon community measures and implement a system
for monitoring success. Other communities have taken this approach.
For example, Miami-Dade County maintains a health report card measuring:
»
Binge drinking among adults
»
Rates of hospitalization due to alcohol abuse
»
Arrest rates for driving under the inuence of alcohol or drugs
Maine measures progress on:
»
Leadership, structure, and sustainability in place to oversee substance use
»
Resources available to support substance use initiatives
»
Legislative initiatives that impact substance use, including laws and
regulations that prevent recovering individuals from getting jobs,
education and other services for successful reintegration, which have been
identied as potentially requiring review and repeal
»
Measurement and accountability: holding agencies and contracted
providers accountable for performance and for meeting goals
e Join Together handbook, produced with the support of the Robert Wood
Johnson Foundation, outlines dierent indicators that can be used to
measure progress on community substance abuse.
Our community should
determine which of these indicators have the most meaning and identify a
body to collect, maintain, and report the data.
Critical Issue [ ] | 38
[ ]
Specific subpopulations lack access to
treatment appropriate for their needs.
e services provided by traditional treatment centers and Alcoholics
Anonymous are primarily based on the needs and experiences of middle-class
white males. As the populations seeking services have become more diverse,
treatment centers have adapted programming to become more relevant to
a broader array of clients. In Travis County, however, a number of groups
lack sucient access to relevant and appropriate treatment resources. ese
include:
»
Phoenix House has an inpatient adolescent treatment
center in Austin. In June , Phoenix House added residential
treatment beds for females to the beds available for adolescent males.
While this adds overall community capacity, residential beds for low-
income adolescents are still limited.
»
() Austin
Recovery, now e Council on Recovery, closed its detox beds in
July due to an inability to cover operating costs with available
reimbursement rates. Ambulatory detox remains available and there
are eorts to identify additional locations and resources, however,
this gap in the continuum has yet to be fully lled, especially for low-
income individuals, who are currently receiving detox services in other
communities due to the lack of access in Travis County.
»
e Council on Recovery provides -
day inpatient treatment and support for women and up to children.
However, the majority of these slots are reserved for women involved
with the Department of Family and Protective Services (DFPS) who are at
risk of losing their children to state custody. Most outpatient settings do
not provide child care, which further limits the options for women with
children. Women also face unique issues. Research has shown that physical
and sexual trauma followed by post-traumatic stress disorder (PTSD) is
more common among women seeking treatment than men. Other factors
that can inuence women’s treatment processes include issues around
provider referrals, nancial independence and pregnancy.
»
- mental health and substance use
disorders – while the majority of treatment providers address co-occurring
mental health and substance use disorders, most lack the sta expertise
and/or depth of programming necessary to adequately address the needs of
individuals with serious mental illness.
»
() an estimated to of gay and transgender people abuse
substances, compared to about of the general population.
Currently,
our community lacks a treatment center with a specic track or program
focused on the LGBTQ community and its unique needs.
Critical Issue [ ] | 39
»
Very few, if any, local providers focus on senior substance use
treatment and seniors are a rapidly growing population. Loneliness and
mental health issues, coupled with pre-existing alcohol and drug habits,
have resulted in many older adults engaging in potentially dangerous drug
and alcohol use. Findings from the National Institute on Alcohol Abuse and
Alcoholism show that to of people ages to have experienced
drinking problems.
»
Of treatment
providers responding to the survey, approximately one-third oered
adult programming in Spanish and two reported providing programs
for individuals with hearing impairments. Only one program, Austin
Travis County Integral Care’s ambulatory detox, stated that it could serve
people in multiple languages. English is also the primary language among
adolescent service providers. Our community is home to rapidly growing
Asian and Hispanic populations, many of whom do not speak English at
home.
»
According to the Ending Community Homelessness
Coalition’s Annual Point in Time Count, there are approximately
, homeless individuals in Travis County on any given day, over of
whom have been diagnosed with substance use disorder. In , SAMHSA
estimated that of homeless people are dependent on alcohol and
abuse other drugs.
Locally, the Ending Community Homelessness
Coalition reported that . of all homeless individuals self-report
heavy alcohol or drug use (but have not necessarily been diagnosed with a
substance use disorder), equating to , homeless individuals in .
In , of the , homeless individuals engaged with the Downtown
Austin Community Court were assessed as having problems with alcohol
or drug abuse. Only about one-third of these individuals were able to
access treatment. Many face additional barriers such as a co-occurring
mental illness, lack of access to aordable housing and intermittent or no
employment. In order successfully treat their substance use disorder, the
basic housing and income needs of these clients must also be met.
»
Youth in foster care or aging out of the
foster care system warrant special acknowledgement. In recent years,
community awareness of the challenges for these populations has increased
signicantly. In , there were children in foster care in Travis
County.
LifeWorks and Austin Children’s Services both provide support
services for youth aging out of foster care, including issues related to
substance use, but neither has a core focus on addressing substance use.
In addition, focus group participants pointed out that the materials used
within treatment centers are often outdated and that many are not culturally
relevant.
Critical Issue [ ] | 40
[ ]
Current funding is inadequate to support a
quality system and workforce.
When e Council on Recovery closed its detox beds in July , many in
the community were surprised and concerned that such a critical part of the
continuum was no longer available. However, it was a necessary nancial step.
Providing detox services costs approximately - per patient, per day. e
Department of State Health Services’ reimbursement rate for sub-acute detox
is only per day and there was no consistent funding source to ll the gap.
Other providers report similar challenges, noting that typical reimbursement
rates do not fully cover costs. Most local providers were not comfortable sharing
their cost of services, so the following estimates are based on national ranges.
Funding for substance use disorder treatment is low, and
prevention and recovery resources are limited
Currently, most local funding for substance use services for low-income
individuals comes from Austin Travis County Integral Care’s (Integral Care’s)
Managed Services Organization (MSO). e MSO supports provision of services
by providing credentialing, gate functions, utilization management, quality
management, contract monitoring, claims payment, nancial management and
network development.
Individuals often present for substance use treatment at the emergency
department or a provider agency. Providers assess their need for treatment.If an
individual is in need of services, the provider contacts Integral Care’s Utilization
Management Department to determine nancial and program eligibility and to
obtain authorization for an appropriate level of service. If the individual is not
eligible or the appropriate level of service is not available through that provider,
the Utilization Management Department works with the region’s Outreach,
Screening, Assessment and Referral center to identify an appropriate provider.
Utilization Management continuously reviews the appropriate level, intensity
and duration of services to prevent over- and under-utilization of services.
e services available through the provider network are: solution-focused
counseling services, outpatient services, intensive and supportive residential
treatment, detoxication services, recovery supports (goods and services) case
management, sober housing and aftercare services.
weeks– weeks ,–,
days ,–,
days ,–,
monthly –
Critical Issue [ ] | 41
e investment in substance use services through the interlocal agreement
with the City of Austin has decreased over the last three years, from approxi-
mately . million in FY to . million in FY . When residential detox
services were discontinued, the use of inpatient care increased, resulting in a
increase in detoxication costs. Many of the individuals served through the
MSO have complex needs and are engaged in multiple systems. is intensity
of need requires coordination of services and connection to social services and
housing. Traditionally, the MSO has focused resources on residential treatment.
However, though the demand for residential treatment has remained high,
there has been an attempt to focus more funding on housing, recovery coach-
ing, and other supports that are critical for helping individuals to maintain
recovery and sobriety. However, despite the movement to provide more
recovery supports, in FY , of funding went to residential treatment.
Austin Travis County Integral Care Managed Services
Organization (MSO) Substance Abuse Claims, 2014
Other signicant funding for community substance use services pays for
treatment provided through the adult and juvenile probation departments and
the Travis County Jail. Additionally, the City of Austin invested approximately
million in the Downtown Austin Community Court for treatment and
recovery supports, including up to days in housing for homeless individuals;
and Travis County invests in the Family Drug Treatment Court, focused on
women engaged with Department of Family and Protective Services. In July
, the St. David’s Foundation increased investment in residential treatment
at e Council on Recovery to , (up from ,) to address the gap
between state funding and actual costs.
Critical Issue [ ] | 42
$92,755
, 7%
$1,197
, < 1%
$53,586
, 4%
$146,589
, 10%
$1,114,198
, 79%
Aftercare, $1,197
Intensive Outpatient, $53,586
Outpatient (including recovery supports), $146,589
Residential Treatment, $1,114,198
Detox, $92,755
e local substance use disorders workforce is inadequate to
meet growing demand and is not well compensated.
With the implementation of the Aordable Care Act and its parity
requirements, the number of people with insurance coverage for alcohol and
drug use disorders is predicted to increase dramatically. However, Travis
County already has a severe shortage of trained and adequately compensated
behavioral health professionals. In January , SAMHSA submitted a report
to Congress outlining “the growing workforce crisis in the addictions eld
due to high turnover rates, worker shortages, an aging workforce, stigma and
inadequate compensation.” e workforce is inadequate throughout most
parts of the country.
Nationally, there are an estimated behavioral health
specialists for every , people with substance use disorder. Texas currently
has only behavioral health specialists for every ,.
Local substance abuse counselors are paid less than comparable providers
elsewhere.
ese salaries compare even less favorable to the average salary for other
healthcare professions in the Austin/Round Rock/San Marcos area. For
example, mental health counselors earn an average salary of ,, licensed
vocational nurses average ,, occupational therapy assistants average
,, physical therapist assistants average ,, and registered nurses
average ,.
e inadequate compensation leads to high turnover, making
it dicult to track individuals working in the eld.
75
/ /
,
,
,
Critical Issue [ ] | 43
Conclusion
Without focus, coordination, and true integration of systems and health
records, it will be challenging to measure results. In order to make
progress, our community should address the current funding and payment
structures for substance use services and ensure the availability of a full
continuum of care with adequately compensated, trained professionals
available to support individuals in need of prevention or recovery services.
•
Our community has an integrated system of care for effective and
efficient prevention of and recovery from substance use disorder
•
Health information exchanges support coordinated substance use
prevention and recovery
•
Coordinated and leveraged funding streams support effective principles,
practices, and programs
•
e quality, consistency, and sharing of local community substance use
data is improved and results are used to adjust interventions
•
e system supports individualized, culturally appropriate approaches
with no-wrong-door access and multiple community-centered pathways
to recovery
•
Individuals report increased quality of life, stable housing, and
employment
•
Evidence-based and promising practices are identified and expanded
•
e number of trained and/or certified individuals who support those in
recovery is increased and these workers are adequately compensated
Critical Issue [ ] | 44
Section | 45
e Community Plan
e guidance provided by the leadership team regarding
the community plan was that recommendations should:
»
Build on existing successful programming and
infrastructure components
»
Address populations that have a demonstrated need for
additional substance use services
»
Divert from more expensive services
»
Leverage other community eorts
»
Incorporate best practices, including recovery-oriented
supports
Build on existing successful programming and
infrastructure components
rough the course of the assessment, it became clear that
Travis County has many assets.
»
Prevention providers work together through the Youth
Substance Abuse Prevention Coalition.
»
Treatment providers provide a continuum of services,
including detox (although with limited access),
outpatient, intensive outpatient, residential, and
aftercare services. Many are incorporating best
practices, including trauma-informed care.
»
e Austin Recovery-Oriented Systems of Care (ROSC)
Initiative is gaining momentum and bringing a voice
to the many pathways of recovery.
»
ere are strong peer support training and
implementation programs.
»
Travis County Criminal Justice programs at the
jail and probation departments invest in screening,
assessment and treatment.
An informed, compassionate, engaged
community that prevents harmful
substance use, provides ready access
to a full continuum of services and
supports, and embraces a culture of
health, recovery, and resilience.
u
e Community Plan | 45
[] [] [] [ ]
Building upon the work of the / Commission, which developed a
continuum for the ideal mental health system, the community advisory team
identied core principles for the behavioral health continuum of care. ese
have been integrated into the pyramid below:
Integrated Behavioral Health System in Travis County
the Desired Continuum of Care
A core challenge for resource holders as the plan is
implemented will be balancing the need for additional
investment in the acute care system while adding resources to
prevention and recovery supports.
Training - Care Management - Peer and Family Recovery Support
$$$$
Strategy 4
Respond effectively
to people in crisis
Inpatient Psych
Med/Psych
Unit
Detox
Crisis Stabilization Services
Residential Treatment
Supported Housing
Intensive Outpatient
Integrated Physical and Behavioral Health Care
Outpatient Treatment
Screening for Mental Health and Substance Use Disorders
System Capabilities
Maximized Use of Technology - Leveraged Funding - Coordinated Care
System Characteristics and Shared Values
Best Practices - Integrated Care - Person-Centered Care - Cultural and Linguistic Competence
Accountability - Multiple Access Points - Trauma-Informed
Supported Recovery Services
Prevention Services
$$$
Strategy 3
Intervene intensively
for persons with
complex needs
$$
Strategy 2
Intervene early with
effective treatment
and supports
$
Strategy 1
Promote behavioral
wellness and support
recovery
Navigation Services
e Community Plan | 46
Plan Summary
is report creates an opportunity for the community
to come together and determine how to move forward
to increase access to and the quality of substance use
services in Travis County. In order to create change,
all parts of the community must identify the roles
they can play in implementing the recommendations
and supporting the incremental changes that lead to
transformation. ere are many strengths within the
system, but addressing our structural and resource
challenges will require a true commitment from all
sectors.
an informed, educated and supportive
community that understands the impact of substance
use disorders, communicates community standards, and
provides relevant information.
»
Establish a “hub” for vetted substance use information
and referrals.
»
Educate health care professionals about substance
use disorders, Medication-Assisted Treatment, and
appropriate community referrals.
Harmful substance use is prevented at
the earliest possible point.
»
Invest in the coordination and leveraging of existing
prevention programs.
»
Increase the overall investment in eective prevention
strategies so that they can be brought to scale.
Integrated, person-centered, community-
based, family focused recovery supports are readily
available.
»
Educate existing healthcare and public safety system
navigators on substance use resources.
»
Educate, employ, and integrate peer coaches.
»
Increase access to withdrawal management (detox).
»
Expand access to recovery supports early in recovery
and maintain for at least one year.
Infrastructure is in place
to identify opportunities to strengthen the substance use
disorder system, to develop sustainable resources and to
monitor eectiveness.
»
Create or identify a group of community leaders to
oversee plan implementation and system integration.
»
Create a capacity and gap analysis to develop
a roadmap for the investment of new funds in
an integrated recovery system, with deliberate
linkages between formal and informal systems,
transitions from acute to community-based care, and
opportunities to increase the overall capacity of the
prevention and recovery systems.
e Community Plan | 47
End Notes | 48
End Notes
Based on estimates from the American
Community Survey and the SAMHSA Center for
Behavioral Health Statistics National Survey on Drug
Use and Health (NSDUH)
Ibid
Arrest Data Analysis Tool, H. Snyder and J. Mulako-
Wangota, Bureau of Justice Statistics, Washington, D.C.,
January , www.bjs.gov
Austin Police Department, APD Chief’s Monthly Report,
December , https://www.austintexas.gov/page/
chiefs-monthly-reports
Information provided electronically by Raul Garcia with
the Travis County Sheri’s Oce, April
Texas Department of Criminal Justice, Fiscal Year
Statistical Report, http://www.tdcj.state.tx.us/
documents/Statistical_Report_FY.pdf
Austin/Travis County Reentry Roundtable (ATCRR),
ATCRRT Report Card, September , http://www.
reentryroundtable.net/wp-content/uploads///
ATCRRT-report-card-revised-Sept-Final.pdf
Sobriety Center Planning Committee, Sobriety
Center Implementation Report, April . https://
lintvkxan.les.wordpress.com///sobriety-center-
nal.pdf
Email communication from Andy Hofmeister, Austin
Travis County EMS, January
Sobriety Center Planning Committee, Sobriety Center
Implementation Report, April https://lintvkxan.
les.wordpress.com///sobriety-center-nal.pdf
Ibid
Austin/Travis County Health and Human Services
Department, Budget Report, August
Travis County Medical Examiner, Annual Report, ,
https://www.traviscountytx.gov/images/medical_
examiner/docs/annual_report.pdf
Email communication from Andy Hofmeister, Austin
Travis County EMS, January
Email communication from Laura Gold, Prevention
Services Manager – Disaster Preparedness & Response,
Mental Health First Aid (MHFA), & Suicide Prevention,
ATCIC. Received from ATCHHS department, July
Substance Use and Teen Pregnancy in the United
States: Evidence from the NSDUH -,
Christopher Salas-Wright et al., Addictive Behaviors,
; :-
Sobriety Center Planning Committee, Sobriety Center
Implementation Report, April https://lintvkxan.
les.wordpress.com///sobriety-center-nal.pdf
Prevalence and Distribution of Alcohol Use in the
Workplace: A U.S. National Survey, MR Frone, Journal
of Studies on Alcohol, ;:-
Substance Use in the Workplace, Hazelden, January
U.S. Department of Health and Human Services:
Substance Abuse and Mental Health Services
Administration, National Survey on Drug Use and
Health: Region A, http://www.samhsa.gov/data/
NSDUH.aspx
SAMHSA NSUDH
Institute for Health Metrics and Evaluation, Alcohol
Use, May , http://vizhub.healthdata.org/us-health-
map/
National Institute on Drug Abuse, Drug Facts:
Nationwide Trends, January , http://www.
drugabuse.gov/publications/drugfacts/nationwide-
trends
Substance Abuse Trends in Texas: June , Jane
Maxwell, , http://www.drugabuse.gov/sites/
default/les/texasa.pdf
Provided by Cmdr. David Mahoney, Austin Police
Department, March
e Changing Face of Heroin Use in the United States: A
Retrospective Analysis of the Past Years, eodore J.
Cicero, PhD; Matthew S. Ellis, MPE; Hilary L. Surratt,
PhD; Steven P. Kurtz, PhD, Journal of the American
Medical Association – Psychiatry, ;():-
Ibid
Flawed numbers mask the scope of prescription drug
problem, M. Roser, Austin-American Statesman, April
, , pp. A, A, A
Substance Abuse Trends in Texas: June , Jane
Maxwell, ,
National Institute on Drug Abuse, Drug Facts: High
School and Youth Trends, , http://www.drugabuse.
gov/publications/drugfacts/high-school-youth-trends
End Notes | 49
Alcohol Consumption Among Young AdultsAges–
in the United States: Results from the –
NESARC Survey, Chiung M. Chen, M.A., Mary C.
Dufour, M.D., M.P.H., and Hsiao ye Yi, Ph.D., ,
http://pubs.niaaa.nih.gov/publications/AA/AA.
htm
Healthy People ,Substance Abuse, July .
https://www.healthypeople.gov//topics-objectives/
topic/substance-abuse
Provided by the Ending Community Homelessness
Coalition (ECHO) based on HMIS data: Adults served in
Homeless Programs Dec -Nov
Elements Behavioral Health, Substance Abuse
and Suicide, March , , http://www.
elementsbehavioralhealth.com/mental-health/
substance-abuse-and-suicide
US Department of Health and Human Services,
Children’s Bureau, Child Maltreatment , December
.
Ibid
Drug & Other Addiction Services, Domestic Violence &
Substance Abuse: ings You Need To Know, Tennessee
Association of Alcohol, http://www.taadas.org/
factsheets/DVFacts.htm
e National Center on Substance Abuse at Columbia
University, Missed Opportunity: National Survey of
Primary Care Physicians and Patients on Substance
Abuse,
Ibid. e National Center on Substance Abuse at
Columbia University, Missed Opportunity: National
Survey of Primary Care Physicians and Patients on
Substance Abuse,
SAMHSA, Medication-Assisted Treatment for Opioid
Addiction: State Proles, . http://dpt.samhsa.
gov/pdf/-MedicationAssistedTreatmentForOpioidAddic
tion_StateProles.pdf
Facts for Families No, Teens: Alcohol and Other
Drugs,American Academy of Child and Adolescent
Psychiatry, July , https://www.aacap.org/AACAP/
Families_and_Youth/Facts_for_Families/Facts_for_
Families_Pages/Teens_Alcohol_And_Other_Drugs_.
aspx
Earlier Drinking Linked to Higher Lifetime Alcohol
Risk,US Department of Health and Human Services,
NIH News, July , http://www.nih.gov/news/pr/
jul/niaaa-.htm
California Society of Addiction Medicine, Blueprint for
Adolescent Drug and Alcohol Treatment in California,
, www.csam-asam.org/fckles/CSAM_Blueprint_
WEB.pdf
Drugs, Brains, and Behavior: e Science of Addiction,
National Institute on Drug Abuse, , http://www.
drugabuse.gov/publications/drugs-brains-behavior-
science-addiction
NIDA Notes: Risk and Protective Factors in Substance
Abuse Prevention, National Institute on Drug Abuse,
;(), http://www.drugabuse.gov/NIDA_Notes/
NNVolN/Risk.html
A Review of Evidence-baseEvidencebase for Harm
Reduction Approaches to Drug Use, Neil Hunt, ,
http://www.forward-thinking-on-drugs.org/review-
print.html
Motivational Interviewing: Preparing People for
Change, Miller and Rollnick, .
Eectiveness and Applicability of Motivational
Interviewing: A Practice-Friendly Review of Four
Meta-Analyses, Brad Lundahl and Brian L. Burke, ,
http://www.antoniocasella.eu/archila/Lundahl_.
pdf
U.S. Department of Justice, Promising Strategies to
Reduce Substance Abuse, , https://www.ncjrs.gov/
pdles/ojp/.pdf
Center for Problem Oriented Policing, Responses to the
Problem of Drunk Driving, accessed via web May ,
http://www.popcenter.org/problems/drunk_driving
One for the Road: Public Transportation, Alcohol
Consumption, and Intoxicated Driving, Karabo Jackson
and Emily Green Owens, Cornell University,
Drug Dependence, a Chronic Medical Illness:
Implications for Treatment, Insurance, and Outcomes
Evaluation. A. omas McLellan, PhD; David C. Lewis,
MD; Charles P. O’Brien, MD, PhD; Herbert D. Kleber,
MD, Journal of the American Medical Association,
;():-
National Institute on Drug Abuse, Dr Francesca
Ducci, , http://psychcentral.com/lib/alcohol-
consumption-and-genetics/
Drug Dependence, a Chronic Medical Illness:
Implications for Treatment, Insurance, and Outcomes
Evaluation. A. omas McLellan, PhD; David C. Lewis,
MD; Charles P. O’Brien, MD, PhD; Herbert D. Kleber,
End Notes | 50
MD, Journal of the American Medical Association,
;():-
e Duration and Correlates of Addiction and
Treatment Careers. Joumal of Substance Abuse,
Treatment () S-S.Dennis MLet al .
Pathways to Healing and Recovery: Perspectives from
Individuals with Histories of Alcohol or Other Drug
Problems, SAMHSA, November http://www.
samhsa.gov/sites/default/les/partnersforrecovery/
docs/Recovery_Pathways_Report.pdf
Comorbidity: Addiction and Other Mental Illnesses
Research Report Series, National Institute on Drug
Abuse, http://www.drugabuse.gov/publications/
comorbidity-addiction-other-mental-illnesses/
how-common-are-comorbid-drug-use-other-mental-
disorders
NIDA Notes: Recovery Checkup System Helps
Substance Abusers Who Have Mental Disorders,
National Institute on Drug Abuse, , http://www.
drugabuse.gov/news-events/nida-notes///
recovery-checkup-system-helps-substance-abusers-
who-have-mental-disorders
Comorbidity of mental disorders with alcohol and other
drug abuse. Results from the Epidemiologic Catchment
Area (ECA) Study, DA Regier et al, Journal of the
American Medical Association, , http://www.ncbi.
nlm.nih.gov/pubmed/
Medication-Assisted Treatment, SAMHSA, http://
www.samhsa.gov/medication-assisted-treatment
Recovery Alliance of Austin, http://raaustin.org/
Youth Victimization: Prevalence and Implications, DG
Kilpatrick, BE Saunders, DW Smith, U.S. Department
of Justice, Oce of Justice Program, National Institute
of Justice, , http://www.ncjrs.gov/pdles/
nij/.pdf
Maltreatment issues by level of adolescent substance
abuse treatment: the extent of the problem at
intake and relationship to early outcomes, Funk RR,
McDermeit M, Godley SH, Adams L, Child Maltreat.
; ():–
Multidimensional Family erapy for Adolescent
Substance Abuse, HA Liddle and A. Hogue, as cited
in Innovations in Adolescent Substance Abuse
Interventions, E.F. Wagner and HB Waldron, , p.
–
SAMHSA/CSAT Treatment Improvement Protocols:
Chapter – Substance Abuse Treatment and Family
erapy, http://www.ncbi.nlm.nih.gov/books/
NBK/
Health Council of South Florida, Miami-Dade County
Community Health Report Card Update, March
, http://www.miamidadematters.org/javascript/
htmleditor/uploads/Miami_Matters_health_report_
card_.pdf
Maine Substance Abuse Services Commission,
Report Card on Maine Substance Use Services,
, http://www.maine.gov/dhhs/samhs/
about/SASCReportCard.pdf
http://www.udetc.org/documents/Join-Together-
Indicators_Handbook-v.pdf
What are the Unique Needs of Women with Substance
Use Disorders?, Principles of Drug Addiction Treatment
(ird Guide), , http://www.drugabuse.gov/
publications/principles-drug-addiction-treatment-
research-based-guide-third-edition/frequently-asked-
questions/what-are-unique-needs-women-substance-
use
Why the Gay and Transgender Population Experiences
Higher Rates of Substance Use, Center for American
Progress, , https://www.americanprogress.org/
issues/lgbt/report/////why-the-gay-and-
transgender-population-experiences-higher-rates-of-
substance-use/
Substance Abuse in Senior Citizens a Serious Problem,
American Osteopathic Association, http://www.
osteopathic.org/osteopathic-health/about-your-health/
health-conditions-library/seniors-health/Pages/senior-
substance-abuse.aspx
Substance Abuse and Homelessness, National Coalition
for the Homeless, , http://www.nationalhomeless.
org/factsheets/addiction.pdf
Email correspondence from ECHO, Ending Community
Homelessness Coalition, December
How Severe is the Shortage of Substance Use
Specialists? Stateline, April , http://www.
pewtrusts.org/en/research-and-analysis/blogs/
stateline////how-severe-is-the-shortage-of-
substance-abuse-specialists
Bureau of Labor Statistics, Occupational Employment
Statistics, May , http://www.bls.gov/oes/current/
oes.htm()
Ibid.
Integral Care’s vision is healthy living for everyone.
is publication was made possible through a
collaboration of multiple stakeholders in Travis County,
ably facilitated by Woollard Nichols & Associates.
For more information, please visit IntegralCare.org.
For inquiries, please email [email protected]
