U.S. Department of Health And Human Services

This monograph examines a wide range of evidence-based practices for screening and assessment of people in the justice system who have co-occurring mental and substance use disorders (CODs). Use of evidence-based approaches for screening and assessment is likely to result in more accurate matching of offenders to treatment services and more effective treatment and supervision outcomes (Shaffer, 2011). This monograph is intended as a guide for clinicians, case managers, program and systems administrators, community supervision staff, jail and prison booking and healthcare staff, law enforcement, court personnel, researchers, and others who are interested in developing and operating effective programs for justice-involved individuals who have CODs. Key systemic and clinical challenges are discussed, as well as state-of-the art approaches for conducting screening and assessment.

This Treatment Improvement Protocol (TIP) update is intended to provide addiction counselors and other providers, supervisors, and administrators with the latest science in the screening, assessment, diagnosis, and management of co-occurring disorders (CODs). For purposes of this TIP, CODs refer to co-occurring substance use disorders (SUDs) and mental disorders. Clients with CODs have one or more disorders relating to the use of alcohol or other substances with misuse potential as well as one or more mental disorders. A diagnosis of CODs occurs when at least one disorder of each type can be established independent of the other and is not simply a cluster of symptoms resulting from the one disorder. Many may think of the typical person with CODs as having a serious mental illness (SMI) combined with a severe SUD, such as schizophrenia combined with alcohol use disorder (AUD).

The audience for these documents includes those interested in familiarizing themselves with the child welfare, alcohol and other drug services, and court systems. These documents are also intended for jurisdictions interested in or in the process of developing cross-systems relationships. The primer and guide are targeted to management and administrative personnel in State, county, and tribal jurisdictions' alcohol and drug services, child welfare, and court systems. The primer is not an exhaustive review of each system's mandates, practices, and policies. However, this document does provide an overview of the framework, target population, key legislation and funding sources, and structure and organization of services for each system.

The profile of opioid misuse and opioid use disorder in the United States is changing, in that nonmedical use of prescription opioids has become as significant a problem as the use of heroin.1 Federal data for 2013 indicate that approximately 4.5 million people in the United States reported nonmedical use of prescription pain relievers in the past month and 289,000 reported use of heroin in the past month.2 Despite the dimensions of the problem, nearly 80 percent of people with an opioid use disorder do not receive treatment because of limited treatment capacity, financial obstacles, social bias, and other barriers to care. Researchers, federal health agencies, and pharmaceutical manufacturers have focused on developing medications that can be used to expand access to treatment of an opioid use disorder in medical office settings, rather than limiting use to specialized opioid treatment programs (OTPs).

The Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (IOP) pack-age provides a structured approach for treating adults who abuse or are dependent on stimulant drugs. The approach followed in the treatment package was developed by the Matrix Institute in Los Angeles, California, and was adapted for this treatment package by the Knowledge Application Program of the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA). The Matrix Intensive Outpatient Treatment for People With Stimulant Use Disorders (IOP) pack-age provides a structured approach for treating adults who abuse or are dependent on stimulant drugs. The approach followed in the treatment package was developed by the Matrix Institute in Los Angeles, California, and was adapted for this treatment package by the Knowledge Application Program of the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration (SAMHSA).

This manual for Brief Marijuana Dependence Counseling (BMDC) is based on the research protocol used by counselors in MTP. The manual provides guidelines for counselors, social workers, and psychologists in both public and private settings who treat adults dependent on marijuana. The 10 weekly one-on-one sessions in the BMDC manual offer examples of how a counselor can help a client understand certain topics, keep his or her determination to change, learn new skills, and access needed community supports (exhibit I-1). Stephens and colleagues (2002) describe the MTP rationale, design, and participant characteristics. Findings from MTP are presented in supplemental reading B of section VII.

No single organization or person can address the multitude of services needed to help people affected by mental health or substance use conditions. The Government is no exception. While the Government can provide financial support and technical assistance to communities to deal with these challenges, it recognizes that the best sources are the people who live, serve, and work in the community and the best results are often seen when they undertake such action together. Today, in the United States, community partnerships are being established around many local challenges, including efforts to promote wellness and overcome issues associated with mental health and substance use conditions. In addressing these matters, unlikely alliances are being formed among community service organizations, the Government, the private sector, health and education systems and, in recent years, with grassroots faith-based organizations.

This publication was developed through a systematic and innovative process in which clinicians, researchers, program and administrative managers, policymakers, and other Federal, State, and independent experts were brought together for a series of intensive sessions. These individuals reviewed and discussed current administrative and clinical practices for treating substance-abusing lesbian, gay, bisexual, and transgender (LGBT) individuals and then wrote and edited the resulting document. The goal of this process was to improve and advance substance abuse treatment for a community of individuals whose health care needs are often ignored, denigrated, or denied.

The primary audience for this TIP is administrators of outpatient substance abuse treatment programs. A few words about this audience are in order. Whereas TIP 8 addressed intensive outpatient treatment, the current TIP drops the word "intensive" from its title because the consensus panel hopes that this TIP will find an audience beyond administrators of IOT programs. Most of the concepts and guidelines included in this TIP apply to the administration of all substance abuse outpatient treatment (OT) programs. On those rare occasions when information applies only to IOT programs, the authors have been sure to make this clear. Although the term "administrator" is used most often to describe the audience for this book, the terms "executive" and "director" appear as well and are used interchangeably with administrator. These overlapping terms emphasize the varied roles and responsibilities that administrators assume.

The expert panel developed guidance statements to offer a general understanding of the context and why it is important to address the specific needs of women. These guidance statements provide information about sex and gender differences, women's experiences, and delivery of substance use treatment and recovery services. The statements are meant to help providers understand how women's experiences impact their recovery, regardless of service delivery setting. Women are diverse, and their individual cultural backgrounds, family histories, and life experiences influence their treatment and recovery needs. The guidance statements are based on experiences and characteristics frequently seen among women and will help providers better respond to and serve women in their centers. These statements serve as overarching concepts that guide the more specific practices and strategies described in the next section.

Current evidence shows that medications are underused in the treatment of alcohol use disorder, including alcohol abuse and dependence.* * Within this document "alcohol abuse" and "alcohol dependence" are used when discussing medication indications or research that is based upon this terminology. For a summary of important differences between DSM-IV and DSM-5, please see the box on this page. This is of concern because of the high prevalence of alcohol problems in the general population.1,2 For example, data show that an estimated 10 percent to 20 percent of patients seen in primary care or hospital settings have a diagnosable alcohol use disorder.3,4 People who engage in risky drinking often have physical and social problems related to their alcohol use. Problems with alcohol influence the incidence, course, and treatment of many other medical and psychiatric conditions.

Crisis Services are a continuum of services that are provided to individuals experiencing a psychiatric emergency. The primary goal of these services is to stabilize and improve psychological symptoms of distress and to engage individuals in an appropriate treatment service to address the problem that led to the crisis. Core crisis services include: 23-hour crisis stabilization/observation beds, short term crisis residential services and crisis stabilization, mobile crisis services, 24/7 crisis hotlines, warm lines, psychiatric advance directive statements, and peer crisis services. The research base on the effectiveness of crisis services is growing. There is evidence that crisis stabilization, community-based residential crisis care, and mobile crisis services can divert individuals from unnecessary hospitalizations and ensure the least restrictive treatment option is available to people experiencing behavioral health crises.

In September 2012, the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare & Medicaid Services (CMS) and the Administration on Children, Youth and Families (ACYF) held a technical expert panel to identify what the research tells us about services for children in therapeutic/treatment foster care (TFC)1 with behavioral health issues (see Appendix A for meeting agenda). A non-Department of Health and Human Services2 16-member panel of researchers representing the fields of mental health, child welfare, measurement and evaluation, social work and psychology came together to provide policymakers with a responsible assessment of currently available information on services for children in therapeutic/treatment foster care with behavioral health issues (see Appendix B for participant list).

This Treatment Improvement Protocol (TIP)is a companion to TIP 51, Substance Abuse Treatment: Addressing the Specific Needs of Women. These two volumes look at how gender-specific treatment strategies can improve outcomes for men and women, respectively. The physical, psychological, social, and spiritual effects of substance use and abuse on men can be quite different from the effects on women, and those differences have implications for treatment in behavioral health settings. Men are also affected by social and cultural forces in different ways than women,and physical differences between the genders influence substance use and recovery as well. This TIP, Addressing the Specific Behavioral Health Needs of Men, addresses these distinctions. It provides practical information based on available evidence and clinical experience that can help counselors more effectively treatment with substance use disorders.

How This TIP Is Organized - This TIP is divided into three parts: * Clinical Supervision and Professional Development of the Substance Abuse Counselor, Part 1. * Clinical Supervision and Professional Development of the Substance Abuse Counselor: An Implementation Guide for Administrators, Part 2. * Clinical Supervision and Professional Development of the Substance Abuse Counselor: A Review of the Literature, Part 3.

This booklet is for you, the family member of a person dependent on alcohol or drugs. Whether your family member is dependent on alcohol, cocaine, heroin, marijuana, prescription medications, or other drugs, his or her dependence affects you and your family, too. This booklet answers questions often asked by families of people entering treatment. The "Resources" section, at the back of this booklet, lists a selection of sources for more information and support groups available to you during this stressful time. Take advantage of this help, ask treatment providers questions, and talk with supportive friends or other family members about your feelings. Millions of Americans abuse or are dependent on alcohol or drugs. All of these people have families-so remember, you are not alone. The fact that your family member is in treatment is a good sign and a big step in the right direction. People with alcohol or drug dependence problems can and do recover.

This handbook is intended to provide the reader with a basic understanding of the Medicaid program. There is a specific emphasis on the interplay between Medicaid principles and behavioral health services. The goal is for the reader to navigate his or her state Medicaid program so that he or she can contribute meaningfully to policy conversations related to provision of behavioral health services to individuals who are eligible for Medicaid. Throughout this document, the term behavioral health encompasses both mental and substance use disorders. When a mental or substance use disorder is addressed singularly, the reference will be only to that disorder. Because each state's Medicaid program is different from all others and because Medicaid laws and policies are ever changing, this handbook cannot contemplate every permutation of program construction.

Implementing these practical and largely achievable suggestions will improve access to timely and targeted mental health services in primary care settings. Program and clinical experts agree that the early prevention and treatment of mental disorders will result in decreases in individual suffering, family burden, and medical costs. This project provided an important opportunity to review policy and service-delivery change mechanisms aimed at improving the reimbursement of mental health services in primary care settings. By using knowledge from a variety of individuals and settings and combining empirical research with qualitative interviews and the Expert Forum proceedings, this project identified areas where Federal agencies, states, provider organizations, and commissioner associations can clarify, collaborate, educate, and provide support to improve the reimbursement of and access to mental health services in primary care settings.

This report is intended to provide a general overview of SDM and the available research on its effects in both general and mental health care. It includes recommendations from the participants of the SDM meeting. Participant perspectives are included throughout the report, as well as in a section specifically devoted to learnings from the meeting. A resource list, to assist those seeking further information about the concept and practice of SDM, is included in Appendix A.

This guide was created to promote the early identification of children and adolescents with mental health and substance use problems as well as to provide guidance, tools, and resources for early identification-including a compendium of the most developmentally, culturally, and environmentally appropriate screening instruments. SAMHSA developed the guide using the input of the members of the Federal/National Partnership* (FNP) Early Identification Workgroup, chaired by representatives from the Centers for Disease Control and Prevention (CDC) and the Health Resources and Services Administration (HRSA).