The priorities for meeting identified needs are therefore, 1) prevent additional funding cuts, and 2) proactively seek additional funding.

The remaining recommendations focus on unmet needs, most of which will require additional funding to meet.

New residential facilities. Increased residential services is a strongly perceived need of the county, AOD service system. Residential treatment, because it offers an intensive, structured program, and because it removes clients from the environment that is linked with their AOD abuse, is the treatment of choice for many clients.

One of the most important issues in providing residential services is the barriers to opening new facilities. More than one provider in the county has experienced neighborhood and local government opposition to the siting of a substance abuse program in their community. Without the required permits, new facilities cannot open. This makes it all the more critical that the current level of residential services be maintained. Once existing treatment slots are lost, it is very difficult to regain them. From time to time it is appropriate to adjust residential treatment by reducing residential services of one type and increasing services of another. But because local opposition significantly lowers the likelihood that programs can relocate and re-open elsewhere, existing programs should not be closed unless there is another program or site that can successfully open, to maintain the current level of services.

Medical detox. The only detox services available are provided at Palm Avenue. This program accepts clients who have been prescribed medications by their physicians for co-occurring conditions (e.g., mental illness, HIV/AIDS, other medical needs). However, the program does not have its own physician. Medical supervision is required when detoxing from certain substances in which the detoxification process may be life-threatening, such as for Valium, Xanax, or barbiturate addictions. A medically supervised detox program would be desirable to implement as part of a comprehensive continuum of care.

Relapse prevention and aftercare. Substance abuse is sometimes referred to as a "disease of relapse." This terms recognizes that recovery from substance abuse is a process that often involves repeated recovery attempts, and that each of these attempts should be supported as progress or steps towards the goal of abstinence. The argument can be made that such aftercare or follow-up services for people in recovery can be the most cost-effective, in that they provide needed assistance to those clients who are most likely to be able to take successful advantage of them.

Budget reductions and changing clientele. As a consequence of cuts in the state DADP budget and county general fund reductions, existing AOD providers received reductions to their county contract budgets in the current fiscal year. Non-residential programs and the detox program all received 20% cuts, and residential programs received 3% cuts.

The providers experience this state of affairs as having less and less resources to deal with more and more difficult clients. Providers are seeing second and third generation substance abusers, more clients from within the criminal justice or welfare systems, and clients who are more violent. More and more of the clientele are also non-reading, either because of learning disabilities or simply because they are illiterate or uneducated. However, while serving this increasingly difficult clientele, case loads (the number of clients per counselor) have remained the same or have increased.

This situation underscores the need for a longer-term funding plan to meet the increasing need, and for increased funding to address specific needs. At the same time, it raises the issue of the potential costs of reducing a basic or "bare bones" AOD recovery system even further. One of the obvious costs of any further reductions in services available to these increasingly difficult clients is that unserved and underserved clients will incur costs in other service systems-criminal justice, welfare, child protective services, and so forth. And because these unserved clients are themselves the products of substance-abusing families, and will reproduce these problems in their own families, their unaddressed needs for substance abuse services will expand to overwhelm the resources of other service systems.

Data and evaluation. The ADP has identified and responded to the need to have its own database about its AOD services. A consultant was retained to develop a new data collection system, and the new system is currently being tested prior to its full implementation. Previously, the only data routinely collected was reported by the providers as required on the CADDS forms. Computer runs on this data have been available from the state ADP upon request. However, the county does not have the ability to directly query the CADDS database, to merge this data with relevant data collected by other county departments, or to add any items that are of interest to the county ADP in its own management information system.

Especially for evaluation purposes, it is highly desirable that the County, ADP will be able to collect other information consistently across all its provider programs. This is particularly true for outcome measurements. The current CADDS form primarily uses successful versus unsuccessful completion of a program as a measure of outcome. When programs begin to report outcome data to the county, such as the percentage of clients who are abstinent at a particular time, the county will have a much more meaningful database for evaluating its services.

The ADP's new Management Information System will provide data for evaluation and tracking of client and program improvements. The data collection system includes three new tools to be used by all programs-an intake form, an exit form, and a 6-month follow-up. Client outcomes will be systematically reported, such as the number reporting abstinence at 6-month follow-up, relapse rates, and improvements in financial (employment or reduced dependence on public assistance), housing (homelessness), health, and legal status (e.g., drug-related arrests). The MIS will also enable the ADP to more readily and accurately identify the number of participants served in different categories such as minorities, women of child-bearing age, HIV positive who receive HIV counseling, disabled, and dual diagnosis. This information will allow the ADP to identify which needs and special populations are being served by the recovery system, identify the levels of service and the programs providing services, and compare changes over time. In addition, the MIS will allow the ADP to monitor the prevalence of AOD problems in the county, such as the numbers of drug related crimes, substance exposed infants, persons injured or killed in alcohol involved accidents, and DUI filings, in order to understand the impact of the ADP programs on these indicators and to develop programming in response to emerging problems.

In terms of recommendations for the use of this new system, we suggest that the County should not expect the same outcome results from all programs, especially between different modalities (e.g., residential and nonresidential programs), and between programs serving very different populations. When promising results or new trends are identified in the data, focused substudies should be conducted to fully understand their meaning and relevance. The data generated by the MIS should also be examined in relation to other data collected by the county, such as incidence and prevalence indicators from the mental health and criminal justice systems.

Analyzing aggregate data-that is, combining all groups and services to look at outcomes-will be of interest, but the most meaningful results may be those from asking specific questions that look at parts of the data. For example: Which programs are most successful for women of color? Which programs have the highest retention rates for clients with HIV? What is the demographic profile of people who drop out of nonresidential treatment? Such specific questions can tell the ADP where particular weaknesses are that need to be remedied, and identify programs that are working well in particular areas.

Other descriptive data about the providers' services (protocols, staff, clients, waiting lists, units of service) should also be accessed to be available for needed reports, identify and track gaps in services, and respond to other information needs. Most importantly, for future funding purposes, such a database will be essential both for preparation of major grant applications and for developing the evaluation plans necessary for successful grant applications.

Services for women and women with children. Women's issues to be addressed in programs designed for this population include sexual abuse, incest, domestic violence, eating disorders, self-esteem problems, and relationship issues. Women with children often cannot participate in programs unless they bring their children with them. But when programs include women's children on site, additional program needs are generated, including needs for child care, staff, and space. The one program in the county that currently provides residential services for women and their children cannot serve women with more than one or two small children. There is a need for a program that could serve women with three or more children. However, such a program would require considerable space and child care services.

Latino services. One of the major barriers to service for this population that the existing providers experience is the lack of Spanish-speaking staff who are familiar with Latino cultures. According to several respondents, recruiting staff in this area is a challenge. Bilingual Spanish-speaking staff are in great demand in all service systems, and salaries in the AOD field are relatively low. Furthermore, according to providers, there are a limited number of qualified individuals in the workforce, who are Spanish-speaking and who have expertise and interest in working in the AOD treatment field. Many providers feel that if they could find and hire qualified staff, their services to the Spanish-speaking would greatly expand. One suggested solution is to get more of the population qualified by providing training and supervision to bilingual/bicultural paraprofessionals who are interested in the field, so they can develop the experience and expertise that is needed. Aside from the problem of identifying resources for extensive training of staff, lack of funds for expanding program staff limit the addition of new staff of any ethnicity.

Asian/Pacific Islander services. There are no recovery programs specifically identified with or designed for the Asian/Pacific Islander population. However, this is a large and growing segment of the county population, As mentioned previously, 17% of the County's population is Asian/Pacific Islander, but less than 2% of those in recovery services come from this group (Tables 5 and 6, above). Cultural issues of shame, denial, saving face, and keeping substance abuse issues within the family may create substantial barriers to addressing this population's treatment needs, and indicate a need for programs that are specifically identified with these cultures. In addition, there is an increase in gang-related activities in some of these cultural groups. Culturally relevant AOD recovery services for Asian/Pacific Islanders appears to be an increasingly important and unmet need in the county AOD recovery system.

Non-U.S. citizens. Whether non-citizens are here on temporary visas, or released from the criminal justice system, or may be here illegally, their AOD problems will continue to create other societal costs if they are not addressed. According to some reports, this group keeps getting larger. Some are being served in the county ADP system, but there are unique problems with serving this group, such as they are not able to receive some entitlement benefits. There is a need to identify this group more precisely, and to define how they should be provided services.

Dual and triple diagnosis. Clients with co-occurring substance abuse and mental health disorders are particularly difficult and resource-consuming to treat. These clients demand a lot of staff time, attention, and follow-up. When additional medical problems are also present, such as HIV/AIDS, the provision and management of services is even more complex. As our understanding and awareness of these problems increases, the true dimensions of the problems emerge. More professionals are recognizing that many problems of mental illness include a substance abuse problem, and vice versa, that many substance abusers have mental health problems that accompany their abuse.

An important issue in serving clients who have co-occurring substance abuse and mental illness is the need for many of these clients to be maintained on psychiatric medications. This requires medical supervision along with medication monitoring and management, creating an increased cost and level of service to serve this population.

Additionally, there is an important issue for some treatment programs. The ban on AOD use can be seen as applying to psychiatric medications, even as part of a treatment protocol. In addition, the absence of medical staff to prescribe and supervise treatment with medications limits the ability of programs to treat dually diagnosed.

There is a need for staff training in this area, for recruitment of qualified staff, and for recovery slots specially identified for this population. Ideally, there would be specific programs designed to serve the dually and triply diagnosed population, with treatment protocols developed to address their specific treatment needs.

HIV/AIDS. Although the county AIDS program provides HIV services at treatment program sites, there are no specific facilities identified for substance abuse clients who are seeking treatment and who are HIV positive or have AIDS. Persons with AIDS or who are HIV positive and who continue to use drugs and participate in other high risk behaviors experience more negative consequences for themselves and have increased needs for services. Research indicates that their lives are shortened, they are sick more often, and their greater needs for medical attention cost the taxpayers a great deal more money. The more these clients can be in a clean and sober environment, the more their own quality of life is improved, the less they are spreading the virus to others, and the greater the benefits to the wider community.

There is a need for AOD providers who are skilled and knowledgeable in dealing with substance abuse clients who are HIV positive, have AIDS, or who are otherwise medically compromised. As with the substance abuse clients who have co-occurring mental disorders, there are also issues of medical supervision, medication management, and providing medication within programs that prohibit use of all drugs. If program structures are not able to accommodate clients in these situations, then these clients are being excluded from treatment.

Ideally, as for the dually diagnosed population, there should be specific programs designed to serve substance abuse clients who are HIV positive or who have AIDS.

African Americans. Given the demonstrated needs for services to this population, the existing levels need to be maintained, and expanded whenever possible.

Gay and lesbian. No AOD services are specifically identified as serving this group. Statistics are not kept on the number of gay/lesbian/bisexual individuals in treatment. Particularly in light of the AIDS epidemic, it would seem desirable to have AOD treatment programs that are especially sensitive to this population, with an identified gay and lesbian staff, and programming designed to address their specific needs.

Homeless. While there is a small residential program that gives priority to serving homeless women with children, no other AOD services are identified as specifically targeting the homeless substance abuser. There are no programs for the homeless that provide linkages to the recovery system, such as outreach and engagement services to encourage homeless persons with AOD problems to enter treatment. There appears to be a need for data to be collected on the homeless now served to assess who is serving them and how. Potentially, HUD funds may be available to provide some services that include substance abuse treatment.

Seniors. Substance abuse among older people is a more recently recognized specific problem. Seniors are a relatively silent group compared to some other special populations. This is another area in which the need has only barely begun to be met.

Children and youth. Children are also victims of substance abuse, in that they suffer emotional, physical, and sexual abuse in families in which one or both parents have a substance abuse problem. Increased services for children and their families are an area of need.