Women, pregnant women, women with children. The 1989 report commented on the number of cocaine exposed infants being born, and that recovery resources for women who are pregnant or have children have been non-existent in the county. The 1992-93 report states that, "A pressing need for women is the provision of residential services that enable a woman to bring her children and allow for group living" (p. 43), but notes that the ADP received federal McKinney Homeless Act grant funds in order to provide these services for women and children at Catholic Charities' Thea Bowman House. Women's perinatal Treatment Expansion Funds (PTEF) supplement this grant in order to provide additional residential recovery services at Thea Bowman House and day treatment services at Sitike. Currently, Women's Recovery Association, Casa Maria, Thea Bowman House, and Hope House are residential facilities serving women. Thea Bowman House is specifically identified as serving women with children. Thus, this need is now being addressed, although capacity is not sufficient to meet demand and there is a waiting list at each of these programs.

Homeless. The 1989 report estimates 5,000 to 6,000 homeless people in San Mateo County, and that as many as 50% have AOD problems. By 1991, this number had risen to an estimated 8,665 (United Way of San Mateo County, Needs Assessment Report, 1993). This number has certainly increased in the last three years. The 1992-93 report describes the Homeless Project, staffed by one county employee, as providing outreach, assessment, referral, and case management services to the homeless, a youth outreach project, and the Homeless Teen Health Care

Team Project which will provide assessment, referral, and case management.

In their 1993 book, A Nation in Denial: The Truth About Homelessness, Alice Baum and Donald Burnes report the results of their study in which they found that 65% to 850/o of the homeless are afflicted by alcoholism, drug addiction, mental illness or a combination of those maladies. The study found that the largest group of homeless (at least 40%) are male alcoholics. An additional 10% to 25% are drug addicts.

Thea Bowman House provides residential services for homeless women with children, and is supported with McKinney Act funds. It is the only program that is identified as specifically providing AOD recovery services to the homeless, although other providers state that they serve this population as part of their clientele.

Ethnic minorities. The 1989 report identifies ethnic minorities as an underserved population, and states that, "Current trends suggest that a significant number of Blacks, Latinos and Asian/Pacific Islanders who might benefit from treatment are not getting it" (p. xii). The report recognizes cultural barriers to treatment, such as the lack of culturally relevant services and language barriers.

The past needs assessments discuss the following racial/ethnic groups:

African-Americans. The 1989 report reviews incidence and prevalence data in the African-American population in general. The 1992-93 report notes that the ADP continues to develop services in East Palo Alto that target African-Americans. (According to the 1993 United Way of San Mateo County Needs Assessment Report, 47.6% of the county's African-American population reside in the South County area, primarily within the city of East Palo Alto.) A new nonresidential program, Free At Last, opened in January, 1994. Free At Last provides drop-in counseling, referrals, and case management. The program has been enthusiastically received, and even in the first month attracted a substantial number of clients. Despite these improvements, waiting list data and key informant respondents both indicate that African-American county residents continue to have unmet needs for recovery services.

Latinos. The 1989 report notes that Latinos with primary drug problems represented 17% of the population in county-supported recovery programs in 1987-88. The 1992-93 report notes that the ADP continued to initiate new services specifically targeting Latinos. Casa Maria is a 6-bed residential program for Latinas. In 1994, the ADP issued two RFP'S: 1) a Latino men's residential program, and 2) a non-residential program for Latino men and women. It is noteworthy that the current proportion of Latino participation in county AOD programs is roughly the same as that reported in 1987-88 (17%). Latinos accounted for 12.5% of the county population in 1980 and 18% in 1990, and many people believe that the Latino proportion of the total county population continues to grow.

The Latino population grew by 56% from the 1980 to 1990 census and comprises the largest ethnic population in the county. According to the 1993 United Way Needs Assessment, the North County sub-area has the largest concentration of Latinos, with 42.8% of the Latino population. The South County sub-area, with 33.4% of the Latino population, contains the fastest growing segment of the Latino population in San Mateo County.

Asian/Pacific Islanders. The 1989 needs assessment states that Asian/Pacific Islanders represented 2.6% of the population in county AOD programs and notes several barriers to this population accessing recovery services, including language barriers, lack of outreach, lack of knowledgeable staff, cultural beliefs about health and the seeking of treatment, and cultural expectations that problems be dealt with within the family. The 1992-93 report mentions the Pacifica Youth Service Bureau (PYSB) as providing nonresidential services targeting Filipinos and other Pacific Islanders. Although the PYSB does provide some prevention and early intervention services to this population, in 1994 the PYSB is not providing specific AOD treatment or recovery services and is not a ADP provider agency. It is noteworthy that the current proportion of ADP participants who are Asian/Pacific Islanders is less than that reported in 1989 (1.9% male and 1.6% female in 1994 vs. 2.6% overall in 1989), while the proportion of Asian/Pacific Islanders in the total county population has certainly continued to grow. (The county's Asian and Pacific Islander population grew by over 94% from the 1980 to the 1990 census, from 56,305 to 109,281.)

According to the 1993 United Way Needs Assessment, Filipinos comprise the largest ethnic population within the county's Asian/Pacific Islander population, and the second largest ethnic group in the county. Over 80% of the Filipino and over 50% of the Chinese population reside in the North County sub-area The majority of the Japanese (53.2%) reside in the Central County area.

Native Americans. The 1989 assessment discusses the dearth of incidence and prevalence data about the American Indian population in general. The 1992-93 report notes that Native Americans comprise .04% of the county population, and receive 1.6% of the county recovery services. "Thus, San Mateo County serves the American Indian population at a rate that exceeds their proportional representation in the county" (p. 48). However, the report estimates that nearly three times as many Native Americans would participate in recovery programs if more services were available, In 1994, no specific new initiatives have been undertaken to address this population.

HIV-positive/persons with AIDS. Perhaps understandably, the 1989 needs assessment does not discuss HIV-positive/persons with AIDS as a specific underserved population for AOD services. The 1992-93 report lists intravenous drug users/HIV-positive alcohol and drug abusers first in its list of unmet and special needs. The 1992-93 report estimates that 6,000 to 7,000 intravenous drug users (IVDU's) live in San Mateo County, and estimates that 10% of these are HIV positive. According to the County AIDS Program Epidemiology Section, 19% of the County's AIDS cases have been among IVDU's. Current estimates of persons infected with HIV in San Mateo County range from 3,000 to 5,000 persons (United Way 1993 Needs Assessment).

HIV affects people who are not IVDU's. Besides injecting drugs, the primary pathways for HIV infection are sexual contact and infection in utero or during the birth process. People infected with HIV through these pathways are not specifically mentioned in the 1992-93 report, but the services provided (described below) are available to all HIV-infected individuals.

The 1992-93 report states that the use of Federal HIV Set-Aside Funding will "augment the work of the state-funded AIDS/HIV counselor in educating, testing, and counseling ADP participants." In other words, a County HIV program staff member goes to the various ADP contractors to provide services to clients in recovery. Although the report states that "Providers admit participants without regard for HIV status," it also acknowledges that "Recovery service providers are unqualified to meet the needs of people with urgent physical complications" (p. 43). Providers refer these people to appropriate health resources. As mentioned elsewhere in this report, there are some reports that people with HIV or AIDS are not allowed to enter some recovery programs.

In 1994, no new programs have been identified to address this population's needs for AOD recovery, but ADP is exploring the possibility for providing additional services. One idea under consideration is a residential program for people with AIDS.

Gays and lesbians. The 1989 needs assessment estimated that between 45,000-90,000 gay men and lesbian women over the age of 15 resided in San Mateo County and that, 'Probably the most invisible of underserved populations, sexual minorities encounter numerous barriers to treatment for alcohol and drug problems" (p. xiii). The report notes issues of homophobia and lack of treatment staff who are sensitive to sexual orientation issues as obstacles to this population accessing treatment, and concludes that, "It is unclear as to how well the gay and lesbian communities are being served by San Mateo County alcohol and drug programs. There is compelling reason for the county to learn more about these populations" (p. 175). The 1992-93 report does not discuss gays and lesbians as an underserved population. According to the State Department of Finance, the total population of San Mateo County as of January 1, 1993 was estimated at 680,900. Using a general estimate that 10% of the population are gay/lesbian, the county gay/lesbian population would then roughly be around 68,000 individuals.

There is an added risk of HIV in this population, and recent reports suggests that there is once again high amphetamine use in this population (sometimes injected). The County AIDS Office reports that 5% of people with AIDS have been Gay or Bisexual intravenous drug abusers. There continues to be a higher level of alcoholism among lesbians and gay men than in the general population. In 1994, no specific initiatives or programming have been developed to address this population.

Dually diagnosed. The 1989 assessment recognized that dual diagnosis clients often fall through the cracks between the mental health and substance abuse systems. Most mental health programs screen out people who have substance abuse problems, and AOD programs generally do not accept people who take psychotropic medications. These barriers to recovery may leave the dual diagnosis client with literally no place to go. County mental health workers estimated that 35% of mentally disabled clients had substantial alcohol and drug problems.

The 1992-93 report stated that needs for improved services for this population included expanding services within existing agencies and coordinating concurrently delivered services to the same client to reduce fragmented care and increase integration of necessary services.

The county had a dual diagnosis recovery project, but this was defunded as a result of budget cuts. The dual diagnosis team provided group and individual counseling at provider programs, psychiatric care on an outpatient basis, and case management. Services to dual diagnosis clients were not provided at a specific program site identified for this population. Although the team was disbanded, individual staff still conduct some assessments, in-service training, and dual diagnosis groups. For example, a psychiatrist conducts a regular group at the Project 90 program, and provides consultation there. Also, Palm Avenue Detox accepts clients who take prescribed psychiatric medications.

Youth. The 1989 report discusses the extent of AOD use among youth, but did not provide detail about County programming. The 1992-93 report indicates that the County implemented an adolescent residential program under contract with Daytop Village. Other prevention and early intervention services are noted, but this is the only recovery program targeted for adolescents. The report states that the county's community planning process identified the need for adolescent day recovery services.

The most recent national data indicate that AOD use among youth is once again increasing. Currently, no new programming is planned that is designed for adolescent AOD recovery (as opposed to prevention or general counseling).

Seniors. The 1989 needs assessment noted the problems of older alcoholics and the use of over-the-counter and prescription medications. A 1986 survey of county agencies serving seniors found that 71% believed there was a need for AOD services directed to seniors. The 1992-93 report notes Pyramid Alternatives' Senior Adult Outreach Project, and mentions the need for a residential program targeting the elderly, which should be addressed if funding becomes available. Currently, Pyramid is the only agency that provides specific AOD programming for this population.

Disabled. The 1989 report states that alcohol and drug abuse among the physically disabled is believed to be much higher than in the general population, and cites provider staff s lack of awareness of special needs, inaccessibility, and negative attitudes as barriers encountered by the physically disabled. The 1992-93 report states that the ADP "continues to develop services for the hearing impaired" (p. 47). It also notes that in 1991-92 the Center for Independence of the Disabled (CID) began providing direct recovery services to disabled people who abuse alcohol and/or drugs. This program continues to operate, sending AOD counselors to the residences of people who are homebound.