There are now three points of entry into Adult Managed-Care Services for clients referred from the Criminal Justice provider system:

• Treatment Options, operated by ARH Recovery Homes, Inc., is a licensed and certified 40-bed treatment center which serves as the DADS Residential Reception Center exclusively for men and women CJS referrals.
• In-custody assessments, conducted by a Jail Assessment Coordinator both at the Main Jail and at Elmwood.
• Drug Treatment Court, to which DADS provides staff to conduct assessments.

Counselors at each of these entry points assess and authorize clients for treatment; and Sofia Abud, Managed-Care Coordinator assigned to CJS, helps place them into Adult Managed Care.

To enhance the mutual understanding of these two large systems, Justice Services--together with the DADS Training Institute--arranged several cross-trainings. In October, a panel of representatives from the District Attorney’s Office, Office of Pre-Trial Services, Public Defender’s Office, Probation Department, Department of Corrections, and the Superior Court provided training to Adult Managed Care staff to explain legal processes; to clarify expectations; and to strengthen our mutual relationships. In the spring, DADS will take a series of three-part workshops "on the road"--specifically for judges throughout the county--to give them an in-depth look into Adult Managed Care and the medical and psychological aspects of addiction. Each series will be offered in three geographical areas to accommodate judges’ busy schedules; judges who miss a particular training segment will have an opportunity to receive the same information at an alternative location.

Working together with CJS, DADS hopes to streamline CJS clients’ entry into treatment. This budding partnership will take time and mutual understanding, but is already succeeding. For more information about Justice Services, please call Julianna Brooks at 408-299-6141, x173.

California Work Opportunities and Responsibility to Kids Program (CalWORKS) is California’s version of the 1996 federal welfare reform law. This merges the former income maintenance (Aid to Families with Dependent Children) and employment (Greater Avenues to Independence) programs into a single, unified "welfare-to-work" program.

Many CalWORKS clients struggle with significant barriers which prevent successful participation both in welfare-to-work activities and in family self-sufficiency. Alcohol and other drug issues typically affect participants’ ability to comply with program requirements and to engage in job training or job-search activities. In many such cases, criminal records and/or serious mental health problems create further problems which clients must overcome to reach self-sufficiency.

The CalWORKS Community Health Alliance was created among various County agencies: Adult and Juvenile Probation, Department of Corrections, Departments of Mental Health and Alcohol & Drug Services, School-Linked Services, and Social Services Agency. The Alliance’s task is to design an effective plan to provide seamless, integrated support services for CalWORKS clients which address the health of the whole person. The Alliance’s objectives are to educate clients and staff on mental health and substance abuse issues; to increase client outreach (using a Mobile Medical Unit) and intervention services (using multidisciplinary teams); and to bridge service gaps.

For more information on the CalWORKS Community Health Alliance, please call Jolene Smith at 441-5613.

SMOKING AND NICOTINE ADDICTION
By Suma Singh, M.D
DADS Staff Physician

Cigarette smoking is common among clients in DADS treatment programs. For example, an estimated 90% of alcoholic clients also smoke.

Smoking has serious medical consequences. Tobacco use results in the most devastating health effects of nicotine. Smoking causes cancer of the lungs, mouth, esophagus, stomach, pancreas, cervix, kidney, and bladder. Smoking also causes emphysema and chronic bronchitis, worsens asthma, and increases the risk of heart attack, stroke, and aneurysm. Secondhand cigarette smoke also causes lung cancer, worsens asthma in children, and may be linked to sudden infant death syndrome ("crib death"). About 20% of all deaths annually in the United States are attributable to tobacco.

Nicotine is addictive. Cigarettes are a highly efficient nicotine-delivery system. Within ten seconds of inhalation, nicotine reaches the brain and creates sensations of pleasure. This pleasure wears off and tolerance develops within minutes. The smoker keeps inhaling, both to maintain pleasure and to prevent withdrawal. Smoking 1 � packs a day provides 300 nicotine "hits" to the brain, which quickly makes nicotine addictive. Nicotine withdrawal causes anxiety, irritability, inability to concentrate, sleep disturbances, increased appetite, and craving. Although most symptoms peak within a few days of quitting and gradually subside over a few weeks, craving may persist for months.

Treatment for nicotine addiction works. The most effective treatment combines nicotine replacement therapy (NRT) with behavioral techniques. NRT (patches, gum, nasal spray, and inhalers) relieves withdrawal safely, avoiding the toxins in tobacco smoke. Buproprion (Zyban�), an antidepressant, may also be used to prevent nicotine craving. Behavioral treatments teach smokers to monitor their smoking, identify high-risk relapse situations, and establish alternative coping responses. The good news is that more than a million people have used NRT/behavioral treatments to quit smoking safely and successfully.

Cigarette smoking is a common yet dangerous habit among our clients. Many clinicians and programs do not address this while treating alcoholism and other drug addictions, believing that smoking cessation would place too great a burden on the client. However, there is no data to justify this fear. In fact, studies show that quitting smoking does not increase relapse.

Located in East San Jose, The Place is Asian American Recovery Services’ (AARS) South Bay site. AARS offers a continuum of alcohol and other drug services including prevention, intervention, and treatment for children, youth, and adults. Office hours are from 9 a.m.-6 p.m. on Mondays, Wednesdays, and Fridays; and 9 a.m.-8 p.m. on Tuesdays and Thursdays.

AARS’ Asian Substance Abuse Treatment Services (ASATS) has been providing culturally and linguistically competent outpatient treatment services in this county since December 1996, and is part of DADS’ Adult Managed Care. In addition to serving Asians and Pacific Islanders, they also work effectively with many other local communities.

Prevention services are available for significant others, family, and friends of those who are (or have been) abusing alcohol or other drugs. Those who have begun experimenting with these substances are also candidates for prevention. Weekly psycho-education groups teach about addiction, basic alcohol and other drug education, relapse prevention, etc. This program also helps clients look at how culture affects substance abuse, addiction, and recovery.

Outpatient services provide assessment, treatment planning, case management, individual/group counseling, and aftercare. Specific groups address psycho-education, relapse prevention, and peer support; and are also language- or gender-specific.

The Place also offers children’s prevention (Kids’ Place), youth intervention (Project CROSSROADS), and youth treatment (Project RECONNECT).

By age 26, Kathy Osorio had two children, no high-school diploma, no job skills, and no life skills. Then, as a client of the Department of Alcohol & Drug Services’ (DADS) Perinatal Substance Abuse Program, she entered the Perinatal Literacy Project and began the process of turning her life around. Kathy now has her General Education Certificate (GED) and started an honors program at San Jose City College, where she earned 2 A’s in her first semester.

The Perinatal Literacy Project, which is funded by DADS and run through the Santa Clara County Library’s Reading Program, helps DADS clients improve their basic literacy and math skills and/or prepare for a GED. Mothers in the program work with volunteer tutors and attend life-skills workshops on budgeting, parenting, job skills (including job seeking), and accessing library and computer resources. Through the program, women realize the importance of education - for themselves and their children.

The Reading Program also serves clients in other DADS Adult Managed-Care Services treatment sites: Mariposa Lodge, Horizon South, Pathways (residential only), Benny McKeown Center, and Proyecto Primavera. These programs help clients acquire the basic literacy, math, and computer skills needed to work with 12-step recovery materials; to obtain their GED; to gain basic life skills; and to find employment and housing when they complete treatment.

As part of their commitment to providing free, ongoing literacy services to all its clients, the Reading Program offers DADS graduates the opportunity to continue their education in other library-based programs throughout the county. For more information about the Reading Program and other Library services, please call 408-262-1349.

Substance-abuse and mental-health professionals are ideal groups to be cross-trained in implementing treatment for people with multiple disorders. In the model described below, training includes education, supervised experiential application of clinical interventions, and program implementation.

Learning about each disorder as an illness needing treatment allows counselors to assess symptoms accurately and to develop empathy. Knowing about the physiological aspects of mental illness and substance abuse--and their interaction--facilitates this understanding. Acceptance of all symptoms replaces moral judgments and stigma, and hope for recovery replaces discouragement. Counselors can then interact with clients in a non-confrontational manner and engage clients at all levels of motivation and readiness for treatment.

The group treatment process begins with the pre-group interview to establish clients’ reasons for participation and their readiness level. The group process includes learning about each disorder, to reduce the shame and guilt caused by misinformation and stigma. Rather than present themselves as experts, counselors explore and learn together with clients. Clients are not expected to self-disclose in this first phase; the focus is on building trust.

In phase two, clients more easily discuss their experiences with dual symptoms. This empowers them to explore and decide how substance abuse affects their mental health and/or how mental-health symptoms affect their substance abuse. As a result, clients become more willing treatment participants.

Phase three is when clients focus on symptom management, symptom remission, stability, and relapse prevention.

This model has been used throughout the nation since 1984. Clients may receive dual-diagnosis treatment and other services in the system with which they more closely identify. Treatment settings include clinics, halfway houses, partial hospitalization, clubhouses, residential programs, multidisciplinary teams, case management, inpatient units, criminal-justice programs, and programs for the homeless.

The availability and quality of comprehensive services for clients with multiple disorders depends on existing programs and trained staff. Outcomes for programs using this model show that even clients who have never had substance-abuse treatment and/or who have avoided mental-health treatment can benefit from dual-diagnosis programs.