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HomeMy WebLinkAboutAGENDApacket__03-14-22_0813_312       NOTICE OF MEETING REGULAR MEETING FOUNTAIN HILLS PLANNING AND ZONING COMMISSION      Chairman Peter Gray  Vice Chairman Scott Schlossberg Commissioner VACANT Commissioner Clayton Corey Commissioner Susan Dempster Commissioner Dan Kovacevic Commissioner Rick Watts, Jr.    TIME:6:00 P.M. – REGULAR MEETING WHEN:MONDAY, MARCH 14, 2022 WHERE:FOUNTAIN HILLS COUNCIL CHAMBERS 16705 E. AVENUE OF THE FOUNTAINS, FOUNTAIN HILLS, AZ Commissioners of the Town of Fountain Hills will attend either in person or by telephone conference call; a quorum of the Town’s Council,  various Commission, Committee or Board members may be in attendance at the Commission meeting. Notice is hereby given that pursuant to A.R.S. §1-602.A.9, subject to certain specified statutory exceptions, parents have a right to consent before the State or any of its political subdivisions make a video or audio recording of a minor child. Meetings of the Commission are audio and/or video recorded and, as a result, proceedings in which children are present may be subject to such recording. Parents, in order to exercise their rights may either file written consent with the Town Clerk to such recording, or take personal action to ensure that their child or children are not present when a recording may be made. If a child is present at the time a recording is made, the Town will assume that the rights afforded parents pursuant to A.R.S. §1-602.A.9 have been waived.    REQUEST TO COMMENT   The public is welcome to participate in Commission meetings. TO SPEAK TO AN AGENDA ITEM, please complete a Request to Comment card, located in the back of the Council Chambers, and hand it to the Executive Assistant prior to discussion of that item, if possible. Include the agenda item on which you wish to comment. Speakers will be allowed three contiguous minutes to address the Commission. Verbal comments should be directed through the Presiding Officer and not to individual Commissioners. TO COMMENT ON AN AGENDA ITEM IN WRITING ONLY, please complete a Request to Comment card, indicating it is a written comment, and check the box on whether you are FOR or AGAINST and agenda item, and hand it to the Executive Assistant prior to discussion, if possible.   REGULAR MEETING        1.CALL TO ORDER, PLEDGE OF ALLEGIANCE AND MOMENT OF SILENCE – Chairman Gray        2.ROLL CALL – Chairman Gray     3.CALL TO THE PUBLIC Pursuant to A.R.S. §38-431.01(H), public comment is permitted (not required) on matters NOT listed on the agenda. Any such comment (i) must be within the jurisdiction of the Commission, and (ii) is subject to reasonable time, place, and manner restrictions. The Commission will not discuss or take legal action on matters raised during Call to the Public unless the matters are properly noticed for discussion and legal action. At the conclusion of the Call to the Public, individual commissioners may (i) respond to criticism, (ii) ask staff to review a matter, or (iii) ask that the matter be placed on a future Commission agenda.     4.CONSIDERATION AND POSSIBLE ACTION: approving the regular meeting minutes of the Planning and Zoning Commission February 14, 2022.     5.HOLD A PUBLIC HEARING, CONSIDER AND POSSIBLE ACTION: regarding Ordinance 22-01, amending Chapters 1, 5, 10, and 11 of the Zoning Ordinance to provide the definitions of family and community residences, the regulations for community residences, and the zoning districts where allowed.     6.REVIEW AND DISCUSS: possible Zoning Ordinance text amendments to address drug and alcohol treatment centers and detoxification facilities.     7.COMMISSION DISCUSSION/REQUEST FOR RESEARCH to staff.    8.SUMMARY OF COMMISSION REQUESTS from Development Services Director.    9.REPORT from Development Services Director.    10.ADJOURNMENT       CERTIFICATE OF POSTING OF NOTICE The undersigned hereby certifies that a copy of the foregoing notice was duly posted in accordance with the statement filed by the Planning and Zoning Commission with the Town Clerk. Dated this ______ day of ____________________, 2022. _____________________________________________  Paula Woodward, Executive Assistant   The Town of Fountain Hills endeavors to make all public meetings accessible to persons with disabilities. Please call 480-816-5199 (voice) or 1-800-367-8939 (TDD) 48 hours prior to the meeting to request a reasonable accommodation to participate in the meeting or to obtain agenda information in large print format. Supporting documentation and staff reports furnished the Commission with this agenda are available for review in the Development Services' Office.    Planning and Zoning Commission Meeting of March 14, 2022 2 of 2 ITEM 4. TOWN OF FOUNTAIN HILLS STAFF REPORT    Meeting Date: 03/14/2022 Meeting Type: Planning and Zoning Commission Agenda Type: Submitting Department: Development Services Prepared by: Paula Woodward, Executive Assistant Staff Contact Information: Request to Planning and Zoning Commission (Agenda Language):  CONSIDERATION AND POSSIBLE ACTION: approving the regular meeting minutes of the Planning and Zoning Commission February 14, 2022. Staff Summary (Background) The intent of approving meeting minutes is to ensure an accurate account of the discussion and action that took place at the meeting for archival purposes. Approved minutes are placed on the Town's website and maintained as permanent records in compliance with state law. Related Ordinance, Policy or Guiding Principle N/A Risk Analysis N/A Recommendation(s) by Board(s) or Commission(s) N/A Staff Recommendation(s) Staff recommends approving the meeting minutes of the regular meeting minutes of the Planning and Zoning Commission February 14, 2022.   SUGGESTED MOTION MOVE to approve the regular meeting minutes of the Planning and Zoning Commission February 14, 2022.. Attachments PZ MM 2.14.22 Draft  TOWN OF FOUNTAIN HILLS MINUTES OF THE REGULAR MEETING OF THE FOUNTAIN HILLS PLANNING AND ZONING COMMISSION FEBRUARY 14, 2022            1.CALL TO ORDER, PLEDGE OF ALLEGIANCE AND MOMENT OF SILENCE      Chairman Gray called the meeting of February 14, 2022, to order at 6:00 p.m.   2.ROLL CALL   Present: Chairman Peter Gray; Vice Chairman Scott Schlossberg; Commissioner Clayton Corey; Commissioner Susan Dempster; Commissioner Dan Kovacevic; Commissioner Roderick Watts, Jr.  Staff Present: Development Services Director John Wesley; Town Attorney Aaron Arnson; Attorney John Paladini; Executive Assistant Paula Woodward  3.CALL TO THE PUBLIC     4.CONSIDERATION AND POSSIBLE ACTION: approving the regular meeting minutes of the Planning and Zoning Commission February 14, 2022.        MOVED BY Commissioner Susan Dempster, SECONDED BY Commissioner Clayton Corey to approve the Planning and Zoning Commission minutes of the Regular Meeting of January 10, 2022.   Vote: 6 - 0 - Unanimously   5.CONSIDERATION AND POSSIBLE DIRECTION: regarding a site plan for Park Place Phase II (16845 E. Avenue of the Fountains) and Phase III (13000 block of N. Verde River, west side).        Mr. Wesley said that the site plans are for the Park Place phase II located at 16845 E Avenue of the Fountains and Phase III located at 13000 block of North Verde River , West side. He explained that the Park Place (three-phase, five building, mixed use project) overall development was approved by the Town council in June of 2016.   The overall master plan for the property included five buildings, up to 420 dwellings and 43,000 square feet of commercial space. The actual dwelling units were reduced to 380 and actual retail space to 41,000 square feet. The overall parking spaces are 150 more than required. He said that under the current Zoning Ordinance the Planning and Zoning Commission    and the Town Council do not typically review and take action on site plans.  However, the Development Agreement requirement is for the review and approval by the Commission and Council.  He noted that the Development Agreement uses the term “Concept Plan” which has since been changed in the Zoning Ordinance to “Site Plan.” “Concept Plan” and “Site Plan” are one and the same. Mr. Wesley said although the project appears to meet technical requirements, specific issues would need to be resolved in order for the project to move forward.  Specific issues to resolve for Phase II, Building E & F are: relocation of the electric boxes out of the right-of-way, solid waste enclosure location, size and accessibility, water feature access and all required site plan pages resubmitted with the approved plans. Staff is concerned with the Avenue of the Fountains streetscape. Issues to resolve for Phase III, building B are: relocation of the utility box-cannot be located in the right-of-way or Art Walk, Fountain Hills Sanitary District Well, Paul Nordin Parkway right-of-way abandonment, new Town parking lot spaces and need a complete plan submittal. Bart Shea, N-Shea Group, the Developer of Park Place, said that it is seven years into the development and it was a two-year process to actually attain the development agreement with the Town. Mr. Shea said that Park Place is successful with 480 residential units and commercial. Currently, the commercial is about 25% under current market for retail space. He said he is providing all the  tenant improvements for free. He said they are 100% committed to the is project but in order to meet the parking requirements, the Art Walk would have to be removed. In response to Commissioner Dempster, Mr. Shea said that seventy-two parking spaces would be gained by removing the Art Walk and the buffer area. There are no issues with the current buildings.There is a 20% parking reduction allowed but are not acting on that. The site for residential and commercial is 100% parked. If the Town wants to make an amendment to parking it can be met.     Commissioner Dempster expressed concern that losing the buffer between the project and Park Place was not a good idea.  Some people bought in the “At the Town Center” with the understanding a buffer would exist between the two properties.   Commissioner Watts asked about the retention location.   Mr. Shea said that the retention area is underground. It is underneath the parking area and pumps out to the Town storm drain.   In response to Chairman Gray, Mr. Wesley replied the current General Plan 2020 is applicable to this project. Mr. Wesley confirmed that, as stated in the Development Agreement, the art fee for the Park Place project was reduced to 50% of the standard art fee charged to developers.   Mr. Wesley said that the project was short 3 parking spaces. The requirement    Planning and Zoning Commission Meeting of February 14, 2022 2 of 18 is130 parking spaces.   Chairman Gray expressed concern regarding the commercial space in building F. The site plan is not clear to how the public would access the area or even know about it.   In regard to the “marquis corner” located at AOTF and Saguaro Blvd. he stated that he could not in good faith approve non-retail at the location. He said there is not enough information regarding the continuity of the facades between then and now.  In regard to building B, he said it deserves more than surface parking.   Mr. Shea said he believes he is not bound by the 2020 General Plan. In the past, The Town Council made sure that retail would not park on that corner.  Parking would eat up too much of the area so that retail would not fit.  It does not make sense. The Town cannot handle as much retail as it thinks it can. He said that he did not disagree but this is not a redesign. Today is to review the site plan that it fits inside the Development Agreement. In response to Commissioner Dempster, Mr. Shea said the buildings will be all rentals.  The average rent in Park Place is $1600 - $1800, more than a home for rent in Fountain Hills at $2500. It may not be affordable but more affordable than a home or condo.  Mr. Shea said he believes the project is in conformance with the downtown TCCD.  The current Park Place commercial rented out is 65%.   Discussion took place among the Commission regarding parking, commercial below grade, continuity of the Avenue, permitted uses – residential and commercial, development agreement and retail on the corner.   Mr. Shea pointed out to the Chairman that it is stated in the Development Agreement “residential only in building F.”  He said all the commercial space was used up on the other end of the Avenue. He said that he is asking for the Commission to vote to recommend approval to the Town Council.   In response to Commissioner Corey, Mr. Wesley said that in the original land use plan there were two parking lots called, “new Town parking” allocating 130 parking spaces.  Due to circumstances out of Mr. Shea’s control the 130 parking spaces were not possible.  By changing the design, 127 parking places would be possible.  130 spaces are required by the Development Agreement.  Some tweaks can be made to pick up the 3 spaces.   Larry Meyers, Fountain Hills resident, said that he doesn’t care what the development agreement says, the Art Walk needs to be done right. He said that downtown will not become vibrant with a bunch of apartments. He suggested that giving up the parking spaces is well worth making the Art Walk tie in with the Centennial Circle.   Ed Stizza, Fountain Hills resident, said he would like to see the premiere corner not become just corners of a building. That corner provides an iconic view. He said he appreciates the Commission looking at this project in detail.    Planning and Zoning Commission Meeting of February 14, 2022 3 of 18    Chairman Gray asked if Mr. Shea is interested in a continuance.   Mr. Shea said he didn’t think he would have enough time for a continuance before the DA expires. He said that he would be willing to make some changes.   Commissioner Kovacevic said he had a hard time going against the development agreement. The Town should honor the agreement.  The Art Walk is a better plan then not and would agree to make parking accommodations to allow for the Art Walk.   Commissioner Corey noted that there is a walk ability theme in the downtown area. The Art Walk ties in with that idea.  This is also a great way to preserve some green space in Town.   Chairman Gray asked Mr. Wesley what he though about managing the administrative process should the Commission provide changes.   Mr. Wesley replied that that things within the scope of work that are outlined in the staff report are understood and ready to work through. The challenge would be the location of additional commercial space in building F.  There are a lot of snowball effects that start happening that cannot be understood in order to take action.  The agreement is to get this project on the March 1, 2022 Town Council meeting. There is not much timeframe to keep things on track for March.    Mr. Wesley replied to Commissioner Watts that he was not sure Mr. Shea was referring to early in the evening regarding deviations.  There is a 20% parking reduction allowed in the development agreement.      MOVED BY Vice Chairman Scott Schlossberg, SECONDED BY Chairman Peter Gray to forward a recommendation to the Town Council to approve the site plan for Park Place Phase II (16845 E Avenue of the Fountains) and Phase III located at (13000 block of North Verde River) with the following stipulations: Return to design of the Art Walk to the size shown on the 2016 approved Land Use Plan; Amend the Development Agreement not to require the 130 Town Parking Lot spaces or find alternatives for required spaces; Explore options to bring the commercial use out to the sidewalk to make it more visible from the street and consider adding commercial use to Building F: Prior to the Building Permit issuance: Address all the items listed in the staff report in revised final site plan for approval; Complete the abandonment of the Paul Nordin Parkway right-of-way; complete and final any easements and maintenance agreements as required by the Development Agreement.   Vote: 6 - 0 - Unanimously   6.REVIEW, DISCUSS AND PROVIDE DIRECTION ON options for possible        Planning and Zoning Commission Meeting of February 14, 2022 4 of 18 6.REVIEW, DISCUSS AND PROVIDE DIRECTION ON options for possible ordinance language updating regulations for group homes.        Mr. Wesley stated that tonight's discussion is directed towards group homes and associated regulations with that particular issue. The companion topic - detox facilities is not part of tonight's presentation or discussion. Staff plans to work on that issue and have it ready for the ready for next meeting.  Detoxification is a medical non-residential activity and is not permitted in residential districts.  The Town understands there is concern that some level of detoxification may be taking place in sober living homes which would be a violation. A person in a sober living home can be in a partial hospitalization program and go to treatment away for the sober living home during the day.  Mr. Wesley provided definitions and requirements that will improve the opportunity to enforce the proper use of group homes as a place of residence not for treatment.   Mr. Wesley said that no changes have been made to the rules and regulations, since the 1993 Town zoning ordinance.  The industry has changed quite a bit since then and warrants updates to the ordinance. Group homes have been approved and in Town since at least 2005.  There are 13 licensed and approved group homes in Fountain Hills.  Two sober living homes have relocated and three new ones have been approved (1 assisted living, 2 sober living). Mr. Wesley explained that the registration process begins with checking the location meets the separation requirement.  Once the application is accepted and requirements met, an onsite inspection is performed by the Fire Marshal and Building Official for life-safety compliance.  The applicant is required to have a state license and a Fountain Hills business license.   Mr. Wesley said recently there has been push back regarding requirements for local registration of a few homes. Part of the enforcement process would be to contact the property owner as means to obtain compliance. The Town has worked with the State when it appears the home is operating outside the allowances in the ordinance. It was suggested that the Town kick these homes out or shut them down.  The Town does not have the authority to just shut down a sober living home. The Town largely relies on the state.   Mr. Wesley provided a fact sheet with details regarding the Fair Housing Act and definition of community residence. He said the Town Attorney is present to answer any questions.    Mr. Wesley reviewed possible amendments to the zoning ordinance definitions in order to clarify allowed activities and address some of the citizens concerns regarding the possible non-residential in these homes.  He said it would assist with future regulation and enforcement compared to the current limited definition.    He recommended the following definition as a possible amendment change: Community residence - A community residence is a residential living arrangement for five to ten individuals with disabilities, excluding staff, living as    Planning and Zoning Commission Meeting of February 14, 2022 5 of 18 arrangement for five to ten individuals with disabilities, excluding staff, living as a family in a single dwelling unit who are in need of the mutual support furnished by other residents of the community residence as well as the support services, if any, provided by the staff of the community residence.  Residents may be self-governing or supervised by a sponsoring entity or its staff, which provides habilitate or rehabilitative services related to the residents' disabilities.  A community residence seeks to emulate a biological family to foster normalization of its residents and integrate them into the surrounding community.  Its primary purpose is to provide shelter in a family-like environment.  Medical treatment is incidental as in any home.  Supportive inter-relationships between residents are an essential component.  Community residence includes sober living homes and assisted living homes but does not include any other group living arrangement for unrelated individuals who are not disabled nor any shelter, rooming house, boarding house or transient occupancy.   Mr. Wesley said that further definition of a community residence can be based on the distinction of the home: long term residency is more similar to single-family land use and short-term residency is less similar to single-family land use.  There would be some registration and regulation based on the difference in community impact. The home cannot be regulated based on the disability type.   He recommended the following subtypes to the definition as a possible amendment change: Family community residence - A community residence that is a relatively permanent living arrangement with no limit on the length of tenancy as determined in practice or by the rules, charter, or other governing documents of the community residence.  The minimum length of tenancy is typically a year or longer.   Transitional community residence - A community residence that provides a relatively temporary living arrangement with a limit on length of tenancy less than a year that is measured in weeks or months, as determined either in practice or by the rules, charter, or other governing document of the community residence.   Mr. Wesley explained that there are regulatory requirements for homes.  The goal is to allow the homes but to prevent an over concentration that changes the neighborhood setting. Currently, Fountain Hills requires a 1200 feet separation among these homes. The distance ranges surveyed from other cities and towns are from 800 feet to1320 feet.  The recommendation would be to maintain what currently is used in Fountain Hills. He said another regulatory requirement is licensing.  Not all community residences require a state license.  The recommendation would be to require a license or certification by the State of Arizona Department of Health or by the Arizona Recovery Housing Association or “Permanent “Oxford House Charter. The Oxford House is a national organization that has a set off recognized standards.      Planning and Zoning Commission Meeting of February 14, 2022 6 of 18 As part of the application process Mr. Wesley recommended that the following information be required: if the property is rented, the property owner agree to the use as a community residence; the scope of service provided; length of residency; whether or not residents are ambulatory and acknowledge that persons do not constitute a direct threat; agree to register any resident sex offenders.  More information would be required for a transitional community residence such as: providing a staff contact person in the event of neighborhood concerns; require the contact person to provide staff with a follow-up regarding how the compliant was addressed; a good neighbor policy placing requirements on residents and visitors regarding issues such as parking, noise, smoking, cleanliness of property and loitering; comply with ARS 36-2062 requirement to promote safety in the surrounding neighborhood. In regard to the number of occupants, Mr. Wesley recommended a limit maximum number of 8 residents in a single-family district. The Town would continue to require life safety inspections prior to completing registration; allow up to 120 days to complete licensing or certification process; maximum 45 days to vacate the property of license/ certification is not received or revoked. Mr. Wesley said that another item to consider is the waiver of reasonable accommodation. To avoid legal issues, it would be helpful to establish a procedure to address and process requests for the waivers.   In conclusion Mr. Wesley said that staff understands the concerns of citizens with the current ordinance and the allowance of group homes.  Although the federal law requires that the Town provide and allow homes residential uses, staff has recommended several amendments to the ordinance to address citizen concerns. He said that staff is looking to the Commission for direction on modifications to include in the revised ordinance.   In response to Commissioner Watts, Mr. Wesley said that currently in Fountain Hills there are 9 assisted living homes which are geared toward senior living and then there are 4 homes relating to sober living. The 9 homes would be considered long-term living homes.   In response to Chairman Gray, Mr. Wesley explained that the suggested number of occupants was derived by doubling the amount of the maximum amount of unrelated individual’s occupied under one dwelling definition. A family residence would be 12 or more months occupancy. A person setting up a group home would tell us what a typical stay would entail in that group home. Staff would be excluded from the occupancy number.      Mr. Wesley said in regard to Chairman Gray’s concern regarding the separation requirement.  There are noise ordinances that apply to anyone and would be applied the same if a violation exists in a group home.   Chairman Gray stated that he struggles to understand the difference in all the protections that are afforded to an individual and how those same protections are afforded to a commercial business entity.      Planning and Zoning Commission Meeting of February 14, 2022 7 of 18 Jon Paladini, Town Attorney, said he was the city attorney in Prescott for nine years, from 2013 to just recent. He explained the situation Prescott experienced with sober living homes. At one point in Prescott, population of about 40,000 people, had 225 sober homes. Prescott had two HUD investigations and two DOJ investigations in attempts to regulate group homes, similar to what Fountain Hills is trying to do here. Prescott was fortunate enough to actually win or be exonerated, if you will, by those investigations. We brought the HUD investigators to town and drove them around and showed the clustering problem.  Separation is an important piece when it comes to these homes. Group homes for the disabled are intended to integrate disabled persons into the society or into the neighborhood. If there is a clustering problem or have clustering, it creates what are called social service zones or institutionalized zones. So, the people of the disabled people are living amongst just disabled people or the majority, and that's not the intent of the Fair Housing Act. Prescott sort of invented, if you will, this distinction between the family, community, residents and a transitional community residence. They're both group home and considered group homes for the disabled. Residences were allowed in single family residence or single-family zones by right and the transitional residents were allowed in multifamily by right. The reason for that is the transitional residences have a month to month or maybe a yearlong residency which is more like multifamily housing where it's a lease, and it's a year-to-year lease. Family community residences are more emulate more of a family if you will, and so those are allowed in single family residences. Prescott adopted a heavy layer of operational regulation, which was taken away from the city by state law and now DHS regulates.  What goes on inside those four walls is regulated by Department of Health Services.    Chairman Gray said he appreciates the protection that the American Disabilities Act (ADA) and the Fair Housing Act provide. He asked, how is that same right afforded to a commercial business when they go out and seek to acquire rent without having those individuals under their care already. So, we've lost that direct relationship between the protection of the individual and that individual's right to reside and migrated over to the business.   Mr. Paladini said that Individuals are protected by the Fair Housing Act. There is something called a direct threat exclusion and that direct threat exclusion excludes from that Fair Housing Act protection. People who are currently using controlled substances, illegal controlled substances without a prescription and other people who pose a direct threat, primarily parolees, could be considered that and type two and three sex offenders.  These types of folks cannot be prohibited from being covered or being allowed in the group, in the Community Residence center in town. This is a big concern and the group homes don’t want these individuals either. In court cases, the protections that apply to the residents or the disabled persons to be able to have a combination of the Fair Housing Act. The operator of that group home also has standing because they're the ones providing the housing of a group home. The Oxford House model that was mentioned by Mr. Wesley is unique. It is self-governed, there isn't an outside operator.  The house follows a charter from the Oxford House Organization, and they run it themselves. Group home operators do have    Planning and Zoning Commission Meeting of February 14, 2022 8 of 18 standing to seek injunctive relief and damages against a municipality that doesn't provide the proper reasonable accommodation under the zoning code. Generally, when it comes to lawsuits and challenges to regulations is it's the operators that are bringing the suit. They may bring on board one or two of their residents, as sort of named party. The operators are the ones that are going to have the protection because they're the ones offering the residential. In the case law says that group homes for the disabled are considered a residence or residential use, but they have to emulate a family. When a business operates one or more group homes, that business, the office of that business or the headquarters of that business can't be operating out of the residence, they have to operate in a commercial zone, an office zone or a business zone. The residential component can be placed or is allowed to be placed in the residential zone. There is that distinction between the two. So when your business licensing the business, you can regulate the business office, but I would not recommend licensing the individual homes because they're considered residences.   Chairman Gray asked, isn’t that what we're asking to do, though?   Mr. Paladini said that the tracking is primarily for that separation compliance. The Department of Health services is regulating these sorts of operations inside the home. The zoning code is really regulating the land used impact. If you have four disabled persons living in a home, there is no regulation at all. They are simply, as a matter of right. The five, eight or ten occupancy is where they become group homes or community residences, depending on the type of residency. Trying to push that top number down of occupants is tricky. Ten occupants are a safe number, eight is a risk. Twelve occupants take it to institutional living, so it can limit at ten with the possible reasonable accommodation to eleven or twelve occupants. Once above that, it prohibits that in residential zones. There are reasons why you have six, eight or ten persons in a home that are required as part of the accommodation. Two main reasons are particularly in a sober type home is that from a therapeutic standpoint, that higher occupancy number is actually better than than a lower number because it's a larger group. Studies show that a larger occupancy number is better therapeutically. Another reasonable accommodation also includes the financial ability to operate. The whole point is that the setting has to emulate a family.   Mr. Paladini said that these homes are not allowed to provide partial detox or some sort of medical care. The purpose of these homes is to be residential and that’s it.  They cannot provide more than what would normally transpire in a regular family environment. The distribution of medication can happen to some degree, just like parents distribute medication to their kids, whether it's prescription or not.   Chairman Gray asked, where is the line between detoxification and sober living? Is there a municipal level zoning level consideration?   Mr. Paladini said to be careful using terminology. He said detoxification is a    Planning and Zoning Commission Meeting of February 14, 2022 9 of 18 five-to-seven-day process. The addict goes through a five-to-seven-day chemical, medically supervised detox.The first five to seven days detoxification is full hospitalization. They don't get to go home at night. The addict stays in the clinic or the facility for the five to seven days to medically detoxify off of whatever the addiction is. Then they go into this treatment facility an intensive in-house facility for 30 to 40 days. They are managing the addiction. There the other model described is a partial hospitalization. If the partial hospitalization is two components, a residential component and a medical component, the medical component must be conducted from a land use standpoint. In a business office, commercial or wherever medical treatment is allowed clinical type facilities. The residential component is strictly in residential zones. The Community residence is where they watch TV, sleep, shower, eat there may be some type of group therapy The function of the group home is supposed to emulate a family. It's not intended to be a clinical setting. if you have that operation where you have the medical treatment here and the residential component here, the residential component is allowed in your residential zones. Chairman Gray stated that the jurisdiction in this case is the Department of Health Services.   Mr. Paladini said it is not. It is actually the zoning code. If it violates the zoning code then that's a code enforcement matter.  The challenge is discovering what's going on in the home. The state licensing of those sober homes prohibits any kind of clinical therapeutic treatment in the home. It's intended to regulate the operation in the residential home. The reason that state law came into effect was precisely what Mr. Wesley was talking about. In Prescott, it was discovered that they were inadequately operated. The city regulated it and then the state stepped in. Once it's discovered through your collaboration with the Department of Health Services that the operator is running or is operating something other than a residence in that residential zone, then code enforcement action is taken.  The regulations that Mr. Wesley is proposing will help. If somebody is doing something in one of those homes that's not allowed or if the neighbor suspects, they are going to let the Town and Community know.   Vice Chairman Schlossberg asked about occupancy limit enforcement.   Mr. Paladini said that's a tough one. There is the ability to regulate through the building code and typically two persons per bedroom is allowed. In a 3-bedroom house, even though their upper limit would be eight or ten occupants, it is possible to limit those people to six because you're allowing two people per bedroom.  The general rule of thumb is for every 70 square feet of space, you can have one person.100 square foot bedroom, 10’ by 10’, which is kind of typical is two people. That's the other way you would want to look at and limiting that number of persons because it's a quality-of-life issue for those people. It's undesirable to put two bunk beds in a 10' by 10' room and cram, eight to ten people into a two-bedroom house. It’s not allowed for beds to be put in the living room, garage or things like that. That is another tool in the    Planning and Zoning Commission Meeting of February 14, 2022 10 of 18 toolbox to regulate the number of people to a home. The only way to enforce any of this is to find out about it and be able to prove it. It’s the way the system works.   Chairman Gray asked Mr. Paladini what was his experience in Prescott with reasonable accommodation.   Mr. Paladini replied that Prescott’s top number was twelve occupants for the Community residences. It was six to eight occupants  so one through five was a matter of right. Prescott rarely got requests because once above twelve occupants, it's a real burden to prove that more than twelve is needed. More commonly asked was to make a reasonable accommodation to the separation buffer. A significant number of the “fly by night” operators disappeared because insurance no longer paid, it is mostly all out of pocket.   In response to Chairman Gray, Mr. Paladini said that a reasonable accommodation request would be handled administratively.  A public meeting or hearing would not be part of the process since the address remains confidential.  A staff member is appointed to review and approve/deny the request. There are two primary reasons for reasonable accommodation; financial viability and therapeutic reasons.   In response to the Commission, Mr. Paladini said that the Prescott model is exactly what John has proposed in the staff report.   Commissioner Watts asked if there is a way to tie the demographics, the census data, to zoning and say that the average in this particular locale is three occupants, and so the maximum is three. He said he would like to see the occupancy numbers lower than what staff proposed.   Mr. Paladini said that there are two different measurements. A family that's related by blood or marriage has an unlimited number of people that can live in a residential zone, an unrelated group of people is up to four as a matter of right.  The five to eight occupants are what is really the reasonable accommodation. That's the first step in reasonable accommodation. To allow for disabled people to live in the community, four is a matter of right. Five to eight occupants are aggressive.Ten occupants is a safe number. Five to ten occupants are the sweet spot when it comes to being able to defend challenges. . It is limited by the number of bedrooms in the house. A 3-bedroom house, will have six occupants, two people to each room. If there's a seven-bedroom house, the cap is eight to ten occupants. In a three-bedroom house, the six occupants do not include the manager.   Commissioner Watts asked if it is mandatory for the manager be on site 24/7?   Mr. Paladini said that there are two ways the manager can act: as a shift worker or as the manager living there. Typically, there is one house manager and six to seven residents.  The manager is able to leave the house to do whatever normal people do when they leave the house. Since four occupants is    Planning and Zoning Commission Meeting of February 14, 2022 11 of 18 a matter of right, six would be risky. Most challenges come from the upper number, eight to ten unrelated living together and the separation requirement. The eight, ten and twelve occupant number is justifiable because it is supported by studies that show eight to twelve people are financially supportable and it is a good therapeutic number. The distance buffer is used to prevent clustering and allow the integration of the residents in the community. The buffer separation applies to all group homes not just sober living.      In response to Vice Chairman Schlossberg, Mr. Paladini confirmed that based on the separation buffer requirement in Fountain Hills, it would be possible for twenty-five sober living homes to exist at one time in Town. As long as they meet the requirements, they are allowed.   Mr. Paladini mentioned that a bill was introduced last week allowing no restrictions to buffer zones for cities and towns or an amendment to no more than 500 feet.   Chairman Gray asked for clarification regarding the transitional component.   Mr. Paladini said that if these residential components are a week to ten days, they are not residential. The intent of a residential sober home is a transition from the treatment facility, whether it's in house or that partial hospitalization to living on their own. It is a three-to-six-month transition. It's something the Town will want to look in to.  He said he thinks it's worthwhile to say if this partial hospitalization operations are using homes for seven to ten days, then it's closer to Airbnb’s than it is to a group home for the disabled. A transitional community residence is relatively short. It's really a transient stay. This is something staff can look in to and is an interesting twist.   Chairman Gray said that he would like staff to look into the transitional community residence. Commissioner Watts said that to the point of the seven to ten days, there are organizations that have what they refer to as intensive outpatient programs.  Residents work during the day and in the evening, they migrate to these houses. That’s a sudden influx of people. How is that regulated.   Mr. Paladini replied that it really doesn't fit into a group home for the disabled. Even though these folks aren't disabled, it doesn't emulate a family. It's more like an Airbnb rental. If there are violations on the premise such as narcotics use, they're not protected by Fair Housing Act. The house and the occupants may lose their protection. Under Fair Housing Act it's no longer a group home. Now it's just a party house, for instance. The code enforcement tools would be used for disorderly conduct type issues or laws.  There was a concern in Prescott that this was going to happen, so they adopted a disturbance or disorderly residence ordinance. The process included law enforcement showing up a certain amount of times equaled the property owner charged a fee. These types of ordinances are often found in college towns. Prescott just looked at some and tweaked it to fit Prescott. Bottom line is if they are in violation, they    Planning and Zoning Commission Meeting of February 14, 2022 12 of 18 are no longer protected under the Fair Housing Act. They are considered a direct threat. Mr. Paladini said in his opinion If it is throughout the entire house, they could lose their zoning group and report them to the Department of Health Services.  The zoning code, code enforcement, building code, law enforcement and the Department of Health Services are all multiple tools that can be cobbled together and use as appropriate.   Dr. Carol Rogala, said that she has been in practice for 27 years, board certified in emergency medicine, addiction medicine and primary care psychiatry. She said that this is big business. There are lists of all the people who own sober livings, and they're passed around the rehab community. Their rehab community includes people like myself, drug counselors and the patients themselves and various social workers. If an individual cannot pay, they are tossed out. There are lines of people waiting to get in.  She said that the term Intense outpatient sounds confusing when you hear the words. It is 3 hours a day of counseling for 3 or 4 days. A lot of times this is set up by the court system.  A lot of these people who have been to detox and then go to sober living, they've been court ordered to do various things.   If they don't, depending on whatever their conviction was, they can get into a lot of trouble. So intense outpatient, they're not seeing a doctor. There's no medical care, even though it says outpatient, it's counseling.  As far as a detox facility here and maybe there are plans for another one, but the truth of the matter is well over 90% of patients are done outpatient There is no reason for these luxury rehabs other than people have money, and they do it.      John Kavanagh, State Representative and Fountain Hills resident, said this situation is one of the worst threats he has ever seen to Fountain Hills.   He said that the first thing to is to push the envelope in terms of regulations and laws. He said that if an attorney says there is a 70% chance of losing, that's a 30% chance of winning on an issue like this. It's worth the effort to do that. He said he spent six years on the Fountain Hills Town Council and always said to the attorneys stop telling me what I can't do, tell me what I can do for our community. The second thing, of course, is be prepared to defend this in court. It has to be sure that the Town Council is totally behind pushing the envelope and doing all it can to alleviate this situation otherwise the Town’s reputation is that the Town rolls over on these issues. The third thing is something residents have to do if they live near one of these homes, they must document problems. He said he was a cop for 20 years and in court is a powerful witness is one who gets up and says, I've maintained a log - on January 3rd at 8:30 he did this. Then on February 3rd.this happened. That's powerful testimony.  Even if it's only one of these houses that it needs to be shut down because they're not controlling the situation. He said he met with Chairman Gray and a couple of other residents. Mr. Kavanagh said they met with an enforcement person from the Department of Health Services and the Chairman and the members gave some potentially valuable information about these sober living homes doing more than they're supposed to be doing, and about the qualifications of one of the supervising doctors. The enforcement person from the Department of Health service promised to investigate. In addition, it was learned that unfortunately sex offenders can't be kept out of a sober living home, but they    Planning and Zoning Commission Meeting of February 14, 2022 13 of 18 must be on the registry. So at least they can be monitored. The bottom line is this is a big threat to the Town. The Town has to do whatever it can reasonably to keep the ordinances strong and enforce them strong. It needs the backing of a Town Council who ultimately have to pass these rules, tell staff to adopt those regulations and stick behind them, even if it means a court battle. He said that he wants Fountain Hills to be safe and do whatever it takes to keep it safe.   Cathy Marx, Fountain Hills resident, said that she lives on East Nicholas Drive, two houses away from a practicing sober living home.  They're practicing how to live soberly, which means mistakes. She said she was told that a drug drop off was observed in front of her house..She said she asked people who find drug paraphernalia to collect it. She held up a bag with items found in the neighborhood.  She said this is the reality of citizens and is so tired of law-abiding, taxpaying citizens having no rights, everyone seems to have more rights than we do. So that's being said, we are documenting. She said the collection she held up in the bag was only two weeks’ worth. She said she is glad these were collected before a child picked it up and put it in its mouth. That's what we're living with. She thanked the Commission and said keep up the good work, it is appreciated.   Larry Myers, Fountain Hills resident, said this situation is similar to what he experienced in Austin, TX. He said Miss Marks is right because the Fair Housing Act and the Americans for Disabilities Act, while saying they are creating equality, are creating a greater equality for disabled. He recently spoke with Mr. Wesley regarding one of the sober living homes.  Mr. Wesley informed him that the Town does not have the authority to shut them down and referred him to the state agency. He said that when he called the state, he found out there is only one person working down there and they would look it to it.  That conversation took place on February 1 st. He said he supports what Representative Kavanaugh said about pushing the envelope. The citizens have as many rights as do the disabled. We are equal. It is about equality.   Crystal Kavanaugh, Fountain Hills resident, said that she supports the Commission for trying to provide the residents with protective ordinances, specifically outlining requirements for these group homes slash home based businesses within the residential neighborhoods, including businesses. She said that the state is the entity providing the oversight and monitoring of these licensed sober living homes, but this is an illusion. When she called the Arizona Department of Health Services, she found out that the state has no regular monitoring of the homes other than a yearly visit, and clearly not enough staff assigned to achieve this. There is one man, Wesley Sisson, who is solely responsible for overseeing the ever-growing sober living industry located within our residential neighborhoods. One man for all of Arizona. These yearly visits are actually scheduled in advance. They're not even spontaneous. The homes know precisely when the state is coming, how difficult is it to be in compliance for one day when the homes are given you a heads-up. The sober living licensing stipulates these homes must not provide the clients with any onsite medical or clinical services or medication administration. The state    Planning and Zoning Commission Meeting of February 14, 2022 14 of 18 determines that a current medication list for a recovery client is on file, but they don't actually monitor which medications are being provided and where this even occurs. Currently, there are no local  oversight of these sober living homes. Where is the accountability for the clients, the neighbors and the community? Local code enforcement is limited with whether they have obtained their $50 business license and the clustering of homes. And of course, we're always threatened with interference or discrimination towards the protective group even when it's not the case. This is an unacceptable level of monitoring that our community is told to depend on and we desperately need to be allowed some level of oversight at the local level, in addition to modifications of state regulations for the benefit of all involved, as Representative John Cavanaugh indicated, a small group of us have been addressing concerns with him and others from the state. Hopefully some resolution can occur and the ordinances put forth from tonight are the strongest possible to be used as a valuable tool towards achieving some level of equitable accountability.   Liz Gildersleeve, Fountain Hills resident, thanked the Commission for leading the issue of stronger ordinances in our Town for sober homes and detoxification facilities. Stronger ordinances and regulations will only benefit homeowners and the neighborhoods. From the Town's current lack of strong ordinances and minimal oversight, these recovery businesses have been working overtime the last few months to paint themselves as saintly victims whose only desire is to help people with drug and alcohol addictions.  To the Fountain Hills residents in this room, there is no shame in asking your Town officials to better regulate and oversee the sober homes in your neighborhoods and be proactive about violations. Continue to speak up, ask questions, demand action and accountability. No one moved to Fountain Hills to be surrounded by sober homes. She said she thoroughly enjoyed hearing the discussion tonight and is hopeful that the Town staff will work with the Commission to finally put pen to paper and create fearless, bold, detailed oriented ordinances that will benefit the Town. Steve Baggio, Fountain Hills resident, said that Fountain Hills does not need any more sober homes in a Town with a population of 24,000 and with a large population of seasonal residents. Regulations and zoning restrictions need to be in place so that our neighborhoods can become more family orientated and not filled with the sober homes in short term vacation rentals in every block. There is a problem with people and families trying to find homes for sale in this town as is and do not need to add to this problem. Many of us left big cities and big city problems to live in Fountain Hills. If the town allows more sober homes, Fountain Hills will lose its charm and small town feel that we all adore. Let us work together to make Fountain Hills the great Town it should be, and not to let it turn into decay and a half empty urban wasteland of a town that motorists hit the gas pedal when they approach. He asked the Commission to do what's in best the interest of saving our neighborhoods and not lining the pockets of business operators that live nowhere close to Fountain Hills.   Chairman Gray thanked the speakers and the public for attending the meeting.        Planning and Zoning Commission Meeting of February 14, 2022 15 of 18 Mr. Paladini noted the Town can preclude or prohibit level 2 and 3 sex offenders from residing in any of the homes.   Chairman Gray said he is in agreement with the following: clarification of the definitions, number of occupants, family cap at four occupants, the group home cap at eight occupants. He said he would like to see the transitional home cap at six occupants. He said the1200 feet separation is essential because of the Town topography. The addition of the prohibition of level 2 and 3 sex offenders.   Commissioner Watts agreed with Chairman Gray but suggested that six occupants should include the manager.   Commissioner Kovacevic suggested that the categories be clearly stated in the ordinance. He suggested three categories: less than 30 days stay in a more restricted zoning class, 30-to-365-day stay would fall under multi-family and greater than 365 days would fall under single family zoning district.  He agreed that the manager should count as one of the six occupants.   In response to Commissioner Dempster, Mr. Wesley said that the definition “Community Residence” term is used throughout the industry. Although the definition says “self-governing” the ordinance can be written to include staff in the total number of occupants.   Chairman Gray asked that the Town’s legal department look into the definition of the 7 to 14 days stay range which seems to be the model in Fountain Hills today.  He asked if the proof of insurance information can be requested during the application process.    Commissioner Watts noted that at a previous meeting a Commission discussion decided that an additional insurer be named as a Fountain Hills requirement.       Commissioner Dempster noted that the application needs revisions.   In response to Chairman Gray, Mr. Wesley confirmed that there is a two-week notification requirement, to schedule an earlier meeting would be challenging.   In response to Commissioner Watts, Chairman Gray replied that a moratorium cannot be placed on sober living homes.    Chairman Gray concluded the discussion by saying there is no motion or vote to be made. He thanked the public, Staff and the Commission for their time.   7.COMMISSION DISCUSSION/REQUEST FOR RESEARCH to staff.     None.    Planning and Zoning Commission Meeting of February 14, 2022 16 of 18   8.SUMMARY OF COMMISSION REQUESTS from Development Services Director.     None.     Mr. Wesley said he would be reviewing the Commissions input regarding the group homes.  He said that he will present the updates to the ordinance regarding group homes at the next meeting scheduled on March 14, 2022.   9.REPORT from Development Services Director.     None.   10.ADJOURNMENT      The Regular Meeting of the Fountain Hills Planning and Zoning Commission held February 14, 2022, adjourned at 10:16 p.m.     PLANNING AND ZONING COMMISSION   _______________________________ Chairman Peter Gray                                                                               ATTESTED AND PREPARED BY:                                                                             _________________________________                                                                               Paula Woodward, Executive Assistant   CERTIFICATION I hereby certify that the foregoing minutes are a true and correct copy of the minutes of the Regular Meeting held by the Planning and Zoning Commission, Fountain Hills in the Town Hall Council Chambers on February 14, 2022. I further certify that the meeting was duly called and that a quorum was present. DATED this day of March 7, 2022.                                                                            ______________________________                                                                           Paula Woodward, Executive Assistant     Planning and Zoning Commission Meeting of February 14, 2022 17 of 18    Planning and Zoning Commission Meeting of February 14, 2022 18 of 18 ITEM 5. TOWN OF FOUNTAIN HILLS STAFF REPORT    Meeting Date: 03/14/2022 Meeting Type: Planning and Zoning Commission Agenda Type: Submitting Department: Development Services Prepared by: John Wesley, Development Services Director Staff Contact Information: John Wesley, Development Services Director Request to Planning and Zoning Commission (Agenda Language):  HOLD A PUBLIC HEARING, CONSIDER AND POSSIBLE ACTION: regarding Ordinance 22-01, amending Chapters 1, 5, 10, and 11 of the Zoning Ordinance to provide the definitions of family and community residences, the regulations for community residences, and the zoning districts where allowed. Staff Summary (Background) The Planning and Zoning Commission has been reviewing and discussing options for modifications to the Town's ordinance requirements for group homes for several months.  At the January 2022 meeting the Commission heard from the public and then provided staff with direction as to language they would like to see in a revised ordinance.  Based on the input received, staff has drafted ordinance changes.  The ordinance for consideration and recommendation to the Council is attached. Review of Proposed Ordinance Changes Definitions Staff is proposing the following modifications to the definitions provided in Chapter 1 of the Zoning Ordinance:  Amend the definition of family to set the upper maximum number of unrelated individuals residing together in a home at 4.   1. Remove the existing definition of Group Home for the Handicapped and Elderly and replace it with a new definition of Community Residence. This will include the subcategories of Family Residences (for homes where typical residency is over one year) and Transitional Residences (for homes where the typical residency is between 30 days and one year).  In keeping with the discussion from the January meeting, the proposed language limits programs that keep residents for less than 30 days from being considered community residences and requires that the home be used for residential purposes, not treatment.  Staff will be proposing language as part of the ordinance change addressing detox facilities and drug/alcohol treatment to cover places with a shorter length of tenancy. 2. Community Residence Regulations Staff is proposing to add language into Section 5.13 of the Zoning Ordinance to provide a comprehensive set of rules to govern this type of use.  Those rules are:  A.  Standards 1,200' minimum spacing between homes Maximum 2 people per bedroom, transitional residence limited to 6 including staff (Note, staff had recommended 8 not including staff) Obtain Town business license, if applicable B.  Application requirements Licensing requirement (State, Arizona Recovery Housing Association, Oxford House charter) Property owner acknowledgement of use Description of the scope of services to be provided Cannot house individuals who would be a threat to community; register level 1 sex offenders Copy of liability insurance.  (Note, staff does not see any benefit, but does see some potential problems with naming the Town as an additional insured.) Copy of state or third party license or certification documents that provide:  Contact individuals "Good Neighbor" policies Efforts to promote safety of surrounding neighborhood Floor plan designating bedrooms, living and dining areas. C.  Registration Required; valid for 1 year Inspection by Fire Marshal and Building Official; address deficiencies Complete application based on requirements in B. May issue provisional registration pending receipt of license/certificate; must be received within 90 days or have 45 days to vacate property Must re-register on an annual basis showing ongoing compliance D.  Process and requirements for waiver of reasonable accommodation. Staff believes the provisions in the attached ordinance are consistent with the discussion and direction provided at the last P & Z meeting.  Further adjustments can be made as part of the review and discussion at the meeting on March 14. Related Ordinance, Policy or Guiding Principle Zoning Ordinance Section 1.12, Definitions Zoning Ordinance Section 10.02 A Permitted Uses Zoning Ordinance Section 11.02 Permitted Uses Risk Analysis There are a number legal constraints that impact our ability to regulate group home uses.  It is important that these legal parameters be considered in making any modifications to current language. Recommendation(s) by Board(s) or Commission(s) N/A Staff Recommendation(s) Staff Recommendation(s) The staff report for the February 14, 2022, meeting provided significant background on the areas where regulations could be modified to better address this land use.  The proposed ordinance is mostly in keeping with that review and those recommendations.  The one area of difference is the limitation on the number of residents allowed in a transitional residence when located in a single-family zoning district. Staff supports approval of Ordinance 22-01. SUGGESTED MOTION MOVE to recommend approval of Ordinance 22-01. Attachments Ordinance 22-01  ORDINANCE NO. 22-01 AN ORDINANCE OF THE MAYOR AND COUNCIL OF THE TOWN OF FOUNTAIN HILLS, ARIZONA, AMENDING THE TOWN OF FOUNTAIN HILLS ZONING ORDINANCE, CHAPTER 1, INTRODUCTION, SECTION 1.12, DEFINITIONS, AMENDING THE DEFINITIONS OF FAMILY AND GROUP HOME; AMENDING CHAPTER 5, GENERAL PROVISIONS, SECTION 5.13, RESERVED, RENAMING THE SECTION AND PROVIDING REGULATIONS FOR GROUP HOMES; AMENDING CHAPTER 10, SINGLE- FAMILY RESIDENTIAL ZONING DISTRICTS, SECTION 10.02 A. 12. GROUP HOMES FOR THE HANDICAPPED AND ELDERLY CARE; AND, AMENDING CHAPTER 11, SECTION 11.02 A. 11. GROUP HOMES FOR THE HANDICAPPED AND ELDERLY CARE RECITALS: WHEREAS, the Mayor and Council of the Town of Fountain Hills (the “Town Council”) adopted Ordinance No. 93-22 on November 18, 1993, which adopted the Zoning Ordinance for the Town of Fountain Hills (the “Zoning Ordinance”); and WHEREAS, the Town Council desires to amend Chapter 1, Introduction, Section 1.12, Definitions, amending the definitions of Family and Group Home; amending Chapter 5, General Provisions, Section 5.13, Reserved, renaming the section and providing regulations for group homes; amending Chapter 10, Single-family Residential Zoning Districts, Section 10.02 A. 12. Group Homes for the Handicapped and Elderly Care; and, amending Chapter 11, Section 11.02 A. 11. Group Homes for the Handicapped and Elderly Care; and WHEREAS, in accordance with the Zoning Ordinance and pursuant to ARIZ. REV. STAT. § 9-462.04, public hearings regarding this ordinance were advertised in the February 23, 2022 and March 2, 2022 editions of the Fountain Hills Times; and WHEREAS, public hearings were held by the Fountain Hills Planning & Zoning Commission on March 14, 2022, and by the Town Council on April 5, 2022. WHEREAS, in accordance with Article II, Sections 1 and 2, Constitution of Arizona, and the laws of the State of Arizona, the Town Council has considered the individual property rights and personal liberties of the residents of the Town and the probable impact of the proposed ordinance on the cost to construct housing for sale or rent before adopting this ordinance. ENACTMENTS: NOW, THEREFORE, BE IT ORDAINED BY THE MAYOR AND COUNCIL OF THE TOWN OF FOUNTAIN HILLS as follows: SECTION 1. The recitals above are hereby incorporated as if fully set forth herein. SECTION 2. The Zoning Ordinance, Chapter 1, Introduction, Section 1.12, Definitions, is hereby amended as follows: … COMMUNITY RESIDENCE. A COMMUNITY RESIDENCE IS A RESIDENTIAL LIVING ARRANGEMENT FOR FIVE TO TEN INDIVIDUALS WITH DISABILITIES, EXCLUDING STAFF, LIVING AS A FAMILY IN A SINGLE DWELLING UNIT WHO ARE IN NEED OF THE MUTUAL SUPPORT FURNISHED BY OTHER RESIDENTS OF THE COMMUNITY RESIDENCE AS WELL AS THE SUPPORT SERVICES, IF ANY, PROVIDED BY THE STAFF OF THE COMMUNITY RESIDENCE. RESIDENTS MAY BE SELF-GOVERNING OR SUPERVISED BY A SPONSORING ENTITY OR ITS STAFF, WHICH PROVIDES HABILITATIVE OR REHABILITATIVE SERVICES RELATED TO THE RESIDENTS' DISABILITIES. A COMMUNITY RESIDENCE SEEKS TO EMULATE A BIOLOGICAL FAMILY TO FOSTER NORMALIZATION OF ITS RESIDENTS AND INTEGRATE THEM INTO THE SURROUNDING COMMUNITY. ITS PRIMARY PURPOSE IS TO PROVIDE SHELTER IN A FAMILY-LIKE ENVIRONMENT. MEDICAL TREATMENT IS INCIDENTAL AS IN ANY HOME. SUPPORTIVE INTER-RELATIONSHIPS BETWEEN RESIDENTS ARE AN ESSENTIAL COMPONENT. COMMUNITY RESIDENCE INCLUDES SOBER LIVING HOMES AND ASSISTED LIVING HOMES BUT DOES NOT INCLUDE ANY OTHER GROUP LIVING ARRANGEMENT FOR UNRELATED INDIVIDUALS WHO ARE NOT DISABLED NOR ANY SHELTER, ROOMING HOUSE, BOARDING HOUSE OR TRANSIENT OCCUPANCY. FAMILY COMMUNITY RESIDENCE. A COMMUNITY RESIDENCE THAT IS A RELATIVELY PERMANENT LIVING ARRANGEMENT WITH NO LIMIT ON THE LENGTH OF TENANCY AS DETERMINED IN PRACTICE OR BY THE RULES, CHARTER, OR OTHER GOVERNING DOCUMENTS OF THE COMMUNITY RESIDENCE. THE MINIMUM LENGTH OF TENANCY IS TYPICALLY A YEAR OR LONGER. TRANSITIONAL COMMUNITY RESIDENCE. A COMMUNITY RESIDENCE THAT PROVIDES A RELATIVELY TEMPORARY LIVING ARRANGEMENT WITH A LIMIT ON LENGTH OF TENANCY, TYPICALLY MORE THAN THIRTY (30) DAYS AND LESS THAN A YEAR, AS DETERMINED EITHER IN PRACTICE OR BY THE RULES, CHARTER, OR OTHER GOVERNING DOCUMENT OF THE COMMUNITY RESIDENCE. … Family: An individual, or two (2) or more persons related by blood or marriage, or a group of NOT MORE THAN FOUR (4) persons not related by blood or marriage, living together as a single housekeeping group in a dwelling unit. … Group Home for the Handicapped and Adult Care: A dwelling shared by handicapped and/or elderly people as their primary residence and their resident staff, who live together as a single housekeeping unit, sharing responsibilities, meals, and recreation. The staff provides care for the residents. A Group Home for the Handicapped and Adult Care does not include nursing homes, alcohol or other drug treatment centers, community correction facilities, shelter care facilities, or homes for the developmentally disable as regulated by the Arizona Revised Statutes Section 36-582. … SECTION 3. The Zoning Ordinance, Chapter 5, General Provisions, Section 5.13, Reserved, is hereby amended as follows: Section 5.13. ReservedCOMMUNITY RESIDENCES (Deleted per Ordinance 2004-10 – Storage and Parking of Mobile Homes, Boats, Aircraft, Truck Campers, Camping Trailers, Travel Trailers and Other Trailers is hereby deleted in its entirety.) Refer to Chapter 7 – Section 7.02.Community residences are allowed and may be registered as provided below. A. Standards: 1. To prevent the clustering of community residences and to better integrate community residence residents into the surrounding neighbor and community, such home must be located on a lot that is at least one thousand two hundred (1,200) feet from the exterior lot lines of another community residence, measured by a straight line from the property line in any direction. 2. No more than two persons per bedroom up to the maximum allowed for the type of home. For transitional community residences in single-family zoning districts, the maximum number of residents is six (6) including any resident staff. 3. Receives a Town business license, if applicable. 4. An individual required to register under Arizona law as a sex offender and classified as a Level II or Level III community risk (intermediate to high risk) is not permitted to live in a community residence. B. Application requirements: 1. Copy of license or certified through one or more of the following groups or agencies, or produces such license or registration within 90 days: a. License or is certified by the State of Arizona Department of Health; or b. License or is certified by the Arizona Recovery Housing Association; or, c. “Permanent” Oxford House charter. 2. If the property is being rented or leased, an acknowledgement from the property owner agreeing to the use of the property as a community residence. 3. A description of the scope of services to be provided in the home and whether or not the residents will be ambulatory. 4. A statement the home shall not house any person whose tenancy would constitute a direct threat to the health or safety of other individuals or would result in substantial physical damage to the property of others. 5. A copy of liability insurance for the operation of the home at the given address. 6. The portions of any state license or third party certification application requirements that provide: a. Names of contact individual(s) for the home who can respond to complaints or emergencies. b. Information regarding policies and procedures for residents and visitors related to parking, noise emanating from the home, smoking, cleanliness of the public space near the sober living home, and loitering in front of the home or near-by homes are established, known to residents, and enforced. c. Information regarding efforts to promote the safety of the surrounding neighborhood. 7. A floor plan of the home showing all bedrooms, living, and dining areas. C. Registration: 1. Registration of a community residence with the Town is required prior to beginning operation. An approved registration is valid for one year from date administratively issued. 2. Following receipt of a complete application for registration, the property will be inspected by the Building Official and Fire Marshal for compliance with all life safety requirements. Any identified deficiencies must be addressed and compliance verified through a follow up inspection before the registration will be completed. 3. All required documents listed in B. will be reviewed. Any required corrections or clarifications must be submitted to complete the registration process. 4. When all registration requirements have been met, the Development Services director will administratively complete the Town’s registration process. 5. If all other requirements of this ordinance are met, the Development Services Director may issue a provisional registration for up to 90 days while the applicant applies for and receives their license or certificate as required by B.1. If the license or certificate is not received by the Town within 90 days, is not approved, or becomes revoked for any reason, the community residence operator will have 45 days to vacate the property. 6. Reregistration. The community residence operator must register annually by submitting a new application with any updated documents. The registration can be renewed if the following are met: a. The home has maintained a current license or certificate. b. The home or operator has maintained a current Town business license, if applicable. c. Re-inspection of the property has verified ongoing compliance with life safety standards. d. The provider has complied with the policies and procedures established in B. 6. D. Waiver for Reasonable Accommodation. To establish a community residence for more than 10 individuals with disabilities or to reduce the separation requirement to less than 1,200’, the applicant may apply for a Waiver for Reasonable Accommodation. Such request will be reviewed and acted upon by the Development Services Director. ln all cases the Development Services Director shall make findings of fact in support of the determinations and shall render the decision in writing. The Development Services Director may meet with and interview the applicant to ascertain or clarify information sufficiently to make the required findings. 1. To grant a Waiver for Reasonable Accommodation, the Development Services Director shall find affirmatively all of the following standards: a. The applicant demonstrates that the proposed community residence can and will emulate a biological family and function as a residential use rather than an institutional or other nonresidential use. b. The applicant demonstrates that the proposed community residence needs to house more than 10 residents or reduce the separation for financial or therapeutic reasons. c. The applicant demonstrates that the proposed community residence will not interfere with the normalization and community integration of the residents of any existing community residence and that the presence of other community residences will not interfere with the normalization and community integration of the residents of the proposed community residence d. The applicant demonstrates that it will operate the home in a manner similar to that ordinarily required by state licensing to protect the health, safety, and welfare of the occupants of the proposed community residence e. The applicant demonstrates that the proposed community residence in combination with any existing community residences will not alter the residential character of the surrounding neighborhood by creating an institutional atmosphere or by creating a de facto social service district by concentrating community residences on a block or in a neighborhood 2. A community residence operator may appeal denial of a Waiver for Reasonable Accommodation by the Development Services Director pursuant to the procedures set forth in Section 2.07 A, Appeals to the Board of Adjustment. SECTION 4. The Zoning Ordinance, Chapter 10, Single-Family Residential Districts, Section 10.02 A., Permitted Uses, is hereby amended as follows: 12. Group Homes for the Handicapped and Elderly Care; provided, that: COMMUNITY RESIDENCE, SUBJECT TO THE REQUIREMENTS OF SECTION 5.13 a. No such home is located on a lot that is within one thousand – two hundred (1,200) feet, measured by a straight line in any direction of the exterior lot lines of another group home for the handicapped and elderly care. b. No such home contains more than ten (10) residents. c. Such home is licensed by the State of Arizona Department of Health. d. Such home is registered with, and administratively approved by the Community Development Director or designee, as to compliance with the standards of this Ordinance. SECTION 5. The Zoning Ordinance, Chapter 11, Multifamily Zoning Districts, Section 11.02 A, Permitted Uses, is hereby amended as follows: 11. Group Homes for the Handicapped and Elderly Care; provided, that: COMMUNITY RESIDENCE, SUBJECT TO THE REQUIREMENTS OF SECTION 5.13 a. No such home is located on a lot within one thousand – two hundred (1,200) feet, measured by a straight line in any direction, of the exterior lot lines of another group home for the handicapped and elderly care. b. No such home contains more than ten (10) residents. c. Such home is licensed by the State of Arizona Department of Health Services. d. Such home is registered with, and administratively approved by the Community Development Director or designee, as to compliance with the standards of this Ordinance. Section 6. If any section, subsection, sentence, clause, phrase, or portion of this Ordinance is for any reason held to be unconstitutional by the decision of any court of competent jurisdiction, such decision shall not affect the validity of the remaining portions of this Ordinance. PASSED AND ADOPTED by the Mayor and Council of the Town of Fountain Hills, Arizona, this 5th day of April 2022. FOR THE TOWN OF FOUNTAIN HILLS: ATTESTED TO: Ginny Dickey, Mayor Elizabeth A. Klein, Town Clerk REVIEWED BY: APPROVED AS TO FORM: Grady E. Miller, Town Manager Aaron D. Arnson, Town Attorney ITEM 6. TOWN OF FOUNTAIN HILLS STAFF REPORT    Meeting Date: 03/14/2022 Meeting Type: Planning and Zoning Commission Agenda Type: Submitting Department: Development Services Prepared by: John Wesley, Development Services Director Staff Contact Information: John Wesley, Development Services Director Request to Planning and Zoning Commission (Agenda Language):  REVIEW AND DISCUSS: possible Zoning Ordinance text amendments to address drug and alcohol treatment centers and detoxification facilities. Staff Summary (Background) The Zoning Ordinance provides for a variety of different land uses and places those uses in different zoning districts consistent with the nature of the use and the intent of the various districts.  Chapter 12 of the Zoning Ordinance establishes the commercial zoning districts and the uses allowed in each district.  In addition to uses permitted by right in each district, the ordinance also establishes uses which can be approved through a Special Use Permit process.     Toward the end of 2020, staff received inquires regarding the possibility of establishing a detoxification facility in Town.  Detoxification facilities are places people can go for assistance to withdraw from drugs and/or alcohol.  These facilities can range from sub-acute, outpatient facilities to more intense, inpatient facilities.  These facilities can operate in a variety of ways.  In some cases the patients are self-motivated to end their addiction and have the time and means to seek treatment. In other cases the patient may be ordered to go through treatment, starting with the detoxification, or they may not be as personally motivated to seek assistance.  Sometimes their addiction is not as severe and the withdrawal process is not significant.  In other cases the addiction and resulting withdrawal process can be significant and require constant medical supervision. Staff brought this issue up with the Town Council at their annual retreat in February, 2021.  The Council asked staff to explore and make a recommendation on how this use could be incorporated into the Zoning Ordinance.  When staff followed up with a draft ordinance, the Planning and Zoning Commission was addressing the issue of hospitals and possible amendments to allow that use.  Given the public concern about detoxification facilities and possible confusion with what was being considered for hospitals, the Commission voted on April 12, 2021, against the draft ordinance and work on that issue was halted. Following the adoption of a new ordinance addressing hospitals, and with ongoing concern in Town regarding the possibility of detoxification facilities and statements from the Town Attorney that we could not prohibit the use, the Planning and Zoning Commission determined we should move ahead and could not prohibit the use, the Planning and Zoning Commission determined we should move ahead and consider how to address this land use.  A companion issue of group homes and sober living homes was also identified and is being addressed. Through the discussion of detox facilities and group homes, another related issue of treatment centers was identified.  Treatment centers address the early process of recovery from an addiction and provides the patient with the beginning skills to overcome their addiction.  Treatment centers may or may not assist with withdrawal (similar to a detoxification facility) and may have a residential component similar to a sober living home.  Therefore, this use can overlap the other two which creates some challenges with regulation.  This report also covers this land use and how it might be incorporated into the zoning ordinance. In this report, staff is responding to the comments and issues raised by the Commission and public and putting forth some options for how to address these topics.  Based on the feedback received, staff will draft an ordinance for consideration at a future P&Z Commission meeting, potentially in April. When considering the placement of new uses into the zoning ordinance, it is helpful to know the intended use of each district and to review how some existing uses are placed.  Following are the descriptions for the three primary zoning districts where these uses could be considered:    C-1. Neighborhood Commercial and Professional Zoning District: The Neighborhood Commercial and Professional District is established to provide a location for modest, well-designed commercial enterprises to serve a surrounding residential neighborhood, as well as to provide for services to the community, which is not detrimental to the integrity of the surrounding residential neighborhood, and to provide for the appropriate location of professional offices throughout the community. The intent of this district is to integrate limited commercial activity and professional offices with residential land uses in a climate favorable to both. Particular attention is to be paid to the interface between commercial or professional uses and the residential uses within the same neighborhood. C-2. Intermediate Commercial Zoning District: The principal purpose of this Zoning District is to provide for the sale of commodities and the performance of services and other activities in locations for which the market area extends beyond the immediate residential neighborhoods. Principal uses permitted in this Zoning District include furniture stores, hotels, motels, restaurants, and some commercial recreation and cultural facilities such as movies and instruction in art and music. This Zoning District is designed for application at major street intersections. C-3. General Commercial Zoning District: The principal purpose of this Zoning District is to provide for commercial uses concerned with wholesale or distribution activities in locations where there is adequate access to major streets or highways. Principal uses permitted in this Zoning District include retail and wholesale commerce and commercial entertainment. Examples of existing uses allowed in commercial zoning districts include:  All Commercial Districts: Dentist, Physicians, and other medical offices Counselors Medical and clinical laboratories Pharmacies Retail, restaurant, entertainment Additional Uses allowed in C-2 and C-3: Bars Health spas and public gyms Pool halls or billiard centers Uses requiring a Special Use Permit in all Commercial Districts: Group Homes Single and multifamily dwellings Uses requiring a Special Use Permit in C-2 or C-3  Convenience stores Cabinet shops Automobile fuel dispensing Vehicle storage Construction equipment sales, rentals Temporary storage facilities Detoxification Staff was able to identify two levels of detoxification facilities.  One is sub-acute/outpatient facilities.  In these facilities, the level of addiction is low enough that the resulting process of detoxification and withdrawal does not pose significant medical issues or need constant supervision.  With these facilities the patients either live at home or in a group home and come to the facility on a regular basis for a period of time to complete the withdrawal process.  In many ways, these facilities will not be much different from other medical office facilities.  In review of these types of facilities, however, staff has found examples where the clients spend time outside the facility waiting for treatment or for a ride.  This can have a negative impact on surrounding uses and neighborhoods.  Given the purpose statements for the various zoning district found in Section 12.01, and the existing medical uses allowed in the various zoning districts, staff is suggesting this use be comparable to other uses in the C-2 and C-3 Districts.  It may be possible for the ordinance to include some basic requirements along with the allowance for the use such as requiring provision for indoor waiting, a "Good Neighbor" policy, and/or a contact person in case of complaints. The other level of detoxification facilities are termed acute/inpatient facilities.  These facilities are used by individuals with a more significant level of addiction that require medical supervision during the detoxification process.  By the nature of the facility and the service they provide, they need to be open and operate 24/7.  They may also experience emergency situations that could be disruptive to a neighborhood or other surrounding uses. This use also is different from the traditional commercial, office, and entertainment uses typically found in commercial zoning districts.  Therefore, staff is suggesting this use be allowed only through approval of a Special Use Permit in the C-2 and C-3 Zoning District. The SUP application could also require the submittal of information to address any negative impacts of the use. Treatment Centers When doing an Internet search on the government website FindTreatment.gov, one treatment facility is listed in Fountain Hills, Fountain Hills Recovery, and another 8 are listed within 10 miles, all in Scottsdale.  Attached is a document from the National Institute on Drug Abuse that provides information on drug treatment programs.  In summary, there are a lot of different types of treatment programs.  Some include a residential component where treatment and housing is at the same place.  Some treatment programs do not provide any housing option, just medication, counseling, and education at their offices.  Others have a hybrid approach that provides housing for a person going through treatment with the treatment taking place away from the home.  Some programs include using medications (e.g. buprenorphine, methadone, naltrexone) to help in the detoxification/recovery process.  Many include individual and/or group counseling and education.  The rate of "success" depends a lot on the program and the motivation of the individual.  Treatment centers can be either inpatient and outpatient.  With inpatient treatment centers the person resides at the treatment center where the treatment takes place.  Generally, they are confined to the facility with little to no outside contact during the early stages of treatment.  These treatment programs are most often 28-day programs, but can be longer.  This is considered a medical, treatment program and is not a residential land use.  While these programs can be relatively quiet and controlled, they are subject to all hours of activity.  The semi-residential nature of these treatment facilities, they are somewhat more similar with other uses that require approval of a Special Use Permit in the C-2 and C-3 zoning districts. Outpatient treatment programs usually involve clients coming to the facility on a regular basis.  Depending on the client and the program, it can be every day, all day, or it can be a few days a week for a few hours at a time.  Outpatient programs can resemble medical office land use impacts in many ways.  However, the history also shows they can be very similar to detoxification facilities where clients are left to wait for treatments or rides and can be disruptive to surrounding businesses.  Therefore, it may be appropriate to address these uses in a similar manner and allow them only in C-2 and C-3 with some development standards as listed above. Related Ordinance, Policy or Guiding Principle Zoning Ordinance Section 1.12. Definitions Zoning Ordinance Chapter 12, Commercial Zoning Districts Risk Analysis N/A Recommendation(s) by Board(s) or Commission(s) N/A Staff Recommendation(s) Staff is looking for direction from the P&Z Commission regarding the areas that could be modified in the zoning ordinance to address detoxification and treatment center land uses. SUGGESTED MOTION This will be a discussion item.  While staff is looking for direction, no formal motions will be made. Attachments National Institute on Drug Addiction Report  Publications Revised January 2018 Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Table of Contents Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Preface Principles of Effective Treatment Frequently Asked Questions Drug Addiction Treatment in the United States Evidence-Based Approaches to Drug Addiction Treatment Acknowledgments Resources Page 1 Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies described. Preface Drug addiction is a complex illness. It is characterized by intense and, at times, uncontrollable drug craving, along with compulsive drug seeking and use that persist even in the face of devastating consequences. This update of the National Institute on Drug Abuse’s Principles of Drug Addiction Treatment is intended to address addiction to a wide variety of drugs, including nicotine, alcohol, and illicit and prescription drugs. It is designed to serve as a resource for healthcare providers, family members, and other stakeholders trying to address the myriad problems faced by patients in need of treatment for drug abuse or addiction. Addiction affects multiple brain circuits, including those involved in reward and motivation, learning and memory, and inhibitory control over behavior. That is why addiction is a brain disease. Some individuals are more vulnerable than others to becoming addicted, depending on the interplay between genetic makeup, age of exposure to drugs, and other environmental influences. While a person initially chooses to take drugs, over time the effects of prolonged exposure on brain functioning compromise that ability to choose, and seeking and consuming the drug become compulsive, often eluding a person’s self-control or willpower. But addiction is more than just compulsive drug taking—it can also produce far-reaching health and Page 2 social consequences. For example, drug abuse and addiction increase a person’s risk for a variety of other mental and physical illnesses related to a drug-abusing lifestyle or the toxic effects of the drugs themselves. Additionally, the dysfunctional behaviors that result from drug abuse can interfere with a person’s normal functioning in the family, the workplace, and the broader community. Because drug abuse and addiction have so many dimensions and disrupt so many aspects of an individual’s life, treatment is not simple. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. Addiction treatment must help the individual stop using drugs, maintain a drug-free lifestyle, and achieve productive functioning in the family, at work, and in society. Because addiction is a disease, most people cannot simply stop using drugs for a few days and be cured. Patients typically require long- term or repeated episodes of care to achieve the ultimate goal of sustained abstinence and recovery of their lives. Indeed, scientific research and clinical practice demonstrate the value of continuing care in treating addiction, with a variety of approaches having been tested and integrated in residential and community settings. As we look toward the future, we will harness new research results on the influence of genetics and environment on gene function and expression (i.e., epigenetics), which are heralding the development of personalized treatment interventions. These findings will be integrated with current evidence supporting the most effective drug abuse and addiction treatments and their implementation, which are reflected in this guide. Nora D. Volkow, M.D. Director National Institute on Drug Abuse Principles of Effective Treatment 1.Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences. Page 3 2.No single treatment is appropriate for everyone. Treatment varies depending on the type of drug and the characteristics of the patients. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society. 3.Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes. 4.Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture. 5.Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of the patient’s problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment. 6.Behavioral therapies—including individual, family, or group counseling—are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem-solving skills, and facilitating better interpersonal relationships. Also, participation in group therapy and other peer support programs during and following treatment can help maintain abstinence. 7.Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example, methadone, buprenorphine, and naltrexone (including a new long-acting formulation) are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Acamprosate, disulfiram, and naltrexone are medications approved for treating alcohol dependence. For persons addicted to nicotine, a nicotine replacement product (available as patches, gum, lozenges, or nasal spray) or an oral medication (such as bupropion or varenicline) Page 4 can be an effective component of treatment when part of a comprehensive behavioral treatment program. 8.An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs. 9.Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co- occur, treatment should address both (or all), including the use of medications as appropriate. 10.Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal and can, for some, pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivational enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement. 11.Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions. 12.Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs. 13.Treatment programs should test patients for the presence of HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling, linking patients to treatment if necessary. Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can Page 5 facilitate adherence to other medical treatments. Substance abuse treatment facilities should provide onsite, rapid HIV testing rather than referrals to offsite testing—research shows that doing so increases the likelihood that patients will be tested and receive their test results. Treatment providers should also inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug-abusing populations, and help link them to HIV treatment if they test positive. Frequently Asked Questions Treatment varies depending on the type of drug and the characteristics of the patient. The best programs provide a combination of therapies and other services. Why do drug-addicted persons keep using drugs? Nearly all addicted individuals believe at the outset that they can stop using drugs on their own, and most try to stop without treatment. Although some people are successful, many attempts result in failure to achieve long-term abstinence. Research has shown that long-term drug abuse results in changes in the brain that persist long after a person stops using drugs. These drug-induced changes in brain function can have many behavioral consequences, including an inability to exert control over the impulse to use drugs despite adverse consequences—the defining characteristic of addiction. Long-term drug use results in significant changes in brain function that can persist long after the individual stops using drugs. Understanding that addiction has such a fundamental biological component may help explain the difficulty of achieving and maintaining abstinence without treatment. Psychological stress from work, family problems, psychiatric illness, pain associated with medical problems, social cues (such as Page 6 meeting individuals from one’s drug-using past), or environmental cues (such as encountering streets, objects, or even smells associated with drug abuse) can trigger intense cravings without the individual even being consciously aware of the triggering event. Any one of these factors can hinder attainment of sustained abstinence and make relapse more likely. Nevertheless, research indicates that active participation in treatment is an essential component for good outcomes and can benefit even the most severely addicted individuals. What is drug addiction treatment? Drug treatment is intended to help addicted individuals stop compulsive drug seeking and use. Treatment can occur in a variety of settings, take many different forms, and last for different lengths of time. Because drug addiction is typically a chronic disorder characterized by occasional relapses, a short-term, one-time treatment is usually not sufficient. For many, treatment is a long-term process that involves multiple interventions and regular monitoring. There are a variety of evidence-based approaches to treating addiction. Drug treatment can include behavioral therapy (such as cognitive-behavioral therapy or contingency management), medications, or their combination. The specific type of treatment or combination of treatments will vary depending on the patient’s individual needs and, often, on the types of drugs they use. Treatment medications, such as methadone, buprenorphine, and naltrexone (including a new long- acting formulation), are available for individuals addicted to opioids, while nicotine preparations (patches, gum, lozenges, and nasal spray) and the medications varenicline and bupropion are available for individuals addicted to tobacco. Disulfiram, acamprosate, and naltrexone are medications available for treating alcohol dependence,1 which commonly co-occurs with other Page 7 drug addictions, including addiction to prescription medications. Drug addiction treatment can include medications, behavioral therapies, or their combination. Treatments for prescription drug abuse tend to be similar to those for illicit drugs that affect the same brain systems. For example, buprenorphine, used to treat heroin addiction, can also be used to treat addiction to opioid pain medications. Addiction to prescription stimulants, which affect the same brain systems as illicit stimulants like cocaine, can be treated with behavioral therapies, as there are not yet medications for treating addiction to these types of drugs. Behavioral therapies can help motivate people to participate in drug treatment, offer strategies for coping with drug cravings, teach ways to avoid drugs and prevent relapse, and help individuals deal with relapse if it occurs. Behavioral therapies can also help people improve communication, relationship, and parenting skills, as well as family dynamics. Many treatment programs employ both individual and group therapies. Group therapy can provide social reinforcement and help enforce behavioral contingencies that promote abstinence and a non- drug-using lifestyle. Some of the more established behavioral treatments, such as contingency management and cognitive-behavioral therapy, are also being adapted for group settings to improve efficiency and cost-effectiveness. However, particularly in adolescents, there can also be a danger of unintended harmful (or iatrogenic) effects of group treatment—sometimes group members (especially groups of highly delinquent youth) can reinforce drug use and thereby derail the purpose of the therapy. Thus, trained counselors should be aware of and monitor for such effects. Because they work on different aspects of addiction, combinations of behavioral therapies and medications (when available) generally appear to be more effective than either approach used alone. Finally, people who are addicted to drugs often suffer from other health (e.g., depression, HIV), occupational, legal, familial, and social problems that should be addressed concurrently. The best programs provide a combination of therapies and other services to meet an individual patient’s needs. Psychoactive medications, such as antidepressants, anti-anxiety agents, mood stabilizers, and Page 8 antipsychotic medications, may be critical for treatment success when patients have co-occurring mental disorders such as depression, anxiety disorders (including post-traumatic stress disorder), bipolar disorder, or schizophrenia. In addition, most people with severe addiction abuse multiple drugs and require treatment for all substances abused. Treatment for drug abuse and addiction is delivered in many different settings using a variety of behavioral and pharmacological approaches. Another drug, topiramate, has also shown promise in studies and is sometimes prescribed (off-label) for this purpose although it has not received FDA approval as a treatment for alcohol dependence. 1 How effective is drug addiction treatment? In addition to stopping drug abuse, the goal of treatment is to return people to productive functioning in the family, workplace, and community. According to research that tracks individuals in treatment over extended periods, most people who get into and remain in treatment stop using drugs, decrease their criminal activity, and improve their occupational, social, and psychological functioning. For example, methadone treatment has been shown to increase participation in behavioral therapy and decrease both drug use and criminal behavior. However, individual treatment outcomes depend on the extent and nature of the patient’s problems, the appropriateness of treatment and related services used to address those problems, and the quality of interaction between the patient and his or her treatment providers. Relapse rates for addiction resemble those of other chronic diseases such as diabetes, hypertension, and asthma. Like other chronic diseases, addiction can be managed successfully. Treatment enables people to counteract addiction’s powerful disruptive effects on the brain and behavior and to regain control of Page 9 their lives. The chronic nature of the disease means that relapsing to drug abuse is not only possible but also likely, with symptom recurrence rates similar to those for other well-characterized chronic medical illnesses—such as diabetes, hypertension, and asthma (see figure, "Comparison of Relapse Rates Between Drug Addiction and Other Chronic Illnesses”)—that also have both physiological and behavioral components. Unfortunately, when relapse occurs many deem treatment a failure. This is not the case: Successful treatment for addiction typically requires continual evaluation and modification as appropriate, similar to the approach taken for other chronic diseases. For example, when a patient is receiving active treatment for hypertension and symptoms decrease, treatment is deemed successful, even though symptoms may recur when treatment is discontinued. For the addicted individual, lapses to drug abuse do not indicate failure—rather, they signify that treatment needs to be reinstated or adjusted, or that alternate treatment is needed (see figure, "Why is Addiction Treatment Evaluated Differently?"). Page 10 Is drug addiction treatment worth its cost? Substance abuse costs our Nation over $600 billion annually and treatment can help reduce these costs. Drug addiction treatment has been shown to reduce associated health and social costs by far more than the cost of the treatment itself. Treatment is also much less expensive than its alternatives, such as incarcerating addicted persons. For example, the average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient, whereas 1 full year of imprisonment costs approximately $24,000 per person. Drug addiction treatment reduces drug use and its associated health and social costs. According to several conservative estimates, every dollar invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included, total savings can exceed costs by a ratio of 12 to 1. Major savings to the individual and to society also stem from fewer interpersonal conflicts; greater workplace productivity; and fewer drug-related accidents, including overdoses and deaths. Page 11 How long does drug addiction treatment usually last? Individuals progress through drug addiction treatment at various rates, so there is no predetermined length of treatment. However, research has shown unequivocally that good outcomes are contingent on adequate treatment length. Generally, for residential or outpatient treatment, participation for less than 90 days is of limited effectiveness, and treatment lasting significantly longer is recommended for maintaining positive outcomes. For methadone maintenance, 12 months is considered the minimum, and some opioid-addicted individuals continue to benefit from methadone maintenance for many years. Good outcomes are contingent on adequate treatment length. Treatment dropout is one of the major problems encountered by treatment programs; therefore, motivational techniques that can keep patients engaged will also improve outcomes. By viewing addiction as a chronic disease and offering continuing care and monitoring, programs can succeed, but this will often require multiple episodes of treatment and readily readmitting patients that have relapsed. What helps people stay in treatment? Because successful outcomes often depend on a person’s staying in treatment long enough to reap its full benefits, strategies for keeping people in treatment are critical. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Individual factors related to engagement and retention typically include motivation to change drug-using behavior; degree of support from family and friends; and, frequently, pressure from the criminal justice system, child protection services, employers, or family. Within a treatment program, successful clinicians can establish a positive, therapeutic relationship with their patients. The clinician should ensure that a treatment plan is developed cooperatively with the person seeking treatment, that the plan is followed, and that treatment expectations are clearly understood. Medical, psychiatric, and social services Page 12 should also be available. Whether a patient stays in treatment depends on factors associated with both the individual and the program. Because some problems (such as serious medical or mental illness or criminal involvement) increase the likelihood of patients dropping out of treatment, intensive interventions may be required to retain them. After a course of intensive treatment, the provider should ensure a transition to less intensive continuing care to support and monitor individuals in their ongoing recovery. How do we get more substance-abusing people into treatment? It has been known for many years that the "treatment gap” is massive—that is, among those who need treatment for a substance use disorder, few receive it. In 2011, 21.6 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem, but only 2.3 million received treatment at a specialty substance abuse facility. Reducing this gap requires a multipronged approach. Strategies include increasing access to effective treatment, achieving insurance parity (now in its earliest phase of implementation), reducing stigma, and raising awareness among both patients and healthcare professionals of the value of addiction treatment. To assist physicians in identifying treatment need in their patients and making appropriate referrals, NIDA is encouraging widespread use of screening, brief intervention, and referral to treatment (SBIRT) tools for use in primary care settings through its NIDAMED initiative. SBIRT, which evidence shows to be effective against tobacco and alcohol use—and, increasingly, against abuse of illicit and prescription drugs—has the potential not only to catch people before serious drug problems develop, but also to identify people in need of treatment and connect them with appropriate treatment providers. Page 13 How can family and friends make a difference in the life of someone needing treatment? Family and friends can play critical roles in motivating individuals with drug problems to enter and stay in treatment. Family therapy can also be important, especially for adolescents. Involvement of a family member or significant other in an individual's treatment program can strengthen and extend treatment benefits. Where can family members go for information on treatment options? Trying to locate appropriate treatment for a loved one, especially finding a program tailored to an individual's particular needs, can be a difficult process. However, there are some resources to help with this process. For example, NIDA’s handbook Seeking Drug Abuse Treatment: Know What to Ask offers guidance in finding the right treatment program. Numerous online resources can help locate a local program or provide other information, including: The Substance Abuse and Mental Health Services Administration (SAMHSA) maintains a Web site (findtreatment.gov) that shows the location of residential, outpatient, and hospital inpatient treatment programs for drug addiction and alcoholism throughout the country. This information is also accessible by calling 1-800-662-HELP. The National Suicide Prevention Lifeline (1-800-273-TALK) offers more than just suicide prevention—it can also help with a host of issues, including drug and alcohol abuse, and can connect individuals with a nearby professional. The National Alliance on Mental Illness (www.nami.org) and Mental Health America ( www.mentalhealthamerica.net) are alliances of nonprofit, self-help support organizations for patients and families dealing with a variety of mental disorders. Both have State and local affiliates throughout the country and may be especially helpful for patients with comorbid conditions. The American Academy of Addiction Psychiatry and the American Academy of Child and Adolescent Psychiatry each have physician locator tools posted on their Web sites at aaap.org and aacap.org, respectively. Page 14 Faces & Voices of Recovery (facesandvoicesofrecovery.org), founded in 2001, is an advocacy organization for individuals in long-term recovery that strategizes on ways to reach out to the medical, public health, criminal justice, and other communities to promote and celebrate recovery from addiction to alcohol and other drugs. The Partnership at Drugfree.org (drugfree.org) is an organization that provides information and resources on teen drug use and addiction for parents, to help them prevent and intervene in their children’s drug use or find treatment for a child who needs it. They offer a toll-free helpline for parents (1-855-378-4373). The American Society of Addiction Medicine (asam.org) is a society of physicians aimed at increasing access to addiction treatment. Their Web site has a nationwide directory of addiction medicine professionals. NIDA’s National Drug Abuse Treatment Clinical Trials Network (drugabuse.gov/about- nida/organization/cctn/ctn) provides information for those interested in participating in a clinical trial testing a promising substance abuse intervention; or visit clinicaltrials.gov. NIDA’s DrugPubs Research Dissemination Center (drugpubs.drugabuse.gov) provides booklets, pamphlets, fact sheets, and other informational resources on drugs, drug abuse, and treatment. The National Institute on Alcohol Abuse and Alcoholism (niaaa.nih.gov) provides information on alcohol, alcohol use, and treatment of alcohol-related problems ( niaaa.nih.gov/search/node/treatment). How can the workplace play a role in substance abuse treatment? Many workplaces sponsor Employee Assistance Programs (EAPs) that offer short-term counseling and/or assistance in linking employees with drug or alcohol problems to local treatment resources, including peer support/recovery groups. In addition, therapeutic work environments that provide employment for drug-abusing individuals who can demonstrate abstinence have been shown not only to promote a continued drug-free lifestyle but also to improve job skills, punctuality, and other behaviors necessary for active employment throughout life. Urine testing facilities, trained personnel, and workplace monitors are needed to implement this type of treatment. Page 15 What role can the criminal justice system play in addressing drug addiction? It is estimated that about one-half of State and Federal prisoners abuse or are addicted to drugs, but relatively few receive treatment while incarcerated. Initiating drug abuse treatment in prison and continuing it upon release is vital to both individual recovery and to public health and safety. Various studies have shown that combining prison- and community-based treatment for addicted offenders reduces the risk of both recidivism to drug-related criminal behavior and relapse to drug use—which, in turn, nets huge savings in societal costs. A 2009 study in Baltimore, Maryland, for example, found that opioid-addicted prisoners who started methadone treatment (along with counseling) in prison and then continued it after release had better outcomes (reduced drug use and criminal activity) than those who only received counseling while in prison or those who only started methadone treatment after their release. Individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The majority of offenders involved with the criminal justice system are not in prison but are under community supervision. For those with known drug problems, drug addiction treatment may be recommended or mandated as a condition of probation. Research has demonstrated that individuals who enter treatment under legal pressure have outcomes as favorable as those who enter treatment voluntarily. The criminal justice system refers drug offenders into treatment through a variety of mechanisms, such as diverting nonviolent offenders to treatment; stipulating treatment as a condition of incarceration, probation, or pretrial release; and convening specialized courts, or drug courts, that handle drug offense cases. These courts mandate and arrange for treatment as an alternative to incarceration, actively monitor progress in treatment, and arrange for other services for drug-involved offenders. The most effective models integrate criminal justice and drug treatment systems and services. Treatment and criminal justice personnel work together on treatment planning—including implementation of screening, placement, testing, monitoring, and supervision—as well as on the Page 16 systematic use of sanctions and rewards. Treatment for incarcerated drug abusers should include continuing care, monitoring, and supervision after incarceration and during parole. Methods to achieve better coordination between parole/probation officers and health providers are being studied to improve offender outcomes. (For more information, please see NIDA’s Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide [revised 2012].) What are the unique needs of women with substance use disorders? Gender-related drug abuse treatment should attend not only to biological differences but also to social and environmental factors, all of which can influence the motivations for drug use, the reasons for seeking treatment, the types of environments where treatment is obtained, the treatments that are most effective, and the consequences of not receiving treatment. Many life circumstances predominate in women as a group, which may require a specialized treatment approach. For example, research has shown that physical and sexual trauma followed by post-traumatic stress disorder (PTSD) is more common in drug-abusing women than in men seeking treatment. Other factors unique to women that can influence the treatment process include issues around how they come into treatment (as women are more likely than men to seek the assistance of a general or mental health practitioner), financial independence, and pregnancy and child care. What are the unique needs of pregnant women with substance use disorders? Using drugs, alcohol, or tobacco during pregnancy exposes not just the woman but also her developing fetus to the substance and can have potentially deleterious and even long-term effects on exposed children. Smoking during pregnancy can increase risk of stillbirth, infant mortality, sudden infant death syndrome, preterm birth, respiratory problems, slowed fetal growth, and low birth weight. Drinking during pregnancy can lead to the child developing fetal alcohol spectrum disorders, Page 17 characterized by low birth weight and enduring cognitive and behavioral problems. Prenatal use of some drugs, including opioids, may cause a withdrawal syndrome in newborns called neonatal abstinence syndrome (NAS). Babies with NAS are at greater risk of seizures, respiratory problems, feeding difficulties, low birth weight, and even death. Research has established the value of evidence-based treatments for pregnant women (and their babies), including medications. For example, although no medications have been FDA-approved to treat opioid dependence in pregnant women, methadone maintenance combined with prenatal care and a comprehensive drug treatment program can improve many of the detrimental outcomes associated with untreated heroin abuse. However, newborns exposed to methadone during pregnancy still require treatment for withdrawal symptoms. Recently, another medication option for opioid dependence, buprenorphine, has been shown to produce fewer NAS symptoms in babies than methadone, resulting in shorter infant hospital stays. In general, it is important to closely monitor women who are trying to quit drug use during pregnancy and to provide treatment as needed. What are the unique needs of adolescents with substance use disorders? Adolescent drug abusers have unique needs stemming from their immature neurocognitive and psychosocial stage of development. Research has demonstrated that the brain undergoes a prolonged process of development and refinement from birth through early adulthood. Over the course of this developmental period, a young person’s actions go from being more impulsive to being more reasoned and reflective. In fact, the brain areas most closely associated with aspects of behavior such as decision-making, judgment, planning, and self-control undergo a period of rapid development during adolescence and young adulthood. Adolescent drug abuse is also often associated with other co-occurring mental health problems. These include attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, and conduct problems, as well as depressive and anxiety disorders. Adolescents are also especially sensitive to social cues, with peer groups and families being highly Page 18 influential during this time. Therefore, treatments that facilitate positive parental involvement, integrate other systems in which the adolescent participates (such as school and athletics), and recognize the importance of prosocial peer relationships are among the most effective. Access to comprehensive assessment, treatment, case management, and family-support services that are developmentally, culturally, and gender-appropriate is also integral when addressing adolescent addiction. Medications for substance abuse among adolescents may in certain cases be helpful. Currently, the only addiction medications approved by FDA for people under 18 are over-the-counter transdermal nicotine skin patches, chewing gum, and lozenges (physician advice should be sought first). Buprenorphine, a medication for treating opioid addiction that must be prescribed by specially trained physicians, has not been approved for adolescents, but recent research suggests it could be effective for those as young as 16. Studies are under way to determine the safety and efficacy of this and other medications for opioid-, nicotine-, and alcohol-dependent adolescents and for adolescents with co- occurring disorders. Are there specific drug addiction treatments for older adults? With the aging of the baby boomer generation, the composition of the general population is changing dramatically with respect to the number of older adults. Such a change, coupled with a greater history of lifetime drug use (than previous older generations), different cultural norms and general attitudes about drug use, and increases in the availability of psychotherapeutic medications, is already leading to greater drug use by older adults and may increase substance use problems in this population. While substance abuse in older adults often goes unrecognized and therefore untreated, research indicates that currently available addiction treatment programs can be as effective for them as for younger adults. Can a person become addicted to medications prescribed by a doctor? Yes. People who abuse prescription drugs—that is, taking them in a manner or a dose other than prescribed, or taking medications prescribed for another person—risk addiction and other serious Page 19 health consequences. Such drugs include opioid pain relievers, stimulants used to treat ADHD, and benzodiazepines to treat anxiety or sleep disorders. Indeed, in 2010, an estimated 2.4 million people 12 or older met criteria for abuse of or dependence on prescription drugs, the second most common illicit drug use after marijuana. To minimize these risks, a physician (or other prescribing health provider) should screen patients for prior or current substance abuse problems and assess their family history of substance abuse or addiction before prescribing a psychoactive medication and monitor patients who are prescribed such drugs. Physicians also need to educate patients about the potential risks so that they will follow their physician’s instructions faithfully, safeguard their medications, and dispose of them appropriately. Is there a difference between physical dependence and addiction? Yes. Addiction—or compulsive drug use despite harmful consequences—is characterized by an inability to stop using a drug; failure to meet work, social, or family obligations; and, sometimes (depending on the drug), tolerance and withdrawal. The latter reflect physical dependence in which the body adapts to the drug, requiring more of it to achieve a certain effect (tolerance) and eliciting drug-specific physical or mental symptoms if drug use is abruptly ceased (withdrawal). Physical dependence can happen with the chronic use of many drugs—including many prescription drugs, even if taken as instructed. Thus, physical dependence in and of itself does not constitute addiction, but it often accompanies addiction. This distinction can be difficult to discern, particularly with prescribed pain medications, for which the need for increasing dosages can represent tolerance or a worsening underlying problem, as opposed to the beginning of abuse or addiction. How do other mental disorders coexisting with drug addiction affect drug addiction treatment? Drug addiction is a disease of the brain that frequently occurs with other mental disorders. In fact, as many as 6 in 10 people with an illicit substance use disorder also suffer from another mental illness; and rates are similar for users of licit drugs—i.e., tobacco and alcohol. For these individuals, one Page 20 condition becomes more difficult to treat successfully as an additional condition is intertwined. Thus, people entering treatment either for a substance use disorder or for another mental disorder should be assessed for the co-occurrence of the other condition. Research indicates that treating both (or multiple) illnesses simultaneously in an integrated fashion is generally the best treatment approach for these patients. Is the use of medications like methadone and buprenorphine simply replacing one addiction with another? No. Buprenorphine and methadone are prescribed or administered under monitored, controlled conditions and are safe and effective for treating opioid addiction when used as directed. They are administered orally or sublingually (i.e., under the tongue) in specified doses, and their effects differ from those of heroin and other abused opioids. Heroin, for example, is often injected, snorted, or smoked, causing an almost immediate "rush," or brief period of intense euphoria, that wears off quickly and ends in a "crash." The individual then experiences an intense craving to use the drug again to stop the crash and reinstate the euphoria. The cycle of euphoria, crash, and craving—sometimes repeated several times a day—is a hallmark of addiction and results in severe behavioral disruption. These characteristics result from heroin’s rapid onset and short duration of action in the brain. As used in maintenance treatment, methadone and buprenorphine are not heroin/opioid substitutes. In contrast, methadone and buprenorphine have gradual onsets of action and produce stable levels of the drug in the brain. As a result, patients maintained on these medications do not experience a rush, while they also markedly reduce their desire to use opioids. If an individual treated with these medications tries to take an opioid such as heroin, the euphoric effects are usually dampened or suppressed. Patients undergoing maintenance treatment do not Page 21 experience the physiological or behavioral abnormalities from rapid fluctuations in drug levels associated with heroin use. Maintenance treatments save lives—they help to stabilize individuals, allowing treatment of their medical, psychological, and other problems so they can contribute effectively as members of families and of society. Where do 12-step or self-help programs fit into drug addiction treatment? Self-help groups can complement and extend the effects of professional treatment. The most prominent self-help groups are those affiliated with Alcoholics Anonymous (AA), Narcotics Anonymous (NA), and Cocaine Anonymous (CA), all of which are based on the 12-step model. Most drug addiction treatment programs encourage patients to participate in self-help group therapy during and after formal treatment. These groups can be particularly helpful during recovery, offering an added layer of community-level social support to help people achieve and maintain abstinence and other healthy lifestyle behaviors over the course of a lifetime. Can exercise play a role in the treatment process? Yes. Exercise is increasingly becoming a component of many treatment programs and has proven effective, when combined with cognitive-behavioral therapy, at helping people quit smoking. Exercise may exert beneficial effects by addressing psychosocial and physiological needs that nicotine replacement alone does not, by reducing negative feelings and stress, and by helping prevent weight gain following cessation. Research to determine if and how exercise programs can play a similar role in the treatment of other forms of drug abuse is under way. Page 22 How does drug addiction treatment help reduce the spread of HIV/AIDS, Hepatitis C (HCV), and other infectious diseases? Drug-abusing individuals, including injecting and non-injecting drug users, are at increased risk of human immunodeficiency virus (HIV), hepatitis C virus (HCV), and other infectious diseases. These diseases are transmitted by sharing contaminated drug injection equipment and by engaging in risky sexual behavior sometimes associated with drug use. Effective drug abuse treatment is HIV/HCV prevention because it reduces activities that can spread disease, such as sharing injection equipment and engaging in unprotected sexual activity. Counseling that targets a range of HIV/HCV risk behaviors provides an added level of disease prevention. Drug abuse treatment is HIV and HCV prevention. Injection drug users who do not enter treatment are up to six times more likely to become infected with HIV than those who enter and remain in treatment. Participation in treatment also presents opportunities for HIV screening and referral to early HIV treatment. In fact, recent research from NIDA’s National Drug Abuse Treatment Clinical Trials Network showed that providing rapid onsite HIV testing in substance abuse treatment facilities increased patients’ likelihood of being tested and of receiving their test results. HIV counseling and testing are key aspects of superior drug abuse treatment programs and should be offered to all individuals entering treatment. Greater availability of inexpensive and unobtrusive rapid HIV tests should increase access to these important aspects of HIV prevention and treatment. Drug Addiction Treatment in the United States Page 23 Treatment for drug abuse and addiction is delivered in many different settings, using a variety of behavioral and pharmacological approaches. Drug addiction is a complex disorder that can involve virtually every aspect of an individual's functioning—in the family, at work and school, and in the community. Because of addiction's complexity and pervasive consequences, drug addiction treatment typically must involve many components. Some of those components focus directly on the individual's drug use; others, like employment training, focus on restoring the addicted individual to productive membership in the family and society (See diagram "Components of Comprehensive Drug Abuse Treatment"), enabling him or her to experience the rewards associated with abstinence. Treatment for drug abuse and addiction is delivered in many different settings using a variety of behavioral and pharmacological approaches. In the United States, more than 14,500 specialized drug treatment facilities provide counseling, behavioral therapy, medication, case management, and other types of services to persons with substance use disorders. Along with specialized drug treatment facilities, drug abuse and addiction are treated in physicians' offices and mental health clinics by a variety of providers, including counselors, physicians, psychiatrists, psychologists, nurses, and social workers. Treatment is delivered in outpatient, inpatient, and residential settings. Although specific treatment approaches often are associated with particular treatment settings, a variety of therapeutic interventions or services can be included in any given setting. Because drug abuse and addiction are major public health problems, a large portion of drug treatment is funded by local, State, and Federal governments. Private and employer-subsidized health plans also may provide coverage for treatment of addiction and its medical consequences. Unfortunately, managed care has resulted in shorter average stays, while a historical lack of or insufficient coverage for substance abuse treatment has curtailed the number of operational programs. The recent passage of parity for insurance coverage of mental health and substance abuse problems will hopefully improve this state of affairs. Health Care Reform (i.e., the Patient Protection and Affordable Care Act of 2010, "ACA") also stands to increase the demand for drug abuse treatment services and presents an opportunity to study how innovations in service delivery, organization, and financing can improve Page 24 access to and use of them. Types of Treatment Programs Research studies on addiction treatment typically have classified programs into several general types or modalities. Treatment approaches and individual programs continue to evolve and diversify, and many programs today do not fit neatly into traditional drug adiction treatment classifications. Most, however, start with detoxification and medically managed withdrawal, often considered the first stage of treatment. Detoxification, the process by which the body clears itself of drugs, is designed to manage the acute and potentially dangerous physiological effects of stopping drug use. As stated previously, detoxification alone does not address the psychological, social, and behavioral problems associated with addiction and therefore does not typically produce lasting behavioral changes necessary for recovery. Detoxification should thus be followed by a formal assessment and referral to drug addiction treatment. Because it is often accompanied by unpleasant and potentially fatal side effects stemming from withdrawal, detoxification is often managed with medications administered by a physician in an inpatient or outpatient setting; therefore, it is referred to as "medically managed withdrawal.” Medications are available to assist in the withdrawal from opioids, benzodiazepines, alcohol, nicotine, barbiturates, and other sedatives. Further Reading: Kleber, H.D. Outpatient detoxification from opiates. Primary Psychiatry 1:42-52, 1996. Long-Term Residential Treatment Long-term residential treatment provides care 24 hours a day, generally in non-hospital settings. The best-known residential treatment model is the therapeutic community (TC), with planned lengths of stay of between 6 and 12 months. TCs focus on the "resocialization" of the individual and use the program’s entire community—including other residents, staff, and the social context—as active Page 25 components of treatment. Addiction is viewed in the context of an individual’s social and psychological deficits, and treatment focuses on developing personal accountability and responsibility as well as socially productive lives. Treatment is highly structured and can be confrontational at times, with activities designed to help residents examine damaging beliefs, self-concepts, and destructive patterns of behavior and adopt new, more harmonious and constructive ways to interact with others. Many TCs offer comprehensive services, which can include employment training and other support services, onsite. Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, homeless individuals, people with severe mental disorders, and individuals in the criminal justice system (see "Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals"). Further Reading: Lewis, B.F.; McCusker, J.; Hindin, R.; Frost, R.; and Garfield, F. Four residential drug treatment programs: Project IMPACT. In: J.A. Inciardi, F.M. Tims, and B.W. Fletcher (eds.), Innovative Approaches in the Treatment of Drug Abuse, Westport, CT: Greenwood Press, pp. 45-60, 1993. Sacks, S.; Banks, S.; McKendrick, K.; and Sacks, J.Y. Modified therapeutic community for co- occurring disorders: A summary of four studies. Journal of Substance Abuse Treatment 34(1):112- 122, 2008. Sacks, S.; Sacks, J.; DeLeon, G.; Bernhardt, A.; and Staines, G. Modified therapeutic community for mentally ill chemical "abusers": Background; influences; program description; preliminary findings. Substance Use and Misuse 32(9):1217-1259, 1997. Stevens, S.J., and Glider, P.J. Therapeutic communities: Substance abuse treatment for women. In: F.M. Tims, G. DeLeon, and N. Jainchill (eds.), Therapeutic Community: Advances in Research and Application, National Institute on Drug Abuse Research Monograph 144, NIH Pub. No. 94-3633, U.S. Government Printing Office, pp. 162-180, 1994. Sullivan, C.J.; McKendrick, K.; Sacks, S.; and Banks, S.M. Modified therapeutic community for offenders with MICA disorders: Substance use outcomes. American Journal of Drug and Alcohol Abuse 33(6):823-832, 2007. Page 26 Short-Term Residential Treatment Short-term residential programs provide intensive but relatively brief treatment based on a modified 12-step approach. These programs were originally designed to treat alcohol problems, but during the cocaine epidemic of the mid-1980s, many began to treat other types of substance use disorders. The original residential treatment model consisted of a 3- to 6-week hospital-based inpatient treatment phase followed by extended outpatient therapy and participation in a self-help group, such as AA. Following stays in residential treatment programs, it is important for individuals to remain engaged in outpatient treatment programs and/or aftercare programs. These programs help to reduce the risk of relapse once a patient leaves the residential setting. Further Reading: Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):291-298, 1998. Miller, M.M. Traditional approaches to the treatment of addiction. In: A.W. Graham and T.K. Schultz (eds.), Principles of Addiction Medicine (2nd ed.). Washington, D.C.: American Society of Addiction Medicine, 1998. Outpatient Treatment Programs Outpatient treatment varies in the types and intensity of services offered. Such treatment costs less than residential or inpatient treatment and often is more suitable for people with jobs or extensive social supports. It should be noted, however, that low-intensity programs may offer little more than drug education. Other outpatient models, such as intensive day treatment, can be comparable to residential programs in services and effectiveness, depending on the individual patient’s characteristics and needs. In many outpatient programs, group counseling can be a major component. Some outpatient programs are also designed to treat patients with medical or other mental health problems in addition to their drug disorders. Further Reading: Page 27 Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, J.; and Etheridge, R.M. Overview of 1-year follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):291-298, 1998. Institute of Medicine. Treating Drug Problems. Washington, D.C.: National Academy Press, 1990. McLellan, A.T.; Grisson, G.; Durell, J.; Alterman, A.I.; Brill, P.; and O'Brien, C.P. Substance abuse treatment in the private setting: Are some programs more effective than others? Journal of Substance Abuse Treatment 10:243-254, 1993. Simpson, D.D., and Brown, B.S. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychology of Addictive Behaviors 11(4):294-307, 1998. Individualized Drug Counseling Individualized drug counseling not only focuses on reducing or stopping illicit drug or alcohol use; it also addresses related areas of impaired functioning—such as employment status, illegal activity, and family/social relations—as well as the content and structure of the patient’s recovery program. Through its emphasis on short-term behavioral goals, individualized counseling helps the patient develop coping strategies and tools to abstain from drug use and maintain abstinence. The addiction counselor encourages 12-step participation (at least one or two times per week) and makes referrals for needed supplemental medical, psychiatric, employment, and other services. Group Counseling Many therapeutic settings use group therapy to capitalize on the social reinforcement offered by peer discussion and to help promote drug-free lifestyles. Research has shown that when group therapy either is offered in conjunction with individualized drug counseling or is formatted to reflect the principles of cognitive-behavioral therapy or contingency management, positive outcomes are achieved. Currently, researchers are testing conditions in which group therapy can be standardized and made more community-friendly. Page 28 Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, presenting opportunities for intervention and treatment prior to, during, after, or in lieu of incarceration. Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug abuse and related crime. Individuals under legal coercion tend to stay in treatment longer and do as well as or better than those not under legal pressure. Studies show that for incarcerated individuals with drug problems, starting drug abuse treatment in prison and continuing the same treatment upon release—in other words, a seamless continuum of services—results in better outcomes: less drug use and less criminal behavior. More information on how the criminal justice system can address the problem of drug addiction can be found in Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (National Institute on Drug Abuse, revised 2012). Treating Criminal Justice-Involved Drug Abusers and Addicted Individuals Often, drug abusers come into contact with the criminal justice system earlier than other health or social systems, presenting opportunities for intervention and treatment prior to, during, after, or in lieu of incarceration. Research has shown that combining criminal justice sanctions with drug treatment can be effective in decreasing drug abuse and related crime. Individuals under legal coercion tend to stay in treatment longer and do as well as or better than those not under legal pressure. Studies show that for incarcerated individuals with drug problems, starting drug abuse treatment in prison and continuing the same treatment upon release—in other words, a seamless continuum of services—results in better outcomes: less drug use and less criminal behavior. More information on how the criminal justice system can address the problem of drug addiction can be found in Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (National Institute on Drug Abuse, revised 2012). Page 29 Evidence-Based Approaches to Drug Addiction Treatment Each approach to drug treatment is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. This section presents examples of treatment approaches and components that have an evidence base supporting their use. Each approach is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. Some of the approaches are intended to supplement or enhance existing treatment programs, and others are fairly comprehensive in and of themselves. The following section is broken down into Pharmacotherapies, Behavioral Therapies, and Behavioral Therapies Primarily for Adolescents. They are further subdivided according to particular substance use disorders. This list is not exhaustive, and new treatments are continually under development. Pharmacotherapies Opioid Addiction Methadone Methadone is a long-acting synthetic opioid agonist medication that can prevent withdrawal symptoms and reduce craving in opioid-addicted individuals. It can also block the effects of illicit opioids. It has a long history of use in treatment of opioid dependence in adults and is taken orally. Methadone maintenance treatment is available in all but three States through specially licensed opioid treatment programs or methadone maintenance programs. Combined with behavioral treatment: Research has shown that methadone maintenance is more Page 30 effective when it includes individual and/or group counseling, with even better outcomes when patients are provided with, or referred to, other needed medical/psychiatric, psychological, and social services (e.g., employment or family services). Further Reading: Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic blockade. Archives of Internal Medicine 118:304–309, 1966. McLellan, A.T.; Arndt, I.O.; Metzger, D.; Woody, G.E.; and O’Brien, C.P. The effects of psychosocial services in substance abuse treatment. The Journal of the American Medical Association 269(15):1953–1959, 1993. The Rockerfeller University. The first pharmacological treatment for narcotic addiction: Methadone maintenance. The Rockefeller University Hospital Centennial, 2010. Available at centennial.rucares.org/index.php?page=Methadone_Maintenance. Woody, G.E.; Luborsky, L.; McClellan, A.T.; O’Brien, C.P.; Beck, A.T.; Blaine, J.; Herman, I.; and Hole, A. Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry 40:639–645, 1983. Buprenorphine Buprenorphine is a synthetic opioid medication that acts as a partial agonist at opioid receptors—it does not produce the euphoria and sedation caused by heroin or other opioids but is able to reduce or eliminate withdrawal symptoms associated with opioid dependence and carries a low risk of overdose. Buprenorphine is currently available in two formulations that are taken sublingually: (1) a pure form of the drug and (2) a more commonly prescribed formulation called Suboxone, which combines buprenorphine with the drug naloxone, an antagonist (or blocker) at opioid receptors. Naloxone has no effect when Suboxone is taken as prescribed, but if an addicted individual attempts to inject Suboxone, the naloxone will produce severe withdrawal symptoms. Thus, this formulation lessens the likelihood that the drug will be abused or diverted to others. Page 31 Buprenorphine treatment for detoxification and/or maintenance can be provided in office-based settings by qualified physicians who have received a waiver from the Drug Enforcement Administration (DEA), allowing them to prescribe it. The availability of office-based treatment for opioid addiction is a cost-effective approach that increases the reach of treatment and the options available to patients. Buprenorphine is also available as in an implant and injection. The U.S. Food and Drug Administration (FDA) approved a 6-month subdermal buprenorphine implant in May 2016 and a once-monthly buprenorphine injection in November 2017. Further Reading: Fiellin, D.A.; Pantalon, M.V.; Chawarski, M.C.; Moore, B.A.; Sullivan, L.E.; O’Connor, P.G.; and Schottenfeld, R.S. Counseling plus buprenorphine/naloxone maintenance therapy for opioid dependence. The New England Journal of Medicine 355(4):365–374, 2006. Fudala P.J.; Bridge, T.P.; Herbert, S.; Williford, W.O.; Chiang, C.N.; Jones, K.; Collins, J.; Raisch, D.; Casadonte, P.; Goldsmith, R.J.; Ling, W.; Malkerneker, U.; McNicholas, L.; Renner, J.; Stine, S.; and Tusel, D. for the Buprenorphine/Naloxone Collaborative Study Group. Office-based treatment of opiate addiction with a sublingual-tablet formulation of buprenorphine and naloxone. The New England Journal of Medicine 349(10):949–958, 2003. Kosten, T.R.; and Fiellin, D.A. U.S. National Buprenorphine Implementation Program: Buprenorphine for office-based practice. Consensus conference overview. The American Journal on Addictions 13(Suppl. 1):S1–S7, 2004. McCance-Katz, E.F. Office-based buprenorphine treatment for opioid-dependent patients. Harvard Review of Psychiatry 12(6):321–338, 2004. Treatment, not Substitution Because methadone and buprenorphine are themselves opioids, some people view these Page 32 treatments for opioid dependence as just substitutions of one addictive drug for another (see Question 19). But taking these medications as prescribed allows patients to hold jobs, avoid street crime and violence, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on these medications can also engage more readily in counseling and other behavioral interventions essential to recovery. Naltrexone Naltrexone is a synthetic opioid antagonist—it blocks opioids from binding to their receptors and thereby prevents their euphoric and other effects. It has been used for many years to reverse opioid overdose and is also approved for treating opioid addiction. The theory behind this treatment is that the repeated absence of the desired effects and the perceived futility of abusing opioids will gradually diminish craving and addiction. Naltrexone itself has no subjective effects following detoxification (that is, a person does not perceive any particular drug effect), it has no potential for abuse, and it is not addictive. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although the treatment should begin after medical detoxification in a residential setting in order to prevent withdrawal symptoms. Naltrexone must be taken orally—either daily or three times a week—but noncompliance with treatment is a common problem. Many experienced clinicians have found naltrexone best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances—for instance, professionals or parolees. Recently, a long-acting injectable version of naltrexone, called Vivitrol, was approved to treat opioid addiction. Because it only needs to be delivered once a month, this version of the drug can facilitate compliance and offers an alternative for those who do not wish to be placed on agonist/partial agonist medications. Further Reading: Cornish, J.W.; Metzger, D.; Woody, G.E.; Wilson, D.; McClellan, A.T.; and Vandergrift, B. Naltrexone Page 33 pharmacotherapy for opioid dependent federal probationers. Journal of Substance Abuse Treatment 14(6):529–534, 1997. Gastfriend, D.R. Intramuscular extended-release naltrexone: current evidence. Annals of the New York Academy of Sciences 1216:144–166, 2011. Krupitsky, E.; Illerperuma, A.; Gastfriend, D.R.; and Silverman, B.L. Efficacy and safety of extended- release injectable naltrexone (XR-NTX) for the treatment of opioid dependence. Paper presented at the 2010 annual meeting of the American Psychiatric Association, New Orleans, LA. Comparing Buprenorphine and Naltrexone A NIDA study comparing the effectiveness of a buprenorphine/naloxone combination and an extended release naltrexone formulation on treating opioid use disorder has found that both medications are similarly effective in treating opioid use disorder once treatment is initiated. Because naltrexone requires full detoxification, initiating treatment among active opioid users was more difficult with this medication. However, once detoxification was complete, the naltrexone formulation had a similar effectiveness as the buprenorphine/naloxone combination. Tobacco Addiction Nicotine Replacement Therapy (NRT) A variety of formulations of nicotine replacement therapies (NRTs) now exist, including the transdermal nicotine patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine is the main addictive ingredient in tobacco, the rationale for NRT is that stable low levels of nicotine will prevent withdrawal symptoms—which often drive continued tobacco use—and help keep people motivated to quit. Research shows that combining the patch with another replacement therapy is more effective than a single therapy alone. Bupropion (Zyban )® Page 34 Bupropion was originally marketed as an antidepressant (Wellbutrin). It produces mild stimulant effects by blocking the reuptake of certain neurotransmitters, especially norepinephrine and dopamine. A serendipitous observation among depressed patients was that the medication was also effective in suppressing tobacco craving, helping them quit smoking without also gaining weight. Although bupropion’s exact mechanisms of action in facilitating smoking cessation are unclear, it has FDA approval as a smoking cessation treatment. Varenicline (Chantix )® Varenicline is the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors in the brain thought to be involved in the rewarding effects of nicotine. Varenicline acts as a partial agonist/antagonist at these receptors—this means that it midly stimulates the nicotine receptor but not sufficiently to trigger the release of dopamine, which is important for the rewarding effects of nicotine. As an antagonist, varenicline also blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing cravings and supporting abstinence from smoking. Combined With Behavioral Treatment Each of the above pharmacotherapies is recommended for use in combination with behavioral interventions, including group and individual therapies, as well as telephone quitlines. Behavioral approaches complement most tobacco addiction treatment programs. They can amplify the effects of medications by teaching people how to manage stress, recognize and avoid high-risk situations for smoking relapse, and develop alternative coping strategies (e.g., cigarette refusal skills, assertiveness, and time management skills) that they can practice in treatment, social, and work settings. Combined treatment is urged because behavioral and pharmacological treatments are thought to operate by different yet complementary mechanisms that can have additive effects. Further Reading: Alterman, A.I.; Gariti, P.; and Mulvaney, F. Short- and long-term smoking cessation for three levels of intensity of behavioral treatment. Psychology of Addictive Behaviors 15:261-264, 2001. Hall, S.M.; Humfleet, G.L.; Muñoz, R.F.; V.I; Prochaska, J.J.; and Robbins, J.A. Using extended Page 35 cognitive behavioral treatment and medication to treat dependent smokers. American Journal of Public Health 101:2349– 2356, 2011. Jorenby, D.E.; Hays, J.T.; Rigotti, N.A.; Azoulay, S.; Watsky, E.J.; Williams, K.E.; Billing, C.B.; Gong, J.; and Reeves, K.R. Varenicline Phase 3 Study Group. Efficacy of varenicline, an ?4?2 nicotinic acetylcholine receptor partial agonist vs. placebo or sustained-release bupropion for smoking cessation: A randomized controlled trial. The Journal of the American Medical Association 296(1):56–63, 2006. King, D.P.; Paciqa, S.; Pickering, E.; Benowitz, N.L.; Bierut, L.J.; Conti, D.V.; Kaprio, J.; Lerman, C.; and Park, P.W. Smoking cessation pharmacogenetics: Analysis of varenicline and bupropion in placebo-controlled clinical trials. Neuropsychopharmacology 37:641–650, 2012. Raupach, T.; and van Schayck, C.P. Pharmacotherapy for smoking cessation: Current advances and research topics. CNS Drugs 25:371–382, 2011. Shah, S.D.; Wilken, L.A.; Winkler, S.R.; and Lin, S.J. Systematic review and meta-analysis of combination therapy for smoking cessation. Journal of the American Pharmaceutical Association 48(5):659–665, 2008. Smith, S.S; McCarthy, D.E.; Japuntich S.J.; Christiansen, B.; Piper, M.E.; Jorenby, D.E.; Fraser, D.L.; Fiore, M.C.; Baker, T.B.; and Jackson, T.C. Comparative effectiveness of 5 smoking cessation pharmacotherapies in primary care clinics. Archives of Internal Medicine 169:2148–2155, 2009. Stitzer, M. Combined behavioral and pharmacological treatments for smoking cessation. Nicotine & Tobacco Research 1:S181–S187, 1999. Alcohol Addiction Naltrexone Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the Page 36 craving for alcohol. It has been shown to reduce relapse to problem drinking in some patients. An extended release version, Vivitrol—administered once a month by injection—is also FDA-approved for treating alcoholism, and may offer benefits regarding compliance. Acamprosate Acamprosate (Campral ) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence. ® Disulfiram Disulfiram (Antabuse ) interferes with degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and plapitations if a person drinks alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy. ® Topiramate Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission, although its precise mechanism of action is not known. Although topiramate has not yet received FDA approval for treating alcohol addiction, it is sometimes used off-label for this purpose. Topiramate has been shown in studies to significantly improve multiple drinking outcomes, compared with a placebo. Combined With Behavioral Treatment While a number of behavioral treatments have been shown to be effective in the treatment of alcohol Page 37 addiction, it does not appear that an additive effect exists between behavioral treatments and pharmacotherapy. Studies have shown that just getting help is one of the most important factors in treating alcohol addiction; the precise type of treatment received is not as important. Further Reading: Anton, R.F.; O’Malley, S.S.; Ciraulo, D.A.; Cisler, R.A.; Couper, D.; Donovan, D.M.; Gastfriend, D.R.; Hosking, J.D.; Johnson, B.A.; LoCastro, J.S.; Longabaugh, R.; Mason, B.J.; Mattson, M.E.; Miller, W.R.; Pettinati, H.M.; Randall, C.L.; Swift, R.; Weiss, R.D.; Williams, L.D.; and Zweben, A., for the COMBINE Study Research Group. Combined pharmacotherapies and behavioral interventions for alcohol dependence: The COMBINE study: A randomized controlled trial. The Journal of the American Medical Association 295(17):2003–2017, 2006. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide, Updated 2005 Edition. Bethesda, MD: NIAAA, updated 2005. Available at pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm Behavioral Therapies Behavioral approaches help engage people in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Below are a number of behavioral therapies shown to be effective in addressing substance abuse (effectiveness with particular drugs of abuse is denoted in parentheses). Cognitive-Behavioral Therapy (Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine) Cognitive-Behavioral Therapy (CBT) was developed as a method to prevent relapse when treating Page 38 problem drinking, and later it was adapted for cocaine-addicted individuals. Cognitive-behavioral strategies are based on the theory that in the development of maladaptive behavioral patterns like substance abuse, learning processes play a critical role. Individuals in CBT learn to identify and correct problematic behaviors by applying a range of different skills that can be used to stop drug abuse and to address a range of other problems that often co-occur with it. A central element of CBT is anticipating likely problems and enhancing patients’ self-control by helping them develop effective coping strategies. Specific techniques include exploring the positive and negative consequences of continued drug use, self-monitoring to recognize cravings early and identify situations that might put one at risk for use, and developing strategies for coping with cravings and avoiding those high-risk situations. Research indicates that the skills individuals learn through cognitive-behavioral approaches remain after the completion of treatment. Current research focuses on how to produce even more powerful effects by combining CBT with medications for drug abuse and with other types of behavioral therapies. A computer-based CBT system has also been developed and has been shown to be effective in helping reduce drug use following standard drug abuse treatment. Further Reading: Carroll, K.M., Easton, C.J.; Nich, C.; Hunkele, K.A.; Neavins, T.M.; Sinha, R.; Ford, H.L.; Vitolo, S.A; Doebrick, C.A.; and Rounsaville, B.J. The use of contingency management and motivational/skills- building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology 74(5):955–966, 2006. Carroll, K.M.; and Onken, L.S. Behavioral therapies for drug abuse. The American Journal of Psychiatry 168(8):1452–1460, 2005. Carroll, K.M.; Sholomskas, D.; Syracuse, G.; Ball, S.A.; Nuro, K.; and Fenton, L.R. We don’t train in vain: A dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology 73(1):106–115, 2005. Carroll, K.; Fenton, L.R.; Ball, S.A.; Nich, C.; Frankforter, T.L.; Shi,J.; and Rounsaville, B.J. Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: A randomized placebo- Page 39 controlled trial. Archives of General Psychiatry 61(3):264–272, 2004. Carroll, K.M.; Ball, S.A.; Martino, S.; Nich, C.; Babuscio, T.A.; Nuro, K.F.; Gordon, M.A.; Portnoy, G.A.; and Rounsaville, B.J. Computer-assisted delivery of cognitive-behavioral therapy for addiction: a randomized trial of CBT4CBT. The American Journal of Psychiatry 165(7):881–888, 2008. Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine) Research has demonstrated the effectiveness of treatment approaches using contingency management (CM) principles, which involve giving patients tangible rewards to reinforce positive behaviors such as abstinence. Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs. Voucher-Based Reinforcement (VBR) augments other community-based treatments for adults who primarily abuse opioids (especially heroin) or stimulants (especially cocaine) or both. In VBR, the patient receives a voucher for every drug-free urine sample provided. The voucher has monetary value that can be exchanged for food items, movie passes, or other goods or services that are consistent with a drug-free lifestyle. The voucher values are low at first, but increase as the number of consecutive drug-free urine samples increases; positive urine samples reset the value of the vouchers to the initial low value. VBR has been shown to be effective in promoting abstinence from opioids and cocaine in patients undergoing methadone detoxification. Prize Incentives CM applies similar principles as VBR but uses chances to win cash prizes instead of vouchers. Over the course of the program (at least 3 months, one or more times weekly), participants supplying drug-negative urine or breath tests draw from a bowl for the chance to win a prize worth between $1 and $100. Participants may also receive draws for attending counseling sessions and completing weekly goal-related activities. The number of draws starts at one and increases with consecutive negative drug tests and/or counseling sessions attended but resets to one with any drug- Page 40 positive sample or unexcused absence. The practitioner community has raised concerns that this intervention could promote gambling—as it contains an element of chance—and that pathological gambling and substance use disorders can be comorbid. However, studies examining this concern found that Prize Incentives CM did not promote gambling behavior. Further Reading: Budney, A.J.; Moore, B.A.; Rocha, H.L.; and Higgins, S.T. Clinical trial of abstinence-based vouchers and cognitivebehavioral therapy for cannabis dependence. Journal of Consulting and Clinical Psychology 74(2):307–316, 2006. Budney, A.J.; Roffman, R.; Stephens, R.S.; and Walker, D. Marijuana dependence and its treatment. Addiction Science & Clinical Practice 4(1):4–16, 2007. Elkashef, A.; Vocci, F.; Huestis, M.; Haney, M.; Budney, A.; Gruber, A.; and el-Guebaly, N. Marijuana neurobiology and treatment. Substance Abuse 29(3):17–29, 2008. Peirce, J.M.; Petry, N.M.; Stitzer, M.L.; Blaine, J.; Kellogg, S.; Satterfield, F.; Schwartz, M.; Krasnansky, J.; Pencer, E.; Silva-Vazquez, L.; Kirby, K.C.; Royer-Malvestuto, C.; Cohen, A.; Copersino, M.L.; Kolodner, K.; and Li, R. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry 63(2):201–208, 2006. Petry, N.M.; Peirce, J.M.; Stitzer, M.L.; Blaine, J.; Roll, J.M.; Cohen, A.; Obert, J.; Killeen, T.; Saladin, M.E.; Cowell, M.; Kirby, K.C.; Sterling, R.; Royer-Malvestuto, C.; Hamilton, J.; Booth, R.E.; Macdonald, M.; Liebert, M.; Rader, L.; Burns, R; DiMaria, J.; Copersino, M.; Stabile, P.Q.; Kolodner, K.; and Li, R. Effect of prizebased incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry 62(10):1148–1156, 2005. Petry, N.M.; Kolodner, K.B.; Li, R.; Peirce, J.M.; Roll, J.M.; Stitzer, M.L.; and Hamilton, J.A. Prize- based contingency management does not increase gambling. Drug and Alcohol Dependence 83(3):269–273, 2006. Page 41 Prendergast, M.; Podus, D.; Finney, J.; Greenwell, L.; and Roll, J. Contingency management for treatment of substance use disorders: A meta-analysis. Addiction 101(11):1546–1560, 2006. Roll, J.M.; Petry, N.M.; Stitzer, M.L.; Brecht, M.L.; Peirce, J.M.; McCann, M.J.; Blaine, J.; MacDonald, M.; DiMaria, J.; Lucero, L.; and Kellogg, S. Contingency management for the treatment of methamphetamine use disorders. The American Journal of Psychiatry 163(11):1993–1999, 2006. Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine, Opioids) Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient therapy for treating people addicted to cocaine and alcohol. It uses a range of recreational, familial, social, and vocational reinforcers, along with material incentives, to make a non-drug-using lifestyle more rewarding than substance use. The treatment goals are twofold: To maintain abstinence long enough for patients to learn new life skills to help sustain it; and To reduce alcohol consumption for patients whose drinking is associated with cocaine use Patients attend one or two individual counseling sessions each week, where they focus on improving family relations, learn a variety of skills to minimize drug use, receive vocational counseling, and develop new recreational activities and social networks. Those who also abuse alcohol receive clinic- monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocaine-negative samples. As in VBR, the value of the vouchers increases with consecutive clean samples, and the vouchers may be exchanged for retail goods that are consistent with a drug-free lifestyle. Studies in both urban and rural areas have found that this approach facilitates patients’ engagement in treatment and successfully aids them in gaining substantial periods of cocaine abstinence. A computer-based version of CRA Plus Vouchers called the Therapeutic Education System (TES) was found to be nearly as effective as treatment administered by a therapist in promoting abstinence from opioids and cocaine among opioid-dependent individuals in outpatient treatment. A version of Page 42 CRA for adolescents addresses problem-solving, coping, and communication skills and encourages active participation in positive social and recreational activities. Further Reading: Brooks, A.C.; Ryder, D.; Carise, D.; and Kirby, K.C. Feasibility and effectiveness of computer-based therapy in community treatment. Journal of Substance Abuse Treatment 39(3):227–235, 2010. Higgins, S.T.; Sigmon, S.C.; Wong, C.J.; Heil, S.H.; Badger, G.J.; Donham, R.; Dantona, R.L.; and Anthony, S. Community reinforcement therapy for cocaine-dependent outpatients. Archives of General Psychiatry 60(10):1043–1052, 2003. Roozen, H.G.; Boulogne, J.J.; van Tulder, M.W.; van den Brink, W.; De Jong, C.A.J.; and Kerhof, J.F.M. A systemic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug and Alcohol Dependence 74(1):1–13, 2004. Silverman, K.; Higgins, S.T.; Brooner, R.K.; Montoya, I.D.; Cone, E.J.; Schuster, C.R.; and Preston, K.L. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53(5):409–415, 1996. Smith, J.E.; Meyers, R.J.; and Delaney, H.D. The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology 66(3):541–548, 1998. Stahler, G.J.; Shipley, T.E.; Kirby, K.C.; Godboldte, C.; Kerwin, M.E; Shandler, I.; and Simons, L. Development and initial demonstration of a community-based intervention for homeless, cocaine- using, African-American women. Journal of Substance Abuse Treatment 28(2):171–179, 2005. Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine) Motivational Enhancement Therapy (MET) is a counseling approach that helps individuals resolve their ambivalence about engaging in treatment and stopping their drug use. This approach aims to Page 43 evoke rapid and internally motivated change, rather than guide the patient stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. In the first treatment session, the therapist provides feedback to the initial assessment, stimulating discussion about personal substance use and eliciting self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions. Research on MET suggests that its effects depend on the type of drug used by participants and on the goal of the intervention. This approach has been used successfully with people addicted to alcohol to both improve their engagement in treatment and reduce their problem drinking. MET has also been used successfully with marijuana-dependent adults when combined with cognitive- behavioral therapy, constituting a more comprehensive treatment approach. The results of MET are mixed for people abusing other drugs (e.g., heroin, cocaine, nicotine) and for adolescents who tend to use multiple drugs. In general, MET seems to be more effective for engaging drug abusers in treatment than for producing changes in drug use. Further Reading: Baker, A.; Lewin, T.; Reichler, H.; Clancy, R.; Carr, V.; Garrett, R.; Sly, K.; Devir, H.; and Terry, M. Evaluation of a motivational interview for substance use with psychiatric in-patient services. Addiction 97(10):1329-1337, 2002. Haug, N.A.; Svikis, D.S.; and Diclemente, C. Motivational enhancement therapy for nicotine dependence in methadone-maintained pregnant women. Psychology of Addictive Behaviors 18(3):289-292, 2004. Marijuana Treatment Project Research Group. Brief treatments for cannabis dependence: Findings from a randomized multisite trial. Journal of Consulting and Clinical Psychology 72(3):455-466, 2004. Miller, W.R.; Yahne, C.E.; and Tonigan, J.S. Motivational interviewing in drug abuse services: A Page 44 randomized trial. Journal of Consulting and Clinical Psychology 71(4):754-763, 2003. Stotts, A.L.; Diclemente, C.C.; and Dolan-Mullen, P. One-to-one: A motivational intervention for resistant pregnant smokers. Addictive Behaviors 27(2):275-292, 2002. The Matrix Model (Stimulants) The Matrix Model provides a framework for engaging stimulant (e.g., methamphetamine and cocaine) abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, and become familiar with self-help programs. Patients are monitored for drug use through urine testing. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is authentic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is critical to patient retention. Treatment materials draw heavily on other tested treatment approaches and, thus, include elements of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain worksheets for individual sessions; other components include family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine tests, 12-step programs, relapse analysis, and social support groups. A number of studies have demonstrated that participants treated using the Matrix Model show statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission. Further Reading: Huber, A.; Ling, W.; Shoptaw, S.; Gulati, V.; Brethen, P.; and Rawson, R. Integrating treatments for Page 45 methamphetamine abuse: A psychosocial perspective. Journal of Addictive Diseases 16(4):41-50, 1997. Rawson, R.; Shoptaw, S.J.; Obert, J.L.; McCann, M.J.; Hasson, A.L.; Marinelli-Casey, P.J.; Brethen, P.R.; and Ling, W. An intensive outpatient approach for cocaine abuse: The Matrix model. Journal of Substance Abuse Treatment 12(2):117-127, 1995. Rawson, R.A.; Huber, A.; McCann, M.; Shoptaw, S.; Farabee, D.; Reiber, C.; and Ling, W. A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Archives of General Psychiatry 59(9):817-824, 2002. 12-Step Facilitation Therapy (Alcohol, Stimulants, Opiates) Twelve-step facilitation therapy is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups, thereby promoting abstinence. Three key ideas predominate: (1) acceptance, which includes the realization that drug addiction is a chronic, progressive disease over which one has no control, that life has become unmanageable because of drugs, that willpower alone is insufficient to overcome the problem, and that abstinence is the only alternative; (2) surrender, which involves giving oneself over to a higher power, accepting the fellowship and support structure of other recovering addicted individuals, and following the recovery activities laid out by the 12-step program; and (3) active involvement in 12-step meetings and related activities. While the efficacy of 12-step programs (and 12- step facilitation) in treating alcohol dependence has been established, the research on its usefulness for other forms of substance abuse is more preliminary, but the treatment appears promising for helping drug abusers sustain recovery. Further Reading: Carroll, K.M.; Nich, C.; Ball, S.A.; McCance, E.; Frankforter, T.L.; and Rounsaville, B.J. One-year follow-up of disulfiram and psychotherapy for cocaine-alcohol users: Sustained effects of treatment. Addiction 95(9):1335-1349, 2000. Page 46 Donovan D.M., and Wells E.A. "Tweaking 12-step": The potential role of 12-Step self-help group involvement in methamphetamine recovery. Addiction 102(Suppl. 1):121-129, 2007. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol 58(1)7-29, 1997. Family Behavior Therapy Family Behavior Therapy (FBT), which has demonstrated positive results in both adults and adolescents, is aimed at addressing not only substance use problems but other co-occurring problems as well, such as conduct disorders, child mistreatment, depression, family conflict, and unemployment. FBT combines behavioral contracting with contingency management. FBT involves the patient along with at least one significant other such as a cohabiting partner or a parent (in the case of adolescents). Therapists seek to engage families in applying the behavioral strategies taught in sessions and in acquiring new skills to improve the home environment. Patients are encouraged to develop behavioral goals for preventing substance use and HIV infection, which are anchored to a contingency management system. Substance-abusing parents are prompted to set goals related to effective parenting behaviors. During each session, the behavioral goals are reviewed, with rewards provided by significant others when goals are accomplished. Patients participate in treatment planning, choosing specific interventions from a menu of evidence-based treatment options. In a series of comparisons involving adolescents with and without conduct disorder, FBT was found to be more effective than supportive counseling. Further Reading: Azrin, N.H.; Donohue, B.; Besalel, V.A.; Kogan, E.S.; and Acierno, R. Youth drug abuse treatment: a controlled outcome study. Journal of Child and Adolescent Substance Abuse 3:1–16, 1994. Carroll, K.M.; and Onken, L.S. Behavioral therapies for drug abuse. American Journal of Psychiatry 168(8):1452–1460, 2005. Page 47 Donohue, B.; Azrin, N.; Allen, D.N.; Romero, V.; Hill, H.H.; Tracy, K.; Lapota, H.; Gorney, S.; Abdel-al, R.; Caldas, D.; Herdzik, K.; Bradshaw, K.; Valdez, R.; and Van Hasselt, V.B. Family Behavior Therapy for substance abuse: A review of its intervention components and applicability. Behavior Modification 33:495–519, 2009. LaPota, H.B.; Donohue, B.; Warren, C. S.; and Allen, D.N. Integration of a Healthy Living curriculum within Family Behavior Therapy: A clinical case example in a woman with a history of domestic violence, child neglect, drug abuse, and obesity. Journal of Family Violence 26:227–234, 2011. Behavioral Therapies Primarily for Adolescents Drug-abusing and addicted adolescents have unique treatment needs. Research has shown that treatments designed for and tested in adult populations often need to be modified to be effective in adolescents. Family involvement is a particularly important component for interventions targeting youth. Below are examples of behavioral interventions that employ these principles and have shown efficacy for treating addiction in youth. Multisystemic Therapy Multisystemic Therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse alcohol and other drugs. These factors include characteristics of the child or adolescent (e.g., favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intensive treatment in natural environments (homes, schools, and neighborhood settings), most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Fewer incarcerations and out-of-home juvenile placements offset the cost of providing this intensive service and maintaining the clinicians’ low caseloads. Further Reading: Henggeler, S.W.; Clingempeel, W.G.; Brondino, M.J.; and Pickrel, S.G. Four-year follow-up of Page 48 multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry 41(7):868-874, 2002. Henggeler, S.W.; Rowland, M.D.; Randall, J.; Ward, D.M.; Pickrel, S.G.; Cunningham, P.B.; Miller, S.L.; Edwards, J.; Zealberg, J.J.; Hand, L.D.; and Santos, A.B. Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: Clinical outcomes. Journal of the American Academy of Child and Adolescent Psychiatry 38(11):1331-1339, 1999. Henggeler, S.W.; Halliday-Boykins, C.A.; Cunningham, P.B.; Randall, J.; Shapiro, S.B.; and Chapman, J.E. Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology 74(1):42–54, 2006. Henggeler, S.W.; Pickrel, S.G.; Brondino, M.J.; and Crouch, J.L. Eliminating (almost) treatment dropout of substance-abusing or dependent delinquents through home-based multisystemic therapy. The American Journal of Psychiatry 153(3):427–428, 1996. Huey, S.J.; Henggeler, S.W.; Brondino, M.J.; and Pickrel, S.G. Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family functioning. Journal of Consulting and Clinical Psychology 68(3):451–467, 2000. Multidimensional Family Therapy Multidimensional Family Therapy (MDFT) for adolescents is an outpatient, family-based treatment for teenagers who abuse alcohol or other drugs. MDFT views adolescent drug use in terms of a network of influences (individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations. During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problem-solving skills. Teenagers acquire vocational skills and skills in communicating their thoughts and feelings to deal better with life stressors. Parallel sessions are held with family members. Parents examine their particular parenting styles, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on Page 49 their children. Further Reading: Dennis, M.; Godley, S.H.; Diamond, G.; Tims, F.M.; Babor, T.; Donaldson, J.; Liddle, H.; Titus, J.C.; Kaminer, Y.; Webb, C.; Hamilton, N.; and Funk, R. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized clinical trials. Journal of Substance Abuse Treatment 27(3):197-213, 2004. Liddle, H.A.; Dakof, G.A.; Parker, K.; Diamond, G.S.; Barrett, K;, and Tejeda, M. Multidimensional family therapy for adolescent drug abuse: Results of a randomized clinical trial. The American Journal of Drug and Alcohol Abuse 27(4):651-688, 2001. Liddle, H.A., and Hogue, A. Multidimensional family therapy for adolescent substance abuse. In E.F. Wagner and H.B. Waldron (eds.), Innovations in Adolescent Substance Abuse Interventions. London: Pergamon/Elsevier Science, pp. 227-261, 2001. Liddle, H.A.; Rowe, C.L.; Dakof, G.A.; Ungaro, R.A.; and Henderson, C.E. Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs 36(1):49-63, 2004. Schmidt, S.E.; Liddle, H.A.; and Dakof, G.A. Effects of multidimensional family therapy: Relationship of changes in parenting practices to symptom reduction in adolescent substance abuse. Journal of Family Psychology 10(1):1-16, 1996. Brief Strategic Family Therapy Brief Strategic Family Therapy (BSFT) targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. Such problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior. BSFT is based on a family systems approach to treatment, in which family members’ behaviors are assumed to be interdependent such that the symptoms of one member (the drug-abusing adolescent, for Page 50 example) are indicative, at least in part, of what else is occurring in the family system. The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent’s behavior problems and to assist in changing those problem-maintaining family patterns. BSFT is meant to be a flexible approach that can be adapted to a broad range of family situations in various settings (mental health clinics, drug abuse treatment programs, other social service settings, and families’ homes) and in various treatment modalities (as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service following residential treatment). Further Reading: Coatsworth, J.D.; Santisteban, D.A.; McBride, C.K.; and Szapocznik, J. Brief Strategic Family Therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent severity. Family Process 40(3):313-332, 2001. Kurtines, W.M.; Murray, E.J.; and Laperriere, A. Efficacy of intervention for engaging youth and families into treatment and some variables that may contribute to differential effectiveness. Journal of Family Psychology 10(1):35–44, 1996. Santisteban, D.A.; Coatsworth, J.D.; Perez-Vidal, A.; Mitrani, V.; Jean-Gilles, M.; and Szapocznik, J. Brief Structural/Strategic Family Therapy with African- American and Hispanic high-risk youth. Journal of Community Psychology 25(5):453-471, 1997. Santisteban, D.A.; Suarez-Morales, L.; Robbins, M.S.; and Szapocznik, J. Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process 45(2):259-271, 2006. Santisteban, D.A.; Szapocznik, J.; Perez-Vidal, A.; Mitrani, V.; Jean-Gilles, M.; and Szapocznik, J. Brief Structural/Strategic Family Therapy with African-American and Hispanic high-risk youth. Journal of Community Psychology 25(5):453–471, 1997. Szapocznik, J., et al. Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology 56(4):552-557, 1988. Page 51 Functional Family Therapy Functional Family Therapy (FFT) is another treatment based on a family systems approach, in which an adolescent’s behavior problems are seen as being created or maintained by a family’s dysfunctional interaction patterns. FFT aims to reduce problem behaviors by improving communication, problem-solving, conflict resolution, and parenting skills. The intervention always includes the adolescent and at least one family member in each session. Principal treatment tactics include (1) engaging families in the treatment process and enhancing their motivation for change and (2) bringing about changes in family members’ behavior using contingency management techniques, communication and problem-solving, behavioral contracts, and other behavioral interventions. Further Reading: Waldron, H.B.; Slesnick, N.; Brody, J.L.; Turner, C.W.; and Peterson, T.R. Treatment outcomes for adolescent substance abuse at 4- and 7-month assessments. Journal of Consulting and Clinical Psychology 69:802–813, 2001. Waldron, H.B.; Turner, C. W.; and Ozechowski, T. J. Profiles of drug use behavior change for adolescents in treatment. Addictive Behaviors 30:1775–1796, 2005. Adolescent Community Reinforcement Approach and Assertive Continuing Care The Adolescent Community Reinforcement Approach (A-CRA) is another comprehensive substance abuse treatment intervention that involves the adolescent and his or her family. It seeks to support the individual’s recovery by increasing family, social, and educational/vocational reinforcers. After assessing the adolescent’s needs and levels of functioning, the therapist chooses from among 17 A- CRA procedures to address problem-solving, coping, and communication skills and to encourage active participation in positive social and recreational activities. A-CRA skills training involves role- playing and behavioral rehearsal. Assertive Continuing Care (ACC) is a home-based continuing-care approach to preventing relapse. Weekly home visits take place over a 12- to 14-week period after an adolescent is discharged from Page 52 residential, intensive outpatient, or regular outpatient treatment. Using positive and negative reinforcement to shape behaviors, along with training in problem-solving and communication skills, ACC combines A-CRA and assertive case management services (e.g., use of a multidisciplinary team of professionals, round-the-clock coverage, assertive outreach) to help adolescents and their caregivers acquire the skills to engage in positive social activities. Further Reading: Dennis, M.; Godley, S.H.; Diamond, G.; Tims, F.M.; Babor, T.; Donaldson, J.; Liddle, H.; Titus, J.C.; Kamier, Y.; Webb, C.; Hamilton, N.; and Funk R. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized trials. Journal of Substance Abuse Treatment 27:197–213, 2004. Godley, S.H.; Garner, B.R.; Passetti, L.L.; Funk, R.R.; Dennis, M.L.; and Godley, M.D. Adolescent outpatient treatment and continuing care: Main findings from a randomized clinical trial. Drug and Alcohol Dependence Jul 1;110 (1-2):44–54, 2010. Godley, M.D.; Godley, S.H.; Dennis, M.L.; Funk, R.; and Passetti, L.L. Preliminary outcomes from the assertive continuing care experiment for adolescents discharged from residential treatment. Journal of Substance Abuse Treatment 23:21–32, 2002. Acknowledgments The National Institute on Drug Abuse wishes to thank the following individuals for reviewing this publication. Martin W. Adler, Ph.D. Temple University School of Medicine Kathleen Brady, M.D., Ph.D. Medical University of South Carolina Greg Brigham, Ph.D. Page 53 Maryhaven, Inc. Kathleen M. Carroll, Ph.D. Yale University School of Medicine Richard R. Clayton, Ph.D. University of Kentucky Linda B. Cottler, Ph.D. Washington University School of Medicine David P. Friedman, Ph.D. Wake Forest University Bowman Gray School of Medicine Reese T. Jones, M.D. University of California at San Francisco Nancy K. Mello, Ph.D. Harvard Medical School William R. Miller, Ph.D. University of New Mexico Charles P. O’Brien, M.D., Ph.D. University of Pennsylvania Jeffrey Selzer, M.D. Zucker Hillside Hospital Eric J. Simon, Ph.D. New York University Langone Medical Center Jose Szapocznik, Ph.D. Page 54 University of Miami Miller School of Medicine George Woody, M.D. University of Pennsylvania Resources National Agencies The National Institute on Drug Abuse (NIDA) leads the Nation in scientific research on the health aspects of drug abuse and addiction. It supports and conducts research across a broad range of disciplines, including genetics, functional neuroimaging, social neuroscience, prevention, medication and behavioral therapies, and health services. It then disseminates the results of that research to significantly improve prevention and treatment and to inform policy as it relates to drug abuse and addiction. Additional information is available at drugabuse.gov or by calling 301-443-1124. National Institute on Alcohol Abuse and Alcoholism (NIAAA) The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides leadership in the national effort to reduce alcohol-related problems by conducting and supporting research in a wide range of scientific areas, including genetics, neuroscience, epidemiology, health risks and benefits of alcohol consumption, prevention, and treatment; coordinating and collaborating with other research institutes and Federal programs on alcohol-related issues; collaborating with international, national, State, and local institutions, organizations, agencies, and programs engaged in alcohol-related work; and translating and disseminating research findings to healthcare providers, researchers, policymakers, and the public. Additional information is available at www.niaaa.nih.gov or by calling 301-443-3860. National Institute of Mental Health (NIMH) The mission of National Institute of Mental Health (NIMH) is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, Page 55 recovery, and cure. In support of this mission, NIMH generates research and promotes research training to fulfill the following four objectives: (1) promote discovery in the brain and behavioral sciences to fuel research on the causes of mental disorders; (2) chart mental illness trajectories to determine when, where, and how to intervene; (3) develop new and better interventions that incorporate the diverse needs and circumstances of people with mental illnesses; and (4) strengthen the public health impact of NIMH-supported research. Additional information is available at nimh.nih.gov or by calling 301-443-4513. Center for Substance Abuse Treatment (CSAT) The Center for Substance Abuse Treatment (CSAT), a part of the Substance Abuse and Mental Health Services Administration (SAMHSA), is responsible for supporting treatment services through a block grant program, as well as disseminating findings to the field and promoting their adoption. CSAT also operates the 24-hour National Treatment Referral Hotline (1-800-662-HELP), which offers information and referral services to people seeking treatment programs and other assistance. CSAT publications are available through SAMHSA's Store (store.samhsa.gov). Additional information about CSAT can be found on SAMHSA's Web site at www.samhsa.gov/about-us/who-we-are/offices- centers/csat. Selected NIDA Educational Resources on Drug Addiction Treatment The following are available from the NIDA DrugPubs Research Dissemination Center, the National Technical Information Service (NTIS), or the Government Printing Office (GPO). To order, refer to the DrugPubs (877-NIDANIH [643-2644]), NTIS (1-800-553-6847), or GPO (202-512-1800) number provided with the resource description. Blending products. NIDA's Blending Initiative—a joint venture with SAMHSA and its nationwide network of Addiction Technology Transfer Centers (ATTCs)—uses "Blending Teams" of community practitioners, SAMHSA trainers, and NIDA researchers to create products and devise strategic dissemination plans for them. Completed products include those that address the value of buprenorphine therapy and onsite rapid HIV testing in community treatment programs; strategies for treating prescription opioid dependence; and the need to enhance healthcare workers' proficiency in Page 56 using tools such as the Addiction Severity Index (ASI), motivational interviewing, and motivational incentives. For more information on Blending products, please visit NIDA's Web site at archives.drugabuse.gov/nidasamhsa-blending-initiative. Addiction Severity Index. Provides a structured clinical interview designed to collect information about substance use and functioning in life areas from adult clients seeking drug abuse treatment. For more information on using the ASI and to obtain copies of the most recent edition, please visit https://eprovide.mapi-trust.org/instruments/addiction-severity-index. Drugs, Brains, and Behavior: The Science of Addiction (Reprinted 2010). This publication provides an overview of the science behind the disease of addiction. Publication #NIH 10-5605. Available online at drugabuse.gov/publications/science-addiction. Principles of Drug Abuse Treatment for Criminal Justice Populations: A Research-Based Guide (Revised 2012). Provides 13 essential treatment principles and includes resource information and answers to frequently asked questions. NIH Publication No.: 11-5316. Available online at drugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations-research- based-guide. NIDA DrugFacts: Treatment Approaches for Drug Addiction (Revised 2009). This is a fact sheet covering research findings on effective treatment approaches for drug abuse and addiction. Available online at drugabuse.gov/publications/drugfacts/treatment-approaches-drugaddiction. Helping Patients Who Drink Too Much: A Clinicians's guide (published by NIAAA). This booklet is written for primary care and mental health clinicians and provides guidance in screening and managing alcohol-dependent patients. Available online at pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm. Research Report Series: Therapeutic Community (2002). This report provides information on the role of residential drug-free settings and their role in the treatment process. NIH Publication #02-4877. Available online at drugabuse.gov/publications/research-reports/therapeutic-community. Initiatives Designed to Move Treatment Research into Practice Page 57 Clinical Trials Network Assessing the real-world effectiveness of evidence-based treatments is a crucial step in bringing research to practice. Established in 1999, NIDA’s National Drug Abuse Treatment Clinical Trials Network (CTN) uses community settings with diverse patient populations and conditions to adjust and test protocols to meet the practical needs of addiction treatment. Since its inception, the CTN has tested pharmacological and behavioral interventions for drug abuse and addiction, along with common co-occurring conditions (e.g., HIV and PTSD) among various target populations, including adolescent drug abusers, pregnant drug-abusing women, and Spanish-speaking patients. The CTN has also tested prevention strategies in drug-abusing groups at high risk for HCV and HIV and has become a key element of NIDA’s multipronged approach to move promising science-based drug addiction treatments rapidly into community settings. For more information on the CTN, please visit drugabuse.gov/CTN. Criminal Justice-Drug Abuse Treatment Studies NIDA is taking an approach similar to the CTN to enhance treatment for drug-addicted individuals involved with the criminal justice system through Criminal Justice–Drug Abuse Treatment Studies (CJ- DATS). Whereas NIDA’s CTN has as its overriding mission the improvement of the quality of drug abuse treatment by moving innovative approaches into the larger community, research supported through CJ-DATS is designed to effect change by bringing new treatment models into the criminal justice system and thereby improve outcomes for offenders with substance use disorders. It seeks to achieve better integration of drug abuse treatment with other public health and public safety forums and represents a collaboration among NIDA; SAMHSA; the Centers for Disease Control and Prevention (CDC); Department of Justice agencies; and a host of drug treatment, criminal justice, and health and social service professionals. Blending Teams Another way in which NIDA is seeking to actively move science into practice is through a joint venture with SAMHSA and its nationwide network of Addiction Technology Transfer Centers (ATTCs). This process involves the collaborative efforts of community treatment practitioners, SAMHSA trainers, and NIDA researchers, some of whom form "Blending Teams" to create products and devise strategic dissemination plans for them. Through the creation of products designed to foster adoption of new Page 58 treatment strategies, Blending Teams are instrumental in getting the latest evidence-based tools and practices into the hands of treatment professionals. To date, a number of products have been completed. Topics have included increasing awareness of the value of buprenorphine therapy and enhancing healthcare workers' proficiency in using tools such as the ASI, motivational interviewing, and motivational incentives. For more information on Blending products, please visit NIDA’s Web site at archives.drugabuse.gov/nidasamhsa-blending-initiative. Other Federal Resources NIDA DrugPubs Research Dissemination Center. NIDA publications and treatment materials are available from this information source. Staff provide assistance in English and Spanish, and have TTY/TDD capability. Phone: 877-NIDA-NIH (877-643-2644); TTY/TDD: 240-645-0228; fax: 240-645- 0227; e-mail: drugpubs@nida.nih.gov; Web site: drugpubs.drugabuse.gov. The National Registry of Evidence-Based Programs and Practices. This database of interventions for the prevention and treatment of mental and substance use disorders is maintained by SAMHSA and can be accessed at www.samhsa.gov/nrepp. SAMHSA's Store has a wide range of products, including manuals, brochures, videos, and other publications. Phone: 800-487-4889; Web site: store.samhsa.gov. The National Institute of Justice. As the research agency of the Department of Justice, the National Institute of Justice (NIJ) supports research, evaluation, and demonstration programs relating to drug abuse in the context of crime and the criminal justice system. For information, including a wealth of publications, contact the National Criminal Justice Reference Service at 800-851-3420 or 301-519-5500; or visit nij.gov. Clinical Trials. For more information on federally and privately supported clinical trials, please visit clinicaltrials.gov. Page 59 This publication is available for your use and may be reproduced in its entirety without permission from NIDA. Citation of the source is appreciated, using the following language: Source: National Institute on Drug Abuse; National Institutes of Health; U.S. Department of Health and Human Services. Page 60