of patients, who are really doing very well in treatment and who have been able to sustain recovery, and have professional business lives and families, but who really can't afford to have their faces plastered on the news and really can't afford to come forward. and we need to find ways to advocate and remember that there are other populations who are doing exceedingly well and who are very grateful for this medication and other treatments. very good. dr. clark, let's move now to talk about, we had mentioned earlier, very quickly, co-occurring conditions. are co-occurring conditions in medication-assisted therapies compatible? of course they are compatible. and the most important thing to recognize is that many of the people who present for specially driven care have co-occurring depressant disorders or co-occurring anxiety disorders or other experiences

like post-traumatic stress disorder and trauma. the issue is that the clinicians in the settings need to be aware if you've got medications for the co-occurring depression or the anxiety disorder and you are contemplating the use of methadone. care must be exercised in the use of methadone and benzodiazepine. they're generally contraindicated. a person may be on an anti-depressant or an antipsychotic person may have an anti-seizure medication. all of these issues need to be taken into consideration, which is why we want to make sure that when people present, they feel comfortable enough to be candid with their physicians, allowing the physician or the nurse to know what medications they're on, what other conditions they have, so that you don't have the secrets going on which may prove detrimental to the patient.

and jane, what types of treatment, is it a different type of treatment for a person with a co-occurring condition? no. ideally it ought to all occur within the treatment program where the person's being treated for both their substance abuse and their mental health issues. you can't treat one and then treat the other, they're often intertwined. people may self-medicate for their mental health issues. so the idea is that it all be treated within the same program. you don't go someplace else to get treatment. and we're seeing more and more co-occurring treatment programs coming in, and actually much more effective because they can address both issues at the same time. let's talk about office-based treatments. obviously we've established, mark, that methadone is not offered at the present time through physician offices, other than for pain, for the treatment of pain. do we see a trend that in the future that might be the case?

i think that as patients become more stable, and as we have a number of patients who are extremely stable in our treatment system, they should move out of the clinic setting. and where the treatment program has aligned itself with physician practitioners who are able to treat the patient in a stepped-down manner where the patient doesn't, at that point in care, require as much services as they've required at the beginning or the middle points of treatment. so that requires good coordination between treatment programs and physicians, and a better understanding of the need to treat such patients. in different parts of the world you have this kind of approach where physicians are more willing to treat the patients, and you have a better alliance in the relationship between the programs and practitioners. and that will evolve in this country as well. dr. clark, how was the transition from clinic to office-based treatment in this country? was it a difficult one? well, we actually haven't had that transition.

we essentially now have parallel systems. opioid treatment programs principally use methadone although there's a growing number there, you just dispense buprenorphine within the program. the buprenorphine is generally prescribed by outpatient physicians. there are a number of physicians, a little over 10,000 physicians in the community out of the 500,000 ambulatory care physicians who prescribe buprenorphine. they have different rule sets, but the focus should be on assisting an individual in recovery to be rehabilitated. opioid treatment programs are more likely to have other treatment strategies like motivational incentives, cognitive behavioral therapy, whereas the office-based practices, there's no immediate requirement for the physician

in that office to be knowledgeable about somebody with psychosocial issues. they need to have the capacity to refer. and in some places those agreements are fairly robust, and in other places they may only be a telephone call and not so sophisticated. so that's been the tradeoff in dealing with office-based practice. clearly a lot of work needs to be done. but the most important thing is we now have a diverse delivery system. they [inaudible] of the delivery system remains opioid treatment programs. jane, if we were attempting to educate an individual who has an addiction problem and is contemplating getting accessed as to whether or not a medication-assisted therapy is good for them, and they may go into a program where they're not as readily sent to a counseling program, what would you say to that individual?

how would you reinforce what dr. clark has just said? i think i would say, you know, you look at what are the other problems; what's going on. have you got a job? is your family happy? are you. everything's perfect except the fact that you can't quit using this drug, or have you got all these other problems that need to be addressed that you're going to need some help with? do you need help with stable housing and help with getting a job? in which case, depending on what your needs are, you might go to office-based or you might go to a full-fledged narcotic treatment program, because you need that range of services. the office-based has been proven to be very good for stable patients who have worked through a lot of their problems and just need to maintain their abstinence and to be able to not face the cues or the relapse. but if you got a lot of problems though you need to go to a narcotic treatment program.

and within the context, dr. clark, of the recovery-oriented systems of care as dr. maxwell just said, if someone really does need support services, support counseling, they should take it. but what happens when they do say "well, i'm pretty stable; i can just go into office-based or i can use a lot of take-home or whatever," would it be appropriate for them to go in to some other type of support groups or continuing care? well i think the most important thing is with the recovery-oriented systems of care, the model is to focus on the individual's need, just as mark was pointing out. the idea is with individual assessments you determine what you need. and that assessment process should never been seen as static, one-time thing; it's an evolving thing, and ongoing thing. and as a person's life stabilizes, as dr. maxwell pointed out, gee, at this point and time,

no, i don't have a job or i lost my job or i just got divorced or i'm just getting married, or i'm going to school, someone's sick or there's a death in the family. all of those things need to be taken into consideration. and ideally you're in a situation where you can have an honest assessment made. and an opioid treatment program would allow that to happen where essentially you're being what you'd call case managed. someone is able to provide you a mirror, if you will, so that you don't deceive yourself. i'm doing fine when in fact someone's able to ask you well, gee, are you really doing fine. and in a positive way as opposed to an accusatory way they'll allow you to work through that. am i doing. well maybe i'm not doing so well, or maybe i'm doing much better than i thought i was doing and i'm ready for the next step. so progress is made both in terms of more intensive treatment or less intensive treatment.

so what we want is individual treatment, and that's what recovery-oriented systems cares about- dealing with the wide spectrum of issues in a person's life, health, mental health, addiction, job, literacy, a host of issues associated with a person's environment. is the faith community available for support; are there 12-step programs available for support; are there non-12-step programs available for support; can family members find assistance in the delivery system? that may come from formal family therapy to informal groups like al-anon or al-ateen. but the key issue is that we're trying to restore a person to a level of function. very good. when we come back we'll talk a little bit about stigma. we'll be right back. [music]

there's life after substance use. if you want one or know someone who does, please call 1-800-662-help. if someone you love has a problem with drugs and alcohol. [whispering] he's not expecting this. [whispering] yeah, but it's the right thing. . there is something you can do. [whispering] do you think he'll be okay with this? [whispering] shhh. here he comes. [all] congratulations! you can celebrate his recovery every chance you get. for drug and alcohol treatment referral for you or someone you know, call 1-800-662-help. [music]

most of us spent all of our childhood or our adult lives for that matter with every, you know, social moment that we have is related to drugs in one way or another. so we all have-we have to learn to have a social life that doesn't involve, you know, pulling out a bag of cocaine or smoking a joint or having a drink. we had a really great luncheon around christmas time where we called our celebratory luncheon where we celebrate the accomplishments of the person, the peers, during the year. and the things we celebrate are one of our female peers got her kids back, or a male peer got his kids back. that's like a huge accomplishment. some of them work a year to get their children back and that's something for us to celebrate, and we do. or somebody gets a job we celebrate and it's important, you know, to be recognized. [music]

upo, in collaboration with the district of columbia health department, has a contract to operate an outpatient opiate treatment program. the doctor begins an examination, the counselors begin to talk with them and do an evaluation of them. medication-assisted therapy is replacement therapy in some sense, and that's what we do here for patients who are primarily addicted to opiates. half of our patients also come in addicted to cocaine, and i would say about half of them also have problems with alcohol. "deep breath." at the time i ended up starting drinking, i wasn't using any heroin or anything but i started drinking. and i started drinking a lot and i was resisting everything

that they were trying to do for me because they were trying to help me. and my counselor was telling me, "man, we're not going to let you die because you're one of the good ones." and from that point on it was just like a burst of light just hit me and i just threw it up crying. i told them to put my life in their hands. the patient is assigned medication. if they are a transfer patient they may already have a dosage level and so typically we'll start with that. "thank you." we try to determine how much opiate, whether it's heroin or oxycontin, the patient is using. and depending on whether or not they've ever been challenged with methadone before, we start with a very low dose and then gradually take them up until they reach the so-called "blocking dose" where they feel comfortable. the patients, all of them who have actually been here for a while, look forward to what they call take-home opportunities, and that means that patients becomes stable. the tests that we do, the urine tests,

as a way that we exercise surveillance to make sure that they're not using other drugs. it works for me because i get two bottles for the weekend. so basically weekends i do not have to come up here, you know. and i just keep it. i've got a lock box that i keep it locked and stored away from everybody. from the beginnings of take-homes in washington, dc, i have had them- i've had them at the maximum allowed and now i get 27 days. so i come in once a month. and it's wonderful. i mean, you know, i can travel, i can go to my beach house in the summertime without having to think about it. on any given day, if we were to sample urines or swab their cheeks to test for an illicit drug, 80% of our patients will test opiate negative. oh, it's been like night and day. i mean, before i got started taking medication, i was having a very, very, hard time.

i mean, i had a very bad heroin addiction. i'd do a lot of stupid things trying to get drugs, you know, and i'd probably be dead in the street somewhere, shot od, or somebody'd kill me trying to take the money or something. so that's how my life would have been if i wasn't in this program. recovery is not all about abstinence. recovery is getting control of your life. it's to stop using heroin, stop using other drugs, use your medication. i find that in working closely with people who suffer from addiction, they're just like other people. they want to be successful, they want to win, and they want to feel good about themselves and they want to be viewed as somebody who's constructive. you can't say abstinence is recovery because we have so many new medications in use and in the pipeline that abstinence is too misunderstood a word because what it does

is it excludes anyone taking medication to treat their addictions and that is just not right. "you too. thank you." mark, we all know that stigma is still alive and well out there, not only related to addiction issues, but in particular, with medication-assisted therapies it has its own dynamic. i don't want to get into the negative, but what is the message that people need to understand about medication-assisted therapies? this is a treatment for chronic and relapsing illness. there's no magic to it. its understanding what happens to a human being. the fact is that there is no time limit. it depends on how the patient is doing in treatment. and the reality is that it is a medication that restores the individual life. this gets a person from a very bad stage of where they are in using drugs; it's not in their control any longer. they enter a treatment program, they see a physician

practitioner, prescribing buprenorphine if that's the case, and then they begin to recover-it's a road to recovery. and what happens to that human being is that they are being treated. they are getting well and they are able to go to work. they are people who was standing next to other people in lines as they check out of the supermarket or they're getting on buses or trains or planes for that matter. and rarely what we're dealing with is the fact that there's very little that separates one person from another in this area. it's simply a matter of you don't know who's going to become addicted to a medication or a substance. it's a matter of once that happens you do your best to treat the patient and understand that this is another human being who faces the same challenges that the rest of us do. and therefore, we have to be careful of our value judgments and then understanding that if we can be that individual then we want the best treatment we can. and that's the essence of i think trying to provide any care to a human being.

very good. lisa, in terms of individuals that are currently maintaining through medication-assisted therapies, what would you want them to do? well, ideally it'd be great if we all could take our medications without any secrecy and be able to get our medications, those of us who are able to, through an office-based treatment or in a primary care setting, assuming that all of our needs were being taken care of in one location. i mean that would greatly improve people's lives and open up this treatment. but i think also we have more options today at our discretion, and i think the more we learn about it, the more we know we don't have to passively sit by and wait for somebody to hit a bottom and to destroy all the bridges and family and employment and

all the institutions in their life. we can. the earlier we come into treatment, the better the results are liable to be. we have effective treatment and recovery is a reality. and i wish, i wish those of us who are in recovery and medicated-assisted treatments could come together and could form a national advocacy organization that really helped to promote some of the changes in laws and got to some of the issues that are out there, and put on a face and help others through the same path that we've come through to know their options. you've gotten recently involved with faces and voices for recovery. tell us a little bit about that organization. well faces and voices for recovery is the sort of national face and voice. that organization is a membership organization that's

young but is trying to put a face and voice on recovery. and the organization's. one of the main organizing themes is diversity that all paths to recovery are welcomed and respected, and that we don't know what's going to work from one person to the next. so it's incumbent upon us to find out as much information as we can about ourselves, our own diseases and what options are available to us and to help each other through the process. more information can be learned about the different treatment modalities that are available, and recovery support services in particular. and i would urge everyone to get involved, even if from a family perspective or if you know somebody who's in addiction, who's having an active addiction treatment prevention or recovery at any of the stages. we definitely need help in perpetuating positive attitudes

and proper information about this disease. i think it's also to break through a wall of secret-keeping. many times as people are going through various cycles of addiction, before they get into treatment, they do a great deal to hide what they're doing until the reality hits that they have no choice, they are at a last stop, and then they do want access treatment. we would certainly encourage people to try to get access to care sooner than later so you don't have to wait for years of devastation and even worsening health. but once you're in treatment, as you go through the process of recovery it's extremely important that you break through that sense of being secretive about treatment, which is a harbinger of when you were secretive about the drugs that you were using prior to treatment. and the programs to treat patients, the physicians that treat patients through medication assisted treatment need to encourage that continually. there has to be an education that constantly goes through each of the communities, whether it's the patients of treatment,

especially the families of patients in treatment, reminding people at the rotary clubs, the lions clubs, the community meetings that this has affected the entire community, that addiction can't be held secret, because then the society tries to keep it secret too with terrible and disastrous results. and dr. clark, recovery month has indeed, i think, helped to change some minds in this country with regards to how they view addiction treatment, would you agree? i think so. i think mark's point and lisa's point are critical points here. what we're trying to highlight is that the beneficiary of recovery is not just the individual who has the substance use disorder problem. that individual's family, that individual's neighborhood, the city, country, tribe, state in which that individual functions all are beneficiaries of recovery. and by focusing on recovery at least once a year during

the month of september we're able to bring together a wide array of interest groups. and i like mark's reference to getting the elk's clubs and the quanta's clubs and the rotary clubs, all of those people have a vested interest in the outcome in terms of decreased crimes, in terms of increase employment, in terms of a safer, healthier community. can't we also remind people that even though we want people to speak out, for some people it's very much still a hidden sort of thing. but you can go on the samhsa web site and you can get a list not only of all the local treatment programs, but you can get a list of the opioid treatment programs, buprenorphine programs. so help is out there. and even if you're not the addict but you love someone who is, there's a place to start. and we want to remind everyone that september is national alcohol and drug addiction recovery month.

and indeed we would hope that in every community all the voices that are in recovery speak out, and all the family members who support those that are in recovery speak out in support of addiction treatment. i want to thank you for being here. it's been a great show. for a copy of this program or other programs in the road to recovery series on dvd or vhs, call samhsa's national clearinghouse for alcohol and drug information at 1-800-729-6686 or order online at recoverymonth.gov and click "multimedia." every september, national alcohol and drug addiction recovery month provides an opportunity for communities like yours to raise awareness of alcohol and drug use disorders

and highlight the effectiveness of treatment. the free recovery month kit can help your organization plan events and activities in commemoration of this year's recovery month observance. this user-friendly kit offers ideas, materials, and tools for planning, organizing and realizing an event or outreach campaign that matches your goals and resources. to obtain your copy of this year's recovery month kit and gain access to other free publications and materials related to addiction treatment and recovery issues, visit the samhsa web site at www.samhsa.gov or call 1-800-662-help. you can also download the kit at www.recoverymonth.gov. it's important that everyone become involved because addiction is our nation's number-one health problem, and treatment is our best tool to address it.

>> this morning, everyone, and welcome to the 2010 s justice some of. there must be justice. i want to begin -- to the 2010 justice summit. there must be justice. i want to begin by welcoming you. i am a public defender here in san francisco, and i will be overseeing the first part of the program today. we are going to be talking about something is called ordinary in justice. if you look if the word, it says, an unjust act, and within the criminal justice system,

there are a lot of fun just as if that occur. we just do not hear about them. -- a lot of unjust acts that occur. we have probably all heard there have been 150 human beings who have been exonerated after being sent to death row. that means 150 people in this country were tried and convicted and sentenced to death and then exonerated face on mostly scientific evidence. some served years. some serve a eighth. we hear about those stories. what we do not often hear about is how the justice system was wrong in other ways that affect everyday people throughout this country, and that is what we are going to be talking about today. we are