let me go to dr. clark and ask him as a physician. does the physician bear some responsibility to explain to their patients what they're getting and how to use it? well, as dr. krantz would note, yes, the physician does, but, again, in a period when you've got multiple medications, sometimes from multiple practitioners, that's not as easily- that's more easily said than done. but one of the things you can do is, you go to a single pharmacy, and in the era of electronic records and electronic prescribing, it's a lot easier for that single pharmacy to have their computer programs acknowledge when there are potential conflicts or adverse reactions. there are delivery models, like medical homes where you've got one entity that is the repository of all your medical information, so if there's a red flag, that can be easily tracked. when you get into the medicare age range, through e-prescribing, again, it's a lot easier to track the records. so we're moving in the direction of having personal health records and electronic medical or electron

dr. clarks a person categorized as homeless? well, the most important thing is to recognize that when a person lacks a permanent, fixed residence, they meet the category of homeless. now, there are a number of temporary arrangements that people have; for instance, it's estimated that roughly 1.6 million people are living in transitional or shelters, and they also meet the definition of homeless. so it's-we're looking for people who have permanent, fixed residence, and if you don't have that, then you're defined as homeless. and dr. milby, can you sort of take us through those categories a little bit? well, there're, there're lots of services that are provided for the homeless, from basic emergency shelters that just provide overnight stay, and people have to leave after-usually serve breakfast and then have to leave after. there are shelters that are more permanent and give people a chance to find more permanent housing. there are shelters also for women with children, for example, so whole fam

dr. clark, what are some of the most effective approaches to dealing with individuals that are homeless and that have an addiction problem or a co-occurring condition? i think the most important thing, when you talk about approaches, is that you do have an individualized assessment of the person. you screen for a full range of issues. from samhsa's point of view, that would include mental health issues, trauma, substance use, etc. but remember, we're dealing with somebody who is homeless, so we need to know what else, what other situations are going on. am i homeless because of economics? am i homeless because of domestic violence? am i homeless because of a physical problem that needs to be addressed? am i a veteran who may have access to resources? will i benefit from peer support? these are all questions the case-, the person doing the assessment should be asking. so then you can move forward. if i'm addicted to opioids, might i benefit from an opioid treatment program, using something like

[music] dr. clark, some groups have come forward and have shared concerns with the public about the use of methadone and other medication-assisted therapies. are their concerns warranted? i think whenever you have complications associated with a medical treatment, the concerns of advocacy groups and of citizens should be taken seriously. one of the things that we're trying to do is to make sure that practitioners are in the field because we believe that the majority of these adverse events are occurring amongst pain docs prescribing for pain, and we want to educate those docs about that. we also believe that a clinic system which has over 1,100 clinics, you may have practitioners who are not as knowledgeable about what it is that they should know. and consumer groups can help bring that to their attention so that we can redouble our efforts to make sure that all of our credited and certified programs are practicing the best medicine possible or providing the best treatment possible. this is healthcare;

dr. h. westley clark, u.s. department of health and human services, substance abuse and mental health services administration, center for substance abuse treatment. dr. jane maxwell, senior research professor, university of texas at austin, golf coast addiction technology transfer center; lisa mojer-torres, esquire, consumer advocate, faces & voices of recovery; mark parrino, founder and president, american association for the treatment of opiod dependence (aatod). dr. clark, let's talk a little bit about medication-assisted therapies and how they're used. well there are a number of medications that are used to help facilitate recovery from substance use disorders. the most popular and most prominent would be buprenorphine and methadone. but there are also medications used for the treatment of alcohol. examples of that would be naltrexone and the camprosate or disulfiram. what they're used to do is to either facilitate the recovery of persons through maintenance, as with methadone or buprenorphine, to facilitate

dr. clark? we also have the notion of the sharing, the earlier point made by dr. krantz in terms of people sharing the medication. you get the drugs from friends or family. there's a cultural thing that somehow sharing your medication is permissible even though the person who's getting the medication is not using it for a therapeutic purpose. when you add the number of people who get it free from friends and family, plus the ones who take it from their medicine cabinet or who buy it from friends and family, it's 70 percent. so we are talking here a cultural phenomenon. we know about the internet. it turns out there are minority people who get their drugs from the internet. we know about drug dealers. it turns out a minority of the people get their drugs from drug dealers. we know about doctors who are not acting in good form, but a minority of people get their drugs from those. so in the aggregate, only 30 percent of the misuse of prescription drugs come from, shall we say, deviant situations, with 70 percent comes from friends and family. so part of the message i

dr. clark, about 33 million people in the u.s. live with a mental illness and a substance-use condition. what are co-occurring conditions? co-occurring conditions are conditions that occur in people who have several things going on. they may have a substance-use disorder and they may have an independent psychological problem such as anxiety or depression, or more serious problems like bi-polar affected disorder or schizophrenia. and, kathy, what are the current barriers of care for individuals with co-occurring conditions? well, there's probably many barriers. one is, you know, accessibility of treatment - availability of treatment programs. you know, certainly in the city there's only so many programs that a person can go to get co-occurring treatment. cost: who's going to pay for the program? you know, is it covered by insurances, you know, is a big barrier. and getting the patients to come to treatment themselves is a significant barrier because many of them are abusing drugs and it may be h

dr. clark, you're a psychiatrist and you're also the head of the substance abuse and mental health services administration's center for substance abuse treatment. what should we be doing in this country in terms of following up on what mark just said, in terms of getting more individuals in the mental health field knowledgeable about addictions, and the ones in addiction knowledgeable about mental health? and i'm going back to that whole integrated system. do we train each party to recognize the symptoms of the other condition? how do we do it? well, i think the answer is not a simple answer. that's one of the reasons why samhsa has embarked on a multi pronged approach to addressing the issue, working at the state level, working with provider organizations. we've developed a treatment improvement protocol on co-occurring disorders. we responded to a congressional request by drafting a congressional report on co-occurring disorders, and we have maintained through a policy academies and creation

dr. clark, why should we be concerned about ethnic and racial differences within the addiction and recovery field, as well as other differences? well, one of the things that we want to make sure is that people who have substance use problems are able to recover and that materials that we use can assist them in that process. and so, you know, there are differences associated with cultural values and beliefs, starting from how one physiologically responds to a particular substance misuse to how certain substances are used in a cultural context. so if we're going to facilitate recovery, we need to understand the language, the beliefs, the social context associated with those substances. and that will help us facilitate that person's recovery by showing that we understand the life experiences that they have associated with their use of substances. and i gather that includes prevalence as well. well, yes, but from a clinical point of view, i mean people look at the epidemiologic data and there are d

dr. clark, what we've been listening to are the challenges to provide integrated systems even within areas where you can refer people and where you can bring in a team. what's happening in the rural areas to co-occurring patients? well, i think you touch on a very important topic, and what we hear from rural communities is that [there's] a lack of providers. there are great geographic differences, and what they're requesting is increased focus on developing models so that they can deal with the needs of people in rural areas. there are fewer specialist providers available so it makes it more difficult to deal with individuals. and also it offers an individual who is ambivalent about care greater opportunity to isolate because that individual can seek refuge in the countryside, if you will, without-there are very few resources immediately available in terms of outreach to come get them. some programs recognize that and, as josh pointed out, they're able to go out and get them, but then that requ

dr. clark, we were talking about, john was talking about complicating factors in terms of health challenges that may present at the time of intake for some special population individuals. can you address, continue to address that? well, one of the things that we at samhsa are stressing is that every person who has a mental health issue or substance use issue needs to also get a good physical health assessment. one of the things we know about the misuse of alcohol or drugs is that it does have an effect on the organic integrity of the body. so you may get liver disease, you may get gastritis, you may get heart disease, you're at greater risks for various infections like hepatitis c or hiv. and we want to make sure that anybody who is on the course of recovery has as much information as possible. there was one quote i read recently and a guy says, "i spent all this time using alcohol and drugs and shooting up, etc., etc., so i finally get into treatment only to discover that i have hepatitis c."

and dr. clark, i know that in csat, for example, a lot of special population clients go to mainstream programs, to nonspecialized programs. what kind of success are we seeing with that? well, the issue of cultural competence is really the important discussion point here. we do find that programs that are run by american indians, alaska natives, for american indians, alaska natives or programs that target hispanics, run by hispanics, tend to produce better outcomes than programs that are not sensitive to those issues. so we use sort of a bias force paradigm. there are programs that are not run by the specific population group, but have modules that are targeted to the unique needs of that group. so they do not as well as the programs that are run by the specific population group, but they do better than programs that are general. so when we look at the outcomes of, say, a woman in a male program or a general program that doesn't have any gender specific programming, she doesn't do as well as the pro

dr. clark, you wanted to add something? yes, and that becomes important. the criminal justice system, law enforcement, the judges, we need to see them as an integral part of the community ethos and the mores of the community so that we get all aspects of the community working together in harmony, that ecosystem again. because if the community is not safe, then you'll find attitudes in the community are really negative toward the individuals in the community who have a alcohol and drug problem. so we want to make sure that it's not only a good public health message, but a good public safety message. and the drug courts are a good model for achieving that, demonstrating that an individual who has a alcohol and drug problem who may have violated the law, but who is nonviolent, can restructure their lives in a way that benefits not only themselves, but their family and the larger community. and a good model for the entire community to support those in recovery is national alcohol and drug addiction recovery month celebrated every september. we encourage you to

dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland; dr. timothy condon, deputy director, national institute on drug abuse, national institutes of health, u.s. department of health and human services, rockville, maryland; dr. barbara krantz, chief executive officer

dr. john. on friday, a look at this year's emmy winners. tonight we will look at the much anticipated address tomorrow night by president obama as he marks the end of combat operations in iraq. wesley clark was a candidate for the white house in 2004. he is a senior fellow and john's us from chicago. good to have you back on the program. the insurgents increase their activity recently. what are they trying to say? >> they are trying to say to their network they are still there and have not been defeated, but they have been substantially defeated. this is why we built the iraqi security forces. >> what does this do to the argument many have made that when we give them a date certain this was expected to happen? >> i think a date certain cuts both ways. you have to tell the host government at some point we are leaving and they need that as an incentive. sometimes you have to say it for the american people because our patience is limited. they have not been able to get them thus far. the u.s. will have a vital interest in iraq for a long time. tavis: we have 50,000 soldiers still left there and yet we have seen lives lost since we announced we were leaving. american soldiers have died. can

dr. h. westley clark, director, center for substance abuse treatment, substance abuse and mental health services administration, u.s. department of health and human services, rockville, maryland; dr. timothy condon, deputy director, national institute on drug abuse, national institutes of health, u.s. department of health and human services, rockville, maryland; dr. barbara krantz, chief executive officer and medical director, hanley center, west palm beach, florida; beverly gmerek, prescription drug abuse prevention program coordinator, peer assistance services inc., denver, colorado. dr. clark, how prevalent is prescription drug misuse in the united states? well, we estimate that there are approximately 15 million people who misuse prescription drugs in the united states, and that gives us an estimated 2.5 million new initiates per year, or, if you think about it, that's about 7,000 new initiates a day. and within that, do one age group uses it more than others? what is the distribution among the age groups? well, i think the most important thing to keep in mind is that prescription drug abuse