1

What Clinicians Need to Know

About Trauma

Amelia Roeschlein, DSW, MA, LMFT

National Council for Mental Wellbeing

June 17, 2021

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Housekeeping

• You will be muted automatically upon entry. Please

keep your phone line muted for the duration of the

webinar.

• Webinar is being recorded and will be archived for

future viewing at www.pcssNOW.org within 2 weeks.

• Submit questions in the Q&A box at the bottom of

your screen.

3

Amelia Roeschlein, DSW, MA, LMFT

Consultant

National Council for Mental Wellbeing

Today's Presenter

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Disclosures

• Dr. Roeschlein has no disclosures.

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Target Audience

• The overarching goal of PCSS is to train healthcare

professionals in evidence-based practices for the

prevention and treatment of opioid use disorders,

particularly in prescribing medications, as well for

the prevention and treatment of substance use

disorders.

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Educational Objectives

• At the conclusion of this activity participants should be able to:

▪ Describe the impact of trauma

▪ Explain the connection between trauma and substance use

▪ Provide two trauma-informed strategies of engagement with clients with substance use disorders

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Overview

• Overview of Trauma

▪ Prevalence and impact

▪ Trauma and the human

stress response

▪ Trauma and its

connection to addiction

• Becoming Trauma-Informed

in Your Daily Work

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Why Address Trauma Now?

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Trauma and Opioid Use

• Exposure to traumatic events is particularly common among individuals with opioid use disorders. A national survey in Australia found very high rates of trauma among individuals with opioid use disorders compared to individuals without an SUD, 87.8% vs. 56.8% respectively after controlling for age and sex

https://pubmed.ncbi.nlm.nih.gov/16585440/

• Among a consecutive sample of 113 treatment-seeking opioid-dependent outpatients seeking buprenorphine treatment, the majority (80.5%) reported a history of childhood sexual, physical, or emotional abuse, physical neglect, or violent trauma

https://pubmed.ncbi.nlm.nih.gov/19197597/

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Individual trauma results from an , series of events, or

set of circumstances that is by an individual

as overwhelming or life-changing and that has profound

on the individual’s psychological development or well-being,

often involving a physiological, social, and/or spiritual impact.

Definition (SAMHSA Experts 2012) includes

eventexperienced

effects

three key elements

What is Trauma?

https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

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Intergenerational (Historical) Trauma

“Cumulative emotional and psychological wounding,

over the lifespan and across generations, emanating

from massive group trauma experiences.”

Heart, M. Y. (2003). The Historical Trauma Response Among Natives and Its

Relationship with Substance Abuse: A Lakota Illustration. Journal of

Psychoactive Drugs, 35(1), 7-13. doi:10.1080/02791072.2003.10399988

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Intergenerational/ Historical Trauma Events

Genocides Slavery Pandemics Massacres

Prohibition/destruction of cultural practices

Discrimination/Systemic prejudice

Forced relocation

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Intergenerational (Historical)

Trauma Effects

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Historical Trauma Perpetuated Today

Microaggressions are everyday experiences of discrimination, racism, and daily hassles that are targeted at individuals from diverse cultural groups (Evans-Campbell, 2008).

• Using endearments

• Same behavior, different description

• Benevolent Sexism

• Underestimating

• Attribution Bias

Evans-Campbell T. Historical trauma in American Indian/Native Alaska

communities: a multilevel framework for exploring impacts on

individuals, families, and communities. J Interpers Violence. 2008

Mar;23(3):316-38. doi: 10.1177/0886260507312290. PMID: 18245571.

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A Client’s Journey

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Current Landscape

According to the National Institute of Mental Health, “members of racial and ethnic minority groups in the U.S. are less likely to have access to mental health services, less likely to use community mental health services, more likely to use inpatient hospitalization and emergency rooms, and more likely to receive lower quality care.”1

• Within psychiatry, it has been shown that racial minorities are less likely to achieve symptom remission and are more likely to be chronically impaired given a mental health diagnosis.2

• Bias and racism have been identified as key factors contributing to these inequities. The legacy of slavery and racism, as well as the current realities of racial oppression and violence, has uniquely impacted the mental health of African Americans.3

1https://www.ncsl.org/Portals/1/HTML_LargeReports/DisparitiesBehHealth_Final.htm#:~:text=According%20to%20t

he%20National%20Institute,and%20more%20likely%20to%20receive

2https://academic.oup.com/swr/article-abstract/36/1/41/1646733?redirectedFrom=fulltext

3https://www.mededportal.org/doi/pdf/10.15766/mep_2374-8265.10618

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Current Landscape(2)

• Additionally, African Americans have higher rates of severe depression, yet lower rates of treatment compared to white populations. 1

• African Americans are less likely to receive office-based counseling for psychological stressors and are more likely to be seen in emergency rooms.2

• The disproportionate diagnosis of schizophrenia among African Americans persists today, and they are more likely to be treated with antipsychotic medications that can have lasting, negative side effects.3

1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1199525/2https://archive.ahrq.gov/research/findings/nhqrdr/nhdr10/nhdr10.pdf3https://www.ncsl.org/Portals/1/HTML_LargeReports/DisparitiesBehHealth_Final.htm#:~:text

=According%20to%20the%20National%20Institute,and%20more%20likely%20to%20receive

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➢Worldview

➢Spirituality

➢Identity

Trauma Shapes Our Beliefs

20https://www.echotraining.org/we-love-science/

Hedges, F. (2012). Fight or Flight. Retrieved from

https://www.acesconnection.com/blog/fight-or-flight-infographic.

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Impact of Trauma on Behavior

Triggers

External reminders

of traumatic event

• Smell

• Sound

• Sight

• Touch

• Taste

Internal reminders

of traumatic event

• Emotions

• Thoughts

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Loneliness

Ali, S. (2018, July 12). What You Need to Know About the Loneliness

Epidemic. Retrieved from https://www.psychologytoday.com/us/blog/modern-

mentality/201807/what-you-need-know-about-the-loneliness-epidemic

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The Elephant in the Room

AngerDifficult concentrating

Physical Illness

Hyper arousal

Low self-esteem

Avoidant behavior

Traumatic grief

Mistrust

Trauma re-enactment

Depression

Sensory sensitivity

Dissociation

Aggression

ShameNeed to control

Inattention

Persistent irritability

Defiance

Difficulty forming relationships

Disrupted MoodRegressive behavior

Perfectionism

Fear

Guilt

Sleep problems

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Trauma and the Human Stress

Response

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Survival Mode Response

Trauma Theory. (2011, November 12). Retrieved June 10, 2020, from

http://kate-thegirlwholived.blogspot.com/2011/11/trauma-theory.html

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Cognition

Social/ Emotional

Regulation

Survival

Cognition

Social/ Emotional

Regulation

Survival

Typical DevelopmentDevelopmental Trauma

Impact of Trauma on Brain

Development

Perry, Bruce D., Szalavitz, Maia (2006). The boy who was raised as a dog:

And other stories from a child psychiatrist's notebook. Basic Books.

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Inability to

• Respond

• Learn

• Process

Survival Mode Response

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How Childhood Trauma Can Make You

a Sick Adult

Davis, B. (Director). (2015). How Childhood Trauma Can Make You A Sick

Adult [Video file]. Retrieved from http://mentalhealthchannel.tv/episode/how-

childhood-trauma-can-make-you-a-sick-adult

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The Adverse Childhood Experience Study:

Behavioral Heath at the Foundation of all Health

• Over 17,000 adults studied from

1995-1997

• Almost 2/3 of participants reported

at least one ACE

• Over 1/5 reported three or more

ACEs, including abuse, neglect,

and other types of childhood trauma

• Major links identified between early

childhood trauma and long term

health outcomes,

• including increased risk of many chronic

illnesses and early death

Adverse Childhood Experiences (ACE) and adolescent health.

Retrieved from https://www.cdc.gov/violenceprevention/acestudy/

30https://www.sciencemag.org/news/2019/07/parents-emotional-trauma-may-change-

their-children-s-biology-studies-mice-show-how

Epigenetics

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Dose gets bigger

Re

spo

nse

ge

ts b

igg

er

Severe obesity 1.6 xDiabetes 1.6 xCigarette Smokers 2.0 xFair/poor health 2.2 xHepatitis/jaundice 2.4 xHad an STD 2.5 x50+ intercourse partners 3.2 x COPD 3.9 xDepressed 2 weeks 4.6 xIllegal drug use 4.7 xAlcoholic 7.4 xInjected drugs

10.3 xSuicide attempt 12.2 x

Dose-Response Relationship:

More ACEs = More Disease

National Center for Injury Prevention and Control, Division of Violence

Prevention. (n.d.). Adverse Childhood Experiences (ACEs). Retrieved from

https://www.cdc.gov/violenceprevention/acestudy/

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Life-Long Physical, Mental & Behavioral Health

Outcomes Linked to ACEs

• Alcohol, tobacco & other drug addiction

• Auto-immune disease

• Chronic obstructive pulmonary disease &

ischemic heart disease

• Depression, anxiety & other mental

illness

• Diabetes

• Multiple divorces

• Fetal death

• High risk sexual activity, STDs &

unintended pregnancy

• Intimate partner violence—perpetration

& victimization

• Liver disease

• Lung cancer

• Obesity

• Self-regulation & anger management

problems

• Skeletal fractures

• Suicide attempts

• Work problems—including absenteeism,

productivity & on-the-job injury

Mate, G. (2003). When the Body Says No: The Cost of Hidden Stress

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Trauma is a risk factor for Substance Abuse

Substance Abuse is a risk factor for Trauma

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PTSD and Opioid Use Disorder

• “Prescription opioid use problems are a risk factor for co-occurring PTSD symptom severity. Being female or younger increase the likelihood of this co-morbidity. Further research is needed to confirm these finding, particularly using more rigorous diagnostic procedures. These data suggest that patients with prescription opioid use problems should be carefully evaluated for PTSD symptoms.

• “The odds of having severe PTSD symptoms was 3.81 times higher for patients with a prescription opioid and sedative use problem (CI: 1.47–9.88, p < 0.01). The odds of having PTSD for those with prescription opioid and cocaine use problems were 2.24 times higher (CI: 1.40–3.57, p ≤ 0.001)." https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4883674/

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Addiction and the Brain

As Gabor Mate notes in his book, In the Realm of Hungry Ghosts, those with

substance use disorder

“self-medicate to sooth their emotional pain – but more than

that, their brain development was sabotaged by their

traumatic experiences.”

Mate, Gabor, MD. (2010). In the Realm of the Hungry Ghosts. Berkeley, CA:

North Atlantic Books. Print. page 203.

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Why do People Use Alcohol and

Drugs?

To feel good

To have

novel:

Feelings

Sensations

Experiences

AND

to share them

To feel better

To lessen:

Anxiety

Worries

Fears

Depression

Hopelessness

Withdrawal

Slide credit: Thomas E. Freese, Ph.D., Co-Director of the UCLA Integrated Substance

Abuse Programs, Director of the Pacific Southwest ATTC

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Shame is the intensely painful feeling or experience of believing

that we are flawed and therefore unworthy of love and

belonging – something we’ve experienced, done, or failed to do

makes us unworthy of connection. Brene Brown

Brene’ Brown, (2012). Daring Greatly: How the Courage to be Vulnerable

Transforms the Way We Live, Love, Parent, and Lead.

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Adverse Childhood Experiences

The #1 Chronic Health Epidemic

in the United States

“The impact of ACEs can now only be ignored as a

matter of conscious choice. With this information

comes the responsibility to use it.”

-Anda and Brown, CDC

• ACE Study DVD from Academy on Violence and Abuse

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ACEs are not Destiny – So What Can We Do?

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Trauma-Informed Resilience-Focused

REALIZES the widespread impact of

trauma and understands potential paths

for recovery

IDENTIFIES programs and best

practices proven to build resiliency

at both individual and systemic levels

RECOGNIZES the signs and symptoms

of trauma in individual and systemic

levels

INOCULATES the system culture from

the effects of stress and trauma

proactively rather than reactively by

having a strategic plan

RESPONDS by fully integrating

knowledge about trauma into policies,

procedures and practices

INSTILLS a shared vocabulary and

skills for resiliency into every aspect of

the life of the system

RESISTS re-traumatization IMPROVES the health of the entire

system by promoting restoration, health

and growth in ongoing ways

Substance Abuse and Mental Health Services Administration. Trauma-Informed Care

in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS

Publication No. (SMA) 13-4801. Rockville, MD: Substance Abuse and Mental Health

Services Administration, 2014.

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Safety and Respect: Creating a Safe and

Secure Environment for EVERYBODY

We need to create a mutually respectful

interpersonal climate that fosters safety, trust,

choice, collaboration, and empowerment

“Mistakes made here often.”

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Cultural Humility

https://thelinkbetweenworlds.com/tag/cultural-humility/

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We need to have…

44Health Care Toolbox. (n.d.). Healthcare Toolbox Home Page. Retrieved June 18,

2020, from https://www.healthcaretoolbox.org/

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Build Relationships

Honor voice and choice

Partner with people

Request feedback

Ensure comfort

“Keep the Human in Human Services”

-Dr. Pat Deegan

Masten, A. (2001). Ordinary Magic: Resilience Processes in Development. American

Psychologist 56, 227-238.

Beardslee et al. (2010). Building Resilience: The Power to Cope with Adversity. Zero to

Three.

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The RSA. (2013, December 10). Brené Brown on Empathy [Video file]. Retrieved from

https://www.youtube.com/watch?v=1Evwgu369Jw

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Organizational Strategies for combatting

bias/stigma in patient-provider relationships

Simplify and translate client-facing forms and documentation

Adopt community-defined , promising practices

Hire providers that represent the local community

Client engagement- provide language support and build mental health literacy

Develop a plan for addressing engagement during the current pandemic, and beyond

Develop an organizational approach to case management

Checks for patient understanding of treatment decisions and next steps

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Be Attentive to All Language

“Lazy”

“Naughty”

“Non-compliant”

“Manipulative”

49

Why It Matters How We Conceptualize It, What

We Call It, People with It

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Studies have shown that…

• Compared to other psychiatric symptoms, Substance Use is more stigmatized, tend to view those using substances as more to blame for their use and consequences of use

• Describing Substance Use as Treatable Helps

• Individuals shown to hold stigmatizing biases against those using substances; view them as unmotivated, manipulative, dishonest

• Survivors who hold more stigmatizing beliefs about Substance Use are less likely to seek treatment; discontinue sooner

https://www.shatterproof.org/about-addiction/stigma/stigma-reducing-language

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Impact the Lower Brain

Interventions that impact the lower brain when someone is

in a dysregulated state focus on the 6 Rs:

Rhythmic Repetitive

Relational

RelevantRewarding

Respectful

Brous, K. (2014, April 11). Perry: Rhythm Regulates the Brain. Retrieved from

https://attachmentdisorderhealing.com/developmental-trauma-3/

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Implications for Practice

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Screen for Trauma

1. Unhealthy substance use is common.

2. Relying on personal impressions is unreliable and may

underestimate prevalence.

3. Opens up a dialogue about other impacts on a person’s

life.

4. Early interventions can prevent development of more

severe substance use disorders.

5. SBIRT has a role in fighting the opioid epidemic

alongside MAT, naloxone and safe prescribing

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Screening to quickly identify the severity of substance use

and appropriate level of treatment.

Brief Intervention to raise awareness of risks and

consequences, internal motivation for change, and help set

healthy lifestyles goals.

Referral to Treatment to facilitate access to specialized

services and coordinate care for patients with higher risk.

SBIRT is a comprehensive, integrated public health model

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Evidence-Based Screening Tools

• AUDIT

• DAST

• ASSIST

• CRAFFT (adolescents)

• S2BI (adolescents)

• PHQ-9 (depression)

• GAD-7 (anxiety)

• ACES

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Educate about Trauma

58

Taking Care of Ourselves

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Understand Daily Translation of

TIROC Principles

Principles of trauma-informed, recovery-oriented care (TIROC):

• Be patient and persistent

• Convey respect

• Be validating and affirming

• Read clients’ needs and respond accurately

• Set realistic expectations and goals

• Provide ongoing choices and supports

• Know your role

• Follow through with what you say you will do

• Provide consistency; minimize surprises

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Recognize our Humanity

We’re all just trying to survive

We frequently observe misplaced Coping Strategies

We are all part of the problem therefore we can all be part of the Solution

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References

• Mills, K. L., Teesson, M., Ross, J., & Peters, L. (2006). Trauma, PTSD, and substance use disorders: findings from the Australian National Survey of Mental Health and Well-Being. American Journal of

Psychiatry, 163(4), 652-658.

• Sansone, R. A., Whitecar, P., & Wiederman, M. W. (2009). The prevalence of childhood trauma among those seeking buprenorphine treatment. Journal of Addiction & Addictive Disorders, 28(1), 64-67.

• https://ncsacw.samhsa.gov/userfiles/files/SAMHSA_Trauma.pdf

• Heart, M. Y. (2003). The Historical Trauma Response Among Natives and Its Relationship with Substance Abuse: A Lakota Illustration. Journal of Psychoactive Drugs, 35(1), 7-13.

doi:10.1080/02791072.2003.10399988

• Evans-Campbell T. Historical trauma in American Indian/Native Alaska communities: a multilevel framework for exploring impacts on individuals, families, and communities. J Interpers Violence. 2008

Mar;23(3):316-38. doi: 10.1177/0886260507312290. PMID: 18245571.

• National Conference of State Legislatures. (2018, Feb). The Costs and Consequences of Disparities in Behavioral Health

Care. https://www.ncsl.org/Portals/1/HTML_LargeReports/DisparitiesBehHealth_Final.htm#:~:text=According%20to%20the%20National%20Institute,and%20more%20likely%20to%20receive

• Eack, S. M. & Newhill, C. E. (2012). Racial Disparities in Mental Health Outcomes after Psychiatric Hospital Discharge among Individuals with Severe Mental Illness. Social Work Research, 36(1), 41-52.

• Medlock, M., Weissman, A., Wong, S. S., Carlo, A., Zeng, M., Borba, C., Curry, M., & Shtasel, D. (2017). Racism as a Unique Social Determinant of Mental Health: Development of a Didactic Curriculum for

Psychiatry Residents. MedEdPORTAL, 13, 10618.

• Dunlop, D. D., Song, J., Lyons, J. S., Manheim, L. M., & Chang, R. W. (2003). Racial/Ethnic Differences in Rates of Depression Among Preretirement Adults. American Journal of Public Health, 93(11), 1945-

1952.

• Agency for Healthcare Research and Quality. (2011, Mar). 2010 National Healthcare Disparities Report. AHRQ Publication No. 11-0005. https://archive.ahrq.gov/research/findings/nhqrdr/nhdr10/nhdr10.pdf

• Echo. (2019). Physical Impact of Trauma. https://www.echotraining.org/we-love-science/

• Hedges, F. (2012). Fight or Flight. Retrieved from https://www.acesconnection.com/blog/fight-or-flight-infographic.

• Ali, S. (2018, July 12). What You Need to Know About the Loneliness Epidemic. Retrieved from https://www.psychologytoday.com/us/blog/modern-mentality/201807/what-you-need-know-about-the-loneliness-

epidemic

• Trauma Theory. (2011, November 12). Retrieved June 10, 2020, from http://kate-thegirlwholived.blogspot.com/2011/11/trauma-theory.html

• Perry, Bruce D., Szalavitz, Maia (2006). The boy who was raised as a dog: And other stories from a child psychiatrist's notebook. Basic Books.

• Davis, B. (Director). (2015). How Childhood Trauma Can Make You A Sick Adult [Video file]. Retrieved from http://mentalhealthchannel.tv/episode/how-childhood-trauma-can-make-you-a-sick-adult

• Adverse Childhood Experiences (ACE) and adolescent health. Retrieved from https://www.cdc.gov/violenceprevention/acestudy/

• Curry, A. (2019, July 18). Parents' emotional trauma may change their children's biology. Studies in mice show how. Science. https://www.sciencemag.org/news/2019/07/parents-emotional-trauma-may-

change-their-children-s-biology-studies-mice-show-how

• National Center for Injury Prevention and Control, Division of Violence Prevention. (n.d.). Adverse Childhood Experiences (ACEs). Retrieved from https://www.cdc.gov/violenceprevention/acestudy/

• Mate, G. (2003). When the Body Says No: The Cost of Hidden Stress.

• Meier, A., Lambert-Harris, C., McGovern, M. P., Xie, H., An, M., & McLeman, B. (2014). Co-occurring prescription opioid use problems and posttraumatic stress disorder symptom severity. American Journal of

Drug and Alcohol Abuse, 40(4), 304-311.

• Mate, Gabor, MD. (2010). In the Realm of the Hungry Ghosts. Berkley, CA: North Atlantic Books. Print. page 203.

• Brene’ Brown, (2012). Daring Greatly: How the Courage to be Vulnerable Transforms the Way We Live, Love, Parent, and Lead.

• Substance Abuse and Mental Health Services Administration. Trauma-Informed Care in Behavioral Health Services. Treatment Improvement Protocol (TIP) Series 57. HHS Publication No. (SMA) 13-4801.

Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.

• https://thelinkbetweenworlds.com/tag/cultural-humility/

• Health Care Toolbox. (n.d.). Healthcare Toolbox Home Page. Retrieved June 18, 2020, from https://www.healthcaretoolbox.org/

• Masten, A. (2001). Ordinary Magic: Resilience Processes in Development. American Psychologist 56, 227-238.

• Beardslee et al. (2010). Building Resilience: The Power to Cope with Adversity. Zero to Three.

• Shatterproof. (2021). Stigma-reducing language. https://www.shatterproof.org/about-addiction/stigma/stigma-reducing-language

• The RSA. (2013, December 10). Brené Brown on Empathy [Video file]. Retrieved from https://www.youtube.com/watch?v=1Evwgu369Jw

• Brous, K. (2014, April 11). Perry: Rhythm Regulates the Brain. Retrieved from https://attachmentdisorderhealing.com/developmental-trauma-3/

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Resources

• Robert Wood Johnson Foundation (2013) Health Policy Brief: Patient Engagement.

People actively involved in their health and health care tend to have better

outcomes—and, some evidence suggests, lower costs.

https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2013/rwjf404446

• Hawkley, L. C., & Cacioppo, J. T. (2010). Loneliness Matters: A Theoretical and

Empirical Review of Consequences and Mechanisms. Annals of Behavioral

Medicine : A Publication of the Society of Behavioral Medicine, 40(2),

10.1007/s12160–010–9210–8. http://doi.org/10.1007/s12160-010-9210-8

• Trauma 101- https://youtu.be/1pNwHMjPrxY

• Trauma-informed Care Guiding Principles-

https://www.samhsa.gov/samhsaNewsLetter/Volume_22_Number_2/trauma_tip/gui

ding_principles.html

• Trauma-informed Care in BH Services-

https://store.samhsa.gov/shin/content/SMA14-4816/SMA14-4816.pdf

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TIP 57: Trauma-Informed Care in Behavioral Health Services

Assists behavioral health professionals in understanding the impact and consequences for those who experience trauma. Discusses patient assessment, treatment planning strategies that support recovery, and building a trauma-informed care workforce. Inventory#: SMA14-4816

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Thank You!

Amelia Roeschlein, DSW, MA, LMFT

Consultant

National Council for Mental Wellbeing

AmiR@thenationalcouncil.org

65

PCSS Mentoring Program

▪ PCSS Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing

medications for opioid use disorder.

▪ PCSS Mentors are a national network of providers with expertise in

addictions, pain, evidence-based treatment including medications for

addiction treatment.

• 3-tiered approach allows every mentor/mentee relationship to be unique

and catered to the specific needs of the mentee.

• No cost.

For more information visit:

https://pcssNOW.org/mentoring/

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PCSS is a collaborative effort led by the American Academy of Addiction

Psychiatry (AAAP) in partnership with:

Addiction Technology Transfer Center American Society of Addiction Medicine

American Academy of Family Physicians American Society for Pain Management Nursing

American Academy of Pain MedicineAssociation for Multidisciplinary Education and

Research in Substance use and Addiction

American Academy of Pediatrics Council on Social Work Education

American Pharmacists Association International Nurses Society on Addictions

American College of Emergency Physicians National Association for Community Health Centers

American Dental Association National Association of Social Workers

American Medical Association National Council for Behavioral Health

American Osteopathic Academy of Addiction

MedicineThe National Judicial College

American Psychiatric Association Physician Assistant Education Association

American Psychiatric Nurses Association Society for Academic Emergency Medicine

68

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Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 from SAMHSA. The views expressed in written conference materials or

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