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18 Disaster and Substance Abuse Services

Dee S. Owens, Brian McKernan, and Julie L. Framingham

CONTENTS

18.1. Introduction........................................................................................................................... 320 18.2. .Literature.Review.of.the.Epidemiology.of.Substance.Use,.Abuse,.and.Dependence.

Postdisaster............................................................................................................................ 320 18.3. Dynamics.of.Substance.Abuse.Postdisaster.......................................................................... 321

18.3.1. Increase.of.Substance.Use.in.the.General.Population.to.Cope.with.Stress............... 321 18.3.2. .Persons.Nearing.Substance.Abuse.or.Dependence.Cross.the.Line........................... 321 18.3.3. Persons.in.Active.Addiction.Increase.Use.of.Substances.......................................... 322 18.3.4. Persons.in.Recovery.Experience.Relapse.................................................................. 322 18.3.5. .Persons.Experiencing.Posttraumatic.Stress.Disorder.or.Depressive.Symptoms.

Increase.Use.of.Substances........................................................................................ 322 18.3.6. .Persons.in.Other.At-Risk.Groups,.Such.as.First.Responders,.Increase.Use.of.

Substances................................................................................................................. 322 18.3.7. Complex.Dynamics................................................................................................... 323

18.3.7.1. .National.Survey.on.Drug.Use.and.Health.Shows.Increase.in. Use among.Hurricane.Katrina.and.Rita.Evacuees.Compared.to. Those Who.Remained................................................................................ 323

18.3.7.2. Changes.in.Drug.Distribution.Networks.Postdisaster................................ 323 18.3.7.3. Localized.versus.Regional.Devastation...................................................... 323

18.4. .Disaster.Impact.on.Substance.Abuse.and.Prevention.Treatment.Infrastructure................... 323 18.4.1. Impact.of.9/11.Attack.on.Lower.Manhattan.Opioid.Treatment.Providers................ 324

18.4.1.1. Impact.of.Hurricane.Katrina.on.Methadone.Provision.in.the.South.......... 324 18.4.2. .Impact.of.2005.Hurricanes.on.Gulf.Coast.Substance.Abuse.Prevention.and.

Treatment.Providers................................................................................................... 324 18.4.3. Loss.or.Disruption.of.Recovery.Networks................................................................ 325

18.5. At-Risk.Populations............................................................................................................... 325 18.5.1. Disaster.Survivors.Who.Are.in.Early.Recovery....................................................... 325 18.5.2. Survivors.Experiencing.Disaster-Related.Mental.Health.Symptoms........................ 325 18.5.3. First.Responders........................................................................................................ 325 18.5.4. Adolescent.Youth....................................................................................................... 326

18.6. Case.Studies........................................................................................................................... 326 18.6.1. Iowa.Disaster.Response............................................................................................. 327

18.6.1.1. 2008:.Catastrophic.Floods.......................................................................... 327 18.6.2. Colorado.Disaster.Response...................................................................................... 329

18.6.2.1. 2008:.Severe.Storms.and.Tornadoes........................................................... 329 18.6.2.2. 2005:.Hurricane.Katrina............................................................................. 329 18.6.2.3. 2002:.Wildfires........................................................................................... 330

18.6.3. Massachusetts.Disaster.Response.............................................................................. 331 18.6.3.1. 2008:.Hurricane.Katrina.Evacuees.and.Response...................................... 331

C o p y r i g h t 2 0 1 2 . C R C P r e s s .

A l l r i g h t s r e s e r v e d . M a y n o t b e r e p r o d u c e d i n a n y f o r m w i t h o u t p e r m i s s i o n f r o m t h e p u b l i s h e r , e x c e p t f a i r u s e s p e r m i t t e d u n d e r U . S . o r a p p l i c a b l e c o p y r i g h t l a w .

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320 Behavioral Health Response to Disasters

18.1  INTRODUCTION

This. chapter. will. use. a. multifaceted. approach. to. bring. the. reader. up. to. date. with. recent. research. on. the. effects. of. disaster. on. survivors. with. substance. use. problems.. The. subject. of. substance.abuse.has.been.the.focus.of.relatively.few.empirical.studies.in.comparison.to.other. areas.of.disaster.research,.including.disaster.mental.health,.which.is.also.a.burgeoning.field. of.study..Much.of.the.serious.research.on.substance.use.postdisaster.occurred.within.the.past. decade,. since. the. terrorist. attacks. of. September. 11,. 2001. (9/11),. and. again. after. observing. the.devastating.impacts.of.Hurricane.Katrina.on.August.29,.2005,.along.the.U.S..Gulf.Coast.. Some. of. these. research. findings. are. discussed. within. this. chapter.. Additionally,. the. field. observations. of. three. different. states’. substance. abuse. responses. to. disasters. are. presented.. Together,.both.the.scholarly.studies.and.the.anecdotal.state.reports.yield.a.number.of.consid- erations. for. disaster. planners. and. responders.. We. will. discuss. some. of. these. considerations. and.how.they.informed.several.important.state.and.federal.disaster.substance.abuse.initiatives. during.the.past.several.years..While.the.precise.relationship.between.disasters.and.substance. use.is.still.not.fully.understood,.the.topic.nevertheless.merits.more.serious.consideration.and. should.be.addressed.in.the.local.or.state.jurisdiction’s.overall.behavioral.health.planning.and. response.to.disasters.

18.2   LITERATURE REVIEW OF THE EPIDEMIOLOGY OF SUBSTANCE  USE, ABUSE, AND DEPENDENCE POSTDISASTER

As.the.study.of.alcohol.and.other.drug.use.after.disaster.is.an.emergent.field,.there.is.growing. evidence.that.survivors.of.disaster.increase.use.of.alcohol.and/or.other.drugs,.and.that,.for.cer- tain.populations,.this.phenomenon.is.especially.ill.advised..While.many.survivors.may.“go.to. the.bars”.more.and.drink.to.relieve.stress,.those.who.have.existing.substance.use.disorders.are. making.potentially.life-threatening.choices.by.doing.so..Most.methodologically.sound.studies. about.alcohol.and.other.drug.use.have.shown.some.increase.or.deviance.in.use.after.a.disaster.. For.example,.almost.30.percent.of.988.New.York.City.residents.surveyed.reported.an.increase. in.the.use.of.alcohol,.cigarettes,.and.marijuana.soon.after.the.9/11.attack.on.the.World.Trade. Center.. Alcohol. consumption. reported. the. largest. increase. with. 24.6. percent,. followed. by. cigarettes.at.9.7.percent,.and.3.2.percent.for.marijuana.(Vlahov.et.al..2002)..Other.studies.of. 2,368.and.1,681.New.York.City.adults.conducted.at.one.and.two.years,.respectively,.after.the. World. Trade. Center. attack,. report. sustained. increases. in. alcohol. consumption. (10. percent). and. alcohol. dependence. after. disaster. exposure,. while. an. increase. in. binge. drinking. was. observed. at. one. year. postdisaster. (Boscarino,. Adams,. and. Galea. 2006;. Adams,. Boscarino,. and.Galea 2006)..Wu.and.colleagues.(2006).demonstrate.that.of.2,731.New.York.City.public. high.school.students.surveyed,.10.9.percent.increased.their.consumption.of.alcohol..Although. 5.4.percent.also.reported.an.increase.in.cigarette.smoking.after.9/11,.this.increase.was.attrib- uted. more. to. the. students’. self-reports. of. past. trauma. experiences. and. posttraumatic. stress. disorder.than.to.disaster.exposure.(Wu.et.al..2006)..Increased.alcohol.consumption.is.noted.

18.7. Lessons.Learned.................................................................................................................... 332 18.8. National.Developments.......................................................................................................... 333

18.8.1. Disaster.Substance.Abuse.Planning.......................................................................... 333 18.8.2. Digital.Access.to.Medication.................................................................................... 334 18.8.3. Disaster.Substance.Abuse.Preparedness.and.Response.Coordination...................... 334

18.9. Conclusion............................................................................................................................. 334 Notes............................................................................................................................................... 334 References....................................................................................................................................... 335

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321Disaster and Substance Abuse Services

among. 13. percent. of. the. survivors. of. the. attack. on. the. Pentagon. as. well. (n. =. 77;. Grieger,. Fullerton,.and.Ursano.2003).

The. effects. of. terrorism. on. drinking. are. also. noted. by. researchers. who. find. that. binge/. intoxication.drinking.postdisaster.is.increased.not.only.by.a.lack.of.social-bonding.variables,.such. as.parenthood,.but.even.political.factors,.such.as.higher.alerts.for.terrorism.(Richman.et.al..2009).. Furthermore,. a. meta-analysis. by. Dimaggio,. Galea,. and. Li. (2009). supports. that. terrorism. influ- ences. substance. use. and. abuse. by. survivors. and. other. groups. affected.. Specifically,. and. using. Bayesian.techniques,.this.analysis.of.31.population-based.studies.finds.that.in.the.first.two.years. after. a. terrorist. event,. 7.3. percent. of. a. population. will. increase. alcohol. use,. with. a. 20. percent. probability.that.at.least.14.percent.of.that.population.will.increase.use..Similarly,.6.8.percent.of.an. affected.group.will.increase.smoking.behaviors,.while.drug.use.(including.prescriptions.and.illicit. substances).will.rise.16.3.percent..

Studies.of.adolescent.survivors.of.Hurricanes.Katrina.and.Rita.also.demonstrated.a.connection. between.disaster.exposure.and.increased.substance.use.and.abuse.(Flory.et.al..2009;.Rohrbach.et. al.. 2009).. Furthermore,. other. types. of. disasters,. such. as. the. 1998. Swissair. Flight. 111. disaster. in. Saint.Margaret’s.Bay,.Nova.Scotia,.Canada,.the.Mount.St..Helens.volcanic.eruption.in.1980,.and. the.Herald.of.Free.Enterprise.disaster.in.1987,.demonstrated.similar.increases.in.substance.use.and. abuse.(Stewart.et.al..2004;.Adams.and.Adams.1984;.Joseph.et.al..1993).

Although.these.studies.support.that.disaster.survivors.may.increase.their.consumption.of.alco- hol,.tobacco,.and.other.substances,.not.all.do..One.study.of.the.Great.Hanshin.Earthquake.in.Japan,. for.instance,.found.that.alcohol.use.was.10–20.percent.lower.than.anticipated.postdisaster.(Shimizu. et. al.. 2000).. Some. research. (Valdez. et. al.. 2009). seems. to. demonstrate. a. lower. immediate. use. of. illicit. drugs. but. higher. alcohol. sales,. indicating. a. likely. disruption. of. drug-supply. networks. after. disaster..These.seeming.disparities.are.replicated.by.other.disaster.studies,.such.as.those.about.first. responders,.where.some.are.seen.to.be.resilient.while.others.are.“more.symptomatic.than.unexposed. comparison.groups”.(North.et.al..2002a,.172)..In.fact,.studies.have.found.higher.rates.of.predisaster. alcohol-use. disorder. among. firefighters,. a. population. that. self-selects. for. traumatic. work. but. that. seems.to.cope.by.drinking.alcohol.(Boxer.and.Wild.1993;.North.et.al..2002b)..While.these.studies. are.more.equivocal.concerning.the.increase.of.substance.use.postdisaster,.they.nevertheless.illus- trate. that. disaster. services. should. include. substance. abuse. as. an. important. portion. of. behavioral. health.planning.and.response.

18.3  DYNAMICS OF SUBSTANCE ABUSE POSTDISASTER

18.3.1  increase of suBsTance use in The general populaTion To cope WiTh sTress

A.meta-analysis.was.conducted.by.Fran.Norris.(2005).including.not.only.United.States.data,. but.also.research.from.34.other.countries,.developing.and.developed,.and.including.132.natu- ral. and. human-caused. disasters.. The. study. shows. that. some. populations. do. increase. the. use. of. alcohol,. other. drugs,. and. cigarettes,. especially. those. who. demonstrate. comorbidity. with. other.disorders..Fifteen.percent.of.survivors.of.a.1994.shooting.in.a.Texas.cafeteria.said.they. used.alcohol.to.cope.with.stress.(North.et.al..1994),.but.the.extent.to.which.alcohol.is.used.as. self-medication.can.be.difficult.to.determine,.as.can.the.relationship.between.alcohol.use.and. stressors.in.general.

18.3.2   persons nearing suBsTance aBuse or dependence cross The line

In.New.York.City.after.9/11,.a.constant.refrain.was.that.many.who.were.borderline.alcoholics.had. “crossed.the.line,”.drinking.to.excess.to.cope.and.then.becoming.dependent.upon.alcohol.for.daily. functioning.(Frank.and.Owens.2002)..This.area.deserves.more.research.so.core.indicators.of.addic- tion.following.disaster.can.be.identified.

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322 Behavioral Health Response to Disasters

18.3.3  persons in acTiVe addicTion increase use of suBsTances

A. characteristic. of. addiction. is. an. increase. in. use. of. the. substance. over. time,. until. such. time. as. either.recovery.or.early.death.or.disability.occurs..There.is.no.reason.to.believe.that.a.stressor.the. size.of.a.disaster,.be.it.natural.or.human.caused,.would.be.any.different.in.its.outcomes..Frank.and. Owens. (2002). found. that. 9/11. New. York. City. street. survivors. and. clients. were. requesting. more. benzodiazepines.from.their.doctors.(50),.while.Stewart.(1996).and.Adams.and.Adams.(1984).found. that.driving-while-intoxicated.(DWI).rates.rise.after.disaster.

18.3.4  persons in recoVery experience relapse

Relapse,.a.clinical.worsening.of.symptoms.(Norris.2005,.3),.increases.upon.exposure.to.disaster.. After. 9/11. in. New. York. City,. staff. of. substance. abuse. treatment. facilities. who. were. in. recovery. sometimes.relapsed,.and.many.left.their.jobs.entirely.(Frank.and.Owens.2002,.19),.while.police,. firefighters,.and.other.responders,.such.as.teachers.in.affected.schools,.in.recovery.were.relapsing. (18).. A. focus. group. of. providers. conducted. by. Rowe. and. Liddle. (2008). found. that,. of. Hurricane. Katrina.adolescent.disaster.survivors,.over.half.of.the.youth.in.drug-abuse-treatment.programs.had. relapsed.during.the.hurricane.and.evacuation..The.Midwestern.floods.of.1993.caused.20.percent.of. those.who.were.in.recovery.from.alcohol-use.disorders.to.use.alcohol.to.cope.after.the.floods.(North. et.al..2004)..Zywiak.and.colleagues.reported.in.2003.that.relapse.among.patients.who.were.detoxi- fied.prior.to.9/11.increased.by.42.percent,.while.a.recent.analysis.by.North.and.colleagues.(2011). found.that.survivors.of.disaster.in.recovery.were.four.times.more.likely.to.drink.than.were.survivors. without.a.previous.addiction..Clearly,.persons.in.recovery,.especially.those.in.early.recovery,.are.in. danger.of.relapsing.back.to.the.addictive.substance.after.disaster.

18.3.5   persons experiencing posTTrauMaTic sTress disorder or  depressiVe syMpToMs increase use of suBsTances

Posttraumatic. stress. disorder. (PTSD). is. a. known. outcome. in. disasters,. but. how. this. diagnosis. relates. to. substance. use. deserves. further. study.. In. Oklahoma. City,. alcohol-use. disorder. among. firefighters. was. correlated. with. less. satisfaction. at. work,. higher. PTSD-related. impairment. in. job.performance.and.personal.relationships,.and.use.of.alcohol.as.a.coping.mechanism.after.the. bombing. (North. et. al.. 2002a).. Vlahov. and. colleagues. (2002). postulate. that. substance. use. after. disaster.may.rise.for.several.reasons,.including.the.increase.in.need.to.cope.with.stress.or.relax;. nervousness.from.withdrawal.symptoms.or.self-medication,.especially.by.those.with.PTSD;.and. a.vicious.cycle.of.substance.use.to.treat.symptoms,.which.in.fact.exacerbates.them.and.prolongs. use.. Norris. (2005). notes. that. the. most. observed. condition. after. disaster. is. PTSD,. followed. by. depression,.and.these.are.made.worse.by.proximity.of.exposure.to.the.disaster.and.by.the.disaster. type,.with.mass.violence.causing.the.most.severe.impairment..Norris.also.discusses.substance.use. in.this.context.as.possibly.increased.because.those.affected.already.had.substance.use.disorders. or.other.psychological.disorders.(3)..It.is.clear.that.PTSD.and.substance.use.are.related;.exactly. what.that.relationship.might.be.is.yet.to.be.fully.determined.by.research..According.to.Adams. and.colleagues.(2006),.understanding.the.relationship.between.substance.use.and.PTSD.is.crucial. because.substance.use.“may.hinder.the.resolution.of.psychological.distress.and.the.treatment.of. psychological.problems”.(205).

18.3.6   persons in oTher aT-risk groups, such as firsT  responders, increase use of suBsTances

Frank.and.Owens.(2002).found.that.police.and.fire.recovery.workers.were.noted.by.treatment.pro- viders.to.be.increasing.alcohol.use,.in.part.due.to.survivor.guilt.(50–51)..Before.and.after.Oklahoma.

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323Disaster and Substance Abuse Services

City,.there.is.a.body.of.literature.that.documents.the.resilience.of.first.responders,.who.“self-select”. for.this.work.(Boxer.and.Wild.1993;.North.2002a.and.2002b;.Frank.and.Owens.2002).along.with. an.admonition.that.drinking.as.a.coping.mechanism.is.significantly.associated.with.poor.outcomes.. For.example,.those.Oklahoma.City.firefighters.who.drank.to.cope.had.four.times.the.alcohol-use. disorders.than.did.others.(North.et.al..2002a,.174;.see.Section.18.5.3.for.further.information).

18.3.7  coMplex dynaMics

18.3.7.1   National Survey on Drug Use and Health Shows Increase in Use among  Hurricane Katrina and Rita Evacuees Compared to Those Who Remained

The. National. Survey. on. Drug. Use. and. Health. reported. on. January. 31,. 2008,. that. although. there. were.no.significant.overall.increases.in.illicit.drug.use.or.binge.alcohol.use.(and.an.actual.decrease. in.marijuana.use).among.the.Gulf.Coast.areas.that.were.hit.by.Hurricanes.Katrina.and.then.Rita,. there.were.higher.rates.of.use.in.all.categories.for.adults.who.were.displaced.from.their.homes.for. at.least.two.weeks.(SAMHSA.2008,.1)..Female.caregivers.who.were.living.in.Federal.Emergency. Management.Agency.(FEMA).trailers.or.hotels.reported.depression.and.anxiety.(68.percent);.they. were. some. of. the. 1.5. million. people. who. were. displaced. for. longer. than. two. weeks. (SAMHSA. 2008,.2)..Clearly,.loss.of.residence.is.a.major.stressor.that.is.related.to.substance.use.

18.3.7.2  Changes in Drug Distribution Networks Postdisaster Valdez. and. colleagues. (2009). demonstrate. that. patterns. of. drug. use. by. the. population. studied. (poverty,. minority. race,. previous. substance. use,. displaced. to. Houston. from. New. Orleans). were. disrupted.because.the.usual.illicit.drug.markets.were.destroyed.or.inaccessible,.and.new.markets. in. Houston. supplied. different. drugs.. As. a. result,. overall. use. of. illicit. drugs. dropped,. despite. an. overall.increase.in.substance.use.(Valdez.et.al..2009,.23)..The.NSDUH.Report.(SAMHSA.2008). shows. that,. although. use. continued. to. rise. in. other. areas. of. the. country,. the. Gulf. states. showed. decreases.in.the.use.of.illicit.drugs,.marijuana,.illegal.use.of.prescriptions,.binge.alcohol.use,.and. cigarette. use. (Tables. 5. and. 6,. p.. 6).. Lack. of. availability. of. all. drugs. certainly. played. into. these. numbers,.as.there.was.no.electricity.or.automobile.gas.in.much.of.the.region.for.weeks,.so.stores. that.sell.legal.drugs.were.generally.not.open.

18.3.7.3  Localized versus Regional Devastation Because.there.was.widespread.and.total.hurricane.destruction.in.many.of.the.Gulf.Coast.areas,.but. especially.from.Biloxi,.Mississippi,.to.beyond.New.Orleans,.Louisiana,.by.Katrina,.and.from.Lake. Charles,.Louisiana,.past.Beaumont,.Texas,.by.Rita,.no.local.help.was.available.for.immediate.call- out.(SAMHSA.2008,.3)..Interstates.in.Mississippi.all.the.way.north.to.Jackson.were.covered.with. trees,.gas.was.unavailable,.and.cell.towers.were.toppled.or.overloaded..Disaster.planning.ought.to. take.these.considerations.into.account.when.devising.plans.for.agencies.and.clients,.especially.in. areas.prone.to.natural.disaster.

18.4   DISASTER IMPACT ON SUBSTANCE ABUSE AND  PREVENTION TREATMENT INFRASTRUCTURE

New.York.City.substance.abuse.treatment.systems.experienced.extraordinary.breaks.in.service. delivery.after.the.attacks.of.9/11..For.example,.everything.below.14th.and.Houston.Streets.was. closed.to.all.clients.and.residents—everyone.except.responders—for.a.long.period.of.time;.those. providers.who.did.not.have.their.offices.destroyed.outright.were.nonetheless.faced.with.cremains. and. ash. six. inches. deep,. with. elevators. that. would. not. work,. and. with. respiratory. issues. upon. return..The.Frank.and.Owens.(2002).report.available.from.the.SAMHSA.Center.for.Substance. Abuse. Treatment. entitled. “The. Impact. of. the. World. Trade. Center. Disaster. on. Treatment. and.

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324 Behavioral Health Response to Disasters

Prevention. Services. for. Alcohol. and. Other. Drug. Abuse. in. New. York”. is. a. lengthy. report. that. describes.what.it.is.like.to.have.infrastructure.destroyed.or.so.ruined.that.it.takes.three.months.to. even.consider.moving.back.in..What.about.records?.Communication.with.staff?.Client.services?. The.report,.complete.with.focus.group.results,.describes.lessons.learned.for.providers.and.pro- grams,. for. state/counties/cities,. and. makes. recommendations. for. the. future.. Examples. include. provision. of. alternative. communication. systems;. cross-disciplinary,. comprehensive. planning;. fiscal. rules. for. quick. resource. allocation;. and. specialized. disaster. and. response. training. for. all. behavioral.health.providers.

18.4.1  iMpacT of 9/11 aTTack on loWer ManhaTTan opioid TreaTMenT proViders

As. noted. in. the. previously. mentioned. report,. lower. Manhattan. opioid. treatment. providers. were. either. inaccessible. or. wiped. out. by. the. collapse. of. the. twin. towers.. Those. who. would. normally. provide. services. ran. for. their. lives,. often. alongside. their. clients,. and. they. would. not. be. allowed. back.for.a.long.time..Clients.were.not.required.to.carry.identification.so.were.technically.unable. to. get. “guest”. doses. of. their. medicine. at. other. clinics—but. these. were. extraordinary. times.. The. state.agency.quickly.told.remaining.providers.to.guest-dose.these.clients.after.asking.the.client.how. much.the.dosage.was.to.be,.which.they.did,.and.there.was.not.one.documented.case.of.abuse.of.this. guest-dosing.privilege,.which.is.extraordinary.in.itself..This.gap.in.the.system.was.quickly.studied. and.filled;.there.are.now.protocols.for.guest-dosing.that.were.shared.nationally.so.that.others.could. benefit.from.the.experience.of.the.New.York.City.providers.

18.4.1.1  Impact of Hurricane Katrina on Methadone Provision in the South With. the. mental. health. and. substance. abuse. treatment. systems. destroyed. along. the. Gulf. Coast,. provision. of. methadone. medication. proved. to. be. difficult,. at. best.. Many. displaced. persons. in. Louisiana. went. to. Baton. Rouge,. where. Tulane. Medical. School. staff. also. relocated.. These. staff. provided.doses.to.clients,.but.only.after.reassessing.their.needs,.as.most.clients.did.not.know.or. have.their.dosage.amounts,.and.records.were.nonexistent.(Winstead.and.Legeai.2007)..In.fact,.at. eight.months.after.the.disaster,.only.1.percent.of.evacuees.to.Houston.were.found.to.use.metha- done.as.a.street.drug,.with.19.percent.preferring.marijuana.to.relieve.physical.and.emotional.pain. (Valdez. et. al.. 2009,. 19).. The. systems. were. not. set. up. to. deal. with. total. displacement. for. many. months—few.are.

18.4.2   iMpacT of 2005 hurricanes on gulf coasT suBsTance  aBuse preVenTion and TreaTMenT proViders

Mental.health.and.substance.abuse.services.to.veterans.were.significantly.disrupted.due.to.destruc- tion. of. Veterans. Affairs. facilities. in. Gulfport,. Mississippi,. and. the. closing. of. the. facility. in. New. Orleans.after.Katrina;.interestingly,.the.Biloxi,.Mississippi,.facility.remained.open,.despite.the.utter. destruction.in.that.area.(Druss,.Henderson,.and.Rosenheck.2007,.155),.and.provided.services.to.the. Gulfport.displaced.veterans.

The. Gulf. Coast. Mental. Health. Center. system. in. southern. Mississippi. was. destroyed. by. the. storm,.and.a.team.of.Indiana.state.police,.conservation.officers.(complete.with.swamp.buggies),. National.Guard.(including.gasoline.and.MREsa),.and.medical.and.mental.health.professionals.was. deployed.to.Biloxi.within.four.days.of.the.hit.by.Hurricane.Katrina.under.a.state-to-state.emer- gency.management.assistance.compact.(EMACb)..The.mental.health.professionals.functioned.as.a. temporary.replacement.for.the.community.mental.health.center,.providing.resources.and.helping. clients.to.obtain.service.when.possible..The.Indiana.group.changed.its.personnel.every.two.weeks. to. avoid. burnout,. for. a. period. of. six. weeks,. until. the. system. could. resume. functionality.. In. this. way,.clients.were.able.to.access.some.services,.and.medications.could.be.obtained.for.those.who. needed.them.

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325Disaster and Substance Abuse Services

18.4.3  loss or disrupTion of recoVery neTWorks

In.New.York.City,.many.lower.Manhattan.Alcoholics.Anonymous.(AA).and.other.peers-in-recovery. meetings.were.lost,.both.people.and.places,.but.the.Ground.Zero.workers.set.up.two.daily.meetings. that.people.could.attend.(see.Section.18.5.3.for.more.information)..In.Biloxi,.Mississippi,.personnel. on. the. ground. within. one. week,. this. author. included,. were. told. that. the. recovery. network. pulled. together,.went.out.to.find.its.members,.and.reestablished.meetings.as.it.could..This.was.self-help.in. the.truest.sense.of.the.term..Since.these.meetings.are.set.up.by.members,.the.recovery.networks,. although.lost,.seemed.to.reestablish.themselves.quickly..The.offices.of.Alcoholics.Anonymous.are. in.New.York.City,.and,.while.not.displaced,.the.staff.there.were.affected.like.anyone.else..The.AA Grapevine,. the. international. publication. of. AA,. discussed. the. story. in. January. 2002,. and. talked. about.the.hardhats.and.boots.at.the.Group.at.Ground.Zero.(S.,.Richard.2002)..These.informal.net- works.were.disrupted.or.lost,.but.the.spirit.of.self-help.caused.them.to.regroup.and.come.together. again.in.support.of.members.who.needed.ongoing.support.

18.5  AT-RISK POPULATIONS

While.most.at-risk.populations.have.been.discussed.in.a.general.manner,.certain.of.these.deserve. special.mention.

18.5.1  disasTer surViVors Who are in early recoVery

From. a. substance. abuse. treatment. perspective,. those. who. are. in. the. first. six. months. of. recovery. from. substance. use. disorders. are. very. vulnerable. to. relapse,. or. the. reinitiation. of. use. of. the. par- ticular.addictive.substance..Disasters,.especially.those.that.are.human.caused.and.have.culpability. associated.with.them,.can.and.do.push.those.newly.in.recovery.to.relapse,.or.“go.back.out”.(Frank. and.Owens.2002)..These.persons.will.need.extra.attention.and.care.following.any.disaster.to.help. them.preserve.their.sobriety.

18.5.2  surViVors experiencing disasTer-relaTed MenTal healTh syMpToMs

Mental.health.diagnoses.including.PTSD.are.infrequently.studied.in.relation.to.postdisaster.sub- stance. use. disorders,. but. it. again. goes. without. saying. that. these. people. need. special. care. and. patience. as. they. process. what. healthy. people. have. difficulty. handling. themselves.. Clients. who. are.displaced.from.their.service.providers,.as.when.the.mental.health.centers.in.lower.Mississippi. and.in.New.Orleans.were.completely.wiped.out.after.Katrina,.may.be.without.a.trusted.therapist,. or.without.medication.(see.Section.18.4.1.1),.and.most.psychotropic.medications.are.not.in.a.push. pack.that.will.come.from.the.Strategic.National.Stockpile.(SNS).c.Setting.up.redundant.provision. of.these.services.will.go.a.long.way.toward.reducing.anxiety.for.both.the.client.and.the.provider,. in.the.event.of.disaster.

18.5.3  firsT responders

Police.and.firefighters.and.other.responders.are.trained.in.many.areas.of.trauma.response,.but.there. is.no.one.who.can.mentally.digest.dealing.with.body.parts.of.children,.for.example..Oklahoma.City. firefighters.had.25.percent.current.alcohol-use.disorder.and.reported.using.alcohol.to.cope.(North. et. al.. 2002a,. 174). after. doing. recovery. work. at. the. Murrah. Federal. Building. site.. Additionally,. these.responders.come.from.what.is.termed.a.“closed.shop”—those.who.come.from.the.outside.are. often.viewed.with.suspicion..Frank.and.Owens.(2002).found.that.police.officers.in.New.York.City. who. would. talk. with. them. were. resentful. when. they. were. required. to. go. through. stress. debrief- ings.at.their.precincts;.a.recent.court.case.had.revealed.that.an.officer.was.alcoholic,.and.no.one.

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326 Behavioral Health Response to Disasters

then.trusted.the.confidentiality.of.services.provided.to.them.(13)..It.is.important.to.work.with.the. Employee.Assistance.Programs.that.are.usually.in.place.for.first.responders;.it.is.here.that.they.will. often.turn.

Self-help.groups.for.first.responders.and.others.make.sense.when.near.a.site.as.enormous.as.that. in.New.York.City..The.officers.and.NYFD.firefighters.who.were.in.recovery.found.that.the.self-help. groups.set.up.at.Ground.Zero.were.lifesaving.for.them.(Frank.and.Owens.2002,.12)..Helping.to.find. sites.so.that.these.groups.can.form.is.one.way.to.assist.first.responders.and.to.help.avoid.relapse.for. those.in.recovery.

18.5.4  adolescenT youTh

Youth.who.are.displaced.or.whose.lives.change.drastically.due.to.disaster.are.finally.being.exam- ined. from. a. substance. abuse. perspective,. as. youth. are. the. most. vulnerable. to. early. onset. of. use.. Rohrbach.and.colleagues.(2009).were.already.studying.a.group.of.Lake.Charles,.Louisiana,.youth. just. before. Hurricane. Katrina. hit,. so. baseline. data. were. established.. While. Katrina. spared. Lake. Charles,.Hurricane.Rita.arrived.28.days.later,.and.this.time.it.did.not.bypass.the.area,.but.devastated. it..Youth.here.were.evacuated.(87.percent),.while.6.percent.of.these.students.were.themselves.hurt,. 7. percent. saw. others. hurt,. 2. percent. saw. someone. die,. and. 38. percent. lost. their. homes.. Surveys. administered. at. 7. and. 19. months. post-Rita. showed. increased. use. of. marijuana. that. was. directly. related.to.exposure.to.the.hurricane.as.well. as.an.increase.in.all.alcohol.and.other.drug. use.as.a. result.of.negative.life.events.caused.by.the.hurricane.(222)..

Following.a. café. fire.in. Volendam,. the. Netherlands,. in. 2001,. a. survey.of. adolescent. survivors. by.Reijneveld.and.colleagues.(2003).found.a.significant.increase.in.alcohol.consumption,.with.cor- responding.increases.in.anxiety,.depression,.and.aggressive.behavior..Prior.to.these.studies,.we.are. aware.of.only.one.other.study.that.has.specifically.examined.adolescent.alcohol.use,.especially.binge. drinking,.in.relation.to.disaster..In.1998,.several.devastating.tornadoes.tore.through.Minnesota,.and. researchers.found.that.adolescents.increased.drinking,.especially.those.who.were.older,.who.had. previous.trauma.history,.and.who.already.had.started.drinking..PTSD.symptoms.correlated.with. higher.levels.of.binge.drinking.in.this.sample.(Schroeder.and.Polusny.2004).

18.6  CASE STUDIES

The. following. disaster. responses. by. three. different. states. that. assisted. survivors. with. substance. abuse. problems. both. support. the. lessons. learned. through. the. cited. empirical. studies. and. offer. additional. lessons. for. future. reflection.. The. state. field. reports. discuss. substance. abuse. services. both. within. and. outside. the. FEMA-funded. Crisis. Counseling. Assistance. and. Training. Program. (CCP)..The.CCP.is.a.supplemental.disaster.behavioral.health.response.and.recovery.grant.for.eli- gible.states,.territories,.and.tribes.and.is.administered.through.an.interagency.agreement.with.the. Substance.Abuse.and.Mental.Health.Services.Administration,.Center.for.Mental.Health.Services.. The. CCP. is. unique. in. that. it. focuses. on. both. individual. and. community. recovery. and. relies. on. a. strengths-based,. outreach-oriented,. public. health. model. for. the. provision. of. crisis. counseling. services.. The. CCP. funds. individual. crisis. counseling;. group. crisis. counseling;. basic. supportive. contacts;. public. education;. community. networking;. assessment,. referral,. and. resource. linkage;. development.and.distribution.of.educational.materials;.and.media.messaging.(SAMHSA.nd)..CCP. services. are. typically. provided. by. paraprofessionals. who. are. supervised. by. master’s. level. team. leaders.. Once. grant. funding. is. received,. the. State. Mental. Health. Authorityd. typically. contracts. with.local.community.mental.health.centers.that.have.experience.with.crisis.counseling.and.the. CCP.model..Since.the.CCP.is.the.“primary.mechanism.for.the.federal.government.to.authorize.the. delivery.of.behavioral.health.services.to.disaster-affected.communities.and.individuals”.(Chapter. 3,. this. volume),. addressing. disaster-related. substance. abuse. through. the. CCP. should. be. a. key. objective.for.state.agencies.

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327Disaster and Substance Abuse Services

18.6.1  ioWa disasTer response

The.following.disaster.substance.abuse.response.field.report.is.based.in.part.on.a.questionnaire.sent. to.Karen.Hyatt,.Emergency.Mental.Health.Specialist.for.the.Iowa.Department.of.Human.Services,. Division.of.Mental.Health.and.Disability.Services.and.a.follow-up.interview,.as.well.as.the.state’s. final.CCP.program.report..The.report.describes.the.experiences.of.incorporating.disaster.substance. abuse. services. into. a. CCP. that. was. implemented. in. response. to. widespread. flooding. in. 2008.. Although.the.CCP.can.address.both.disaster-related.mental.health.and.substance.abuse.issues,.it.has. been.a.challenge.to.consistently.address.disaster-related.substance.abuse.within.CCPs..State.men- tal.health.authorities.infrequently.contract.with.substance.abuse.providers.to.offer.CCP.services.. Further,.ambiguity.in.federal.legislation.concerning.crisis.counseling.and.inconsistent.integration.of. state.public.mental.health.and.substance.abuse.prevention.and.treatment.systems.has.contributed.to. a.misconception.that.the.CCP.cannot.address.substance.abuse..Just.as.disaster-related.mental.health. issues.are.addressed.through.the.parameters.of.the.CCP,.disaster.substance.abuse.can.be.addressed. through. the. provision. of. psychoeducation,. supportive. interventions,. substance. abuse. screenings,. referrals.to.traditional.substance.abuse.treatment.when.indicated,.and.networking.with.community. recovery.support.systems.

18.6.1.1  2008: Catastrophic Floods During.the.summer.of.2008,.catastrophic.storms.caused.widespread.flooding.across.most.of.Iowa,. resulting. in. significant. devastation. to. many. communities. and. a. subsequent. presidential. disaster. declaration.(FEMA-DR-1763;.FEMA.2010)..Ultimately,.78.of.Iowa’s.99.counties.were.declared.for. Individual. Assistance. leading. to. the. largest. Crisis. Counseling. Assistance. and. Training. Program. (CCP).in.the.state’s.history..This.program.was.known.as.Project.Recovery.Iowa.and.came.to.provide. both.disaster.mental.health.and.substance.abuse.services.to.31.counties.

In.the.past,.the.State.relied.on.a.single.health.provider.to.offer.statewide.crisis.counseling.ser- vices,.which.sometimes.resulted.in.services.being.offered.by.a.provider.that.was.not.indigenous.to. the.communities.being.served..Project.Recovery.Iowa,.however,.utilized.a.different.service.delivery. strategy.based.on.disaster.behavioral.health.service.provision.by.six.local.mental.health.and.sub- stance.abuse.providers,.in.addition.to.the.Iowa.Concern.Hotline..One.provider,.in.particular,.was. known.for.traditionally.offering.a.wide.range.of.substance.abuse.prevention.and.treatment.services,. including.services.for.adolescents.

The. establishment. of. community-based. partnerships. was. critical. to. the. success. of. Project. Recovery. Iowa. and. helped. to. provide. additional. disaster. substance. abuse. outreach.. Providers. networked.with.groups.such.as.public.libraries,.farm.associations,.and.faith-based.organizations.. One. provider,. in. particular,. established. community-based. partnerships. with. local. substance. abuse.service.centers.well.known.in.several.communities.(Iowa.Department.of.Human.Services. 2009).. The. State. noted. the. success. of. this. new. model. in. its. final. program. report.. “The. Project. Recovery.Iowa.model.that.was.developed.by.the.MHDS.staff.was.clearly.a.best.practice.for.the. State.of.Iowa..For.the.first.time.in.Iowa’s.CCP.grant.history,.community.mental.health.and.sub- stance.abuse.providers.were.contracted.with.to.provide.the.grant.services..Their.knowledge.and. history. assisted. in. the. needs. assessment. necessary. for. outreach. work,. in. the. projection. of. the. needs.of.people.who.had.experienced.the.disaster.events.and.in.the.recruitment.of.people.to.hire. for.Project.Recovery.Iowa.who.were.indigenous.to.the.communities.served”.(Iowa.Department. of. Human. Services. 2009,. 35).. The. strategy. to. utilize. a. variety. of. behavioral. health. providers. supported.both.the.needs.of.local.communities,.as.well.as.fostered.the.delivery.of.CCP.disaster. substance.abuse.services.

Disaster.substance.abuse.services.benefited.greatly.from.Project.Recovery.Iowa’s.use.of.staff.with. professional.substance.abuse.treatment.backgrounds..All.of.the.CCP.team.leaders.at.one.provider. had.professional.substance.abuse.treatment.backgrounds..These.team.leaders.provided.supportive. substance. abuse. interventions. and. referrals. when. needed. and. provided. project-wide. trainings. on.

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328 Behavioral Health Response to Disasters

substance. abuse. issues.. “As. staff. identified. the. training. needs. of. their. Crisis. Counselors,. Team. Leaders.developed.and.provided.additional.in-services..For.example,.instruction.was.provided.on. how. to. conduct. an. educational. presentation,. facilitate. support. groups,. and. assess. for. substance. abuse.and.mental.health.risk.factors”.(Iowa.Department.of.Human.Services.2009,.68).e.In.addition,. some.of.the.outreach.workers.also.had.paraprofessional.substance.abuse.experience.

Project.Recovery.Iowa’s.crisis.counselors.offered.impacted.communities.a.wide.assortment.of. educational.presentations.and.support.groups,.often.targeting.specific.at-risk.populations.for.addi- tional.support.during.the.recovery.process..For.instance,.they.used.a.variety.of.activities.to.engage. students.in.age-appropriate.discussions.of.feelings.associated.with.the.flooding.and.the.impact.on. their.current.lives..In.the.following.example,.issues.of.substance.abuse.in.the.family.were.addressed,. which.led.to.a.discussion.of.the.student’s.hopes.for.the.family..“Students.made.family.crests..One. student.drew.a.beer.bottle,.and.explained.that.after.the.flood.his.dad.was.stressed.out.and.began. drinking.heavily..The.student.explained.that.this.caused.a.lot.of.arguing.and.fighting.in.the.home. and. how. he. hopes. for. peace. because. his.dad.is.going. to. AA.meetings.. This.opened. a.discussion. about.alcoholism,.and.other.students.related.and.shared.their.experiences.with.this.student”.(Iowa. Department.of.Human.Services.2009,.290).

Of. the. many. CCP. services. provided. by. Project. Recovery. Iowa,. the. consistent. administration. of. substance. abuse. screenings. across. providers. was. a. strength. of. the. program.. Project. Recovery. Iowa. crisis. counselors. and. team. leaders. implemented. alcohol. abuse. screenings. for. adults,. along. with. the. adult. mental. health. screenings,. and. adolescents.. However,. challenges. accompanied. the. introduction.of.the.CAGE.Questionnaire.for.adults.(Ewing.1984).and.the.CRAFFT.for.adolescents. (Knight.et.al..1999)..“Initially,.the.crisis.counseling.staff.was.hesitant.to.use.the.screening.tools;. however,.with.further.training.on.how.to.make.an.appropriate.referral,.staff.started.to.use.the.tools.. The.overall.feedback.from.staff.was.that.the.screening.tools.gave.them.a.comfort.level.in.asking. questions.they.were.not.otherwise.comfortable.asking..Once.the.screening.tools.were.in.place,.there. was.a.positive.increase.in.referrals.to.substance.abuse.treatment.services..The.data.[do].not.show,. however,.whether.the.increase.in.referrals.was.because.more.people.screened.high.on.the.questions. or.whether.staff.became.more.comfortable.referring.to.substance.abuse.treatment.services.based. on.the.new.training.and.the.screening.tool”.(Iowa.Department.of.Human.Services.2009,.43)..It.is. notable.that.staff.across.all.Project.Recovery.Iowa.providers.was.trained.in.the.use.of.these.tools.. In.addition,.all.Iowa.Concern.Hotline.counselors.received.training.in.listening.for.potential.clues.of. substance.abuse.and.how.to.appropriately.respond.when.disaster.survivors.presented.with.substance. abuse.issues.

The.Iowa.Concern.Hotline.was.instrumental.in.the.state’s.substance.abuse.response.to.the.floods.. In. illustration,. “Iowa. Concern. received. a. call. from. a. man. with. a. history. of. substance. abuse.. He. stated.that.he.has.been.working.on.his.house.but.it.has.become.an.emotional.burden..He.is.having. trouble.sleeping.and.concentrating,.and.has.had.memory.loss,.admitting.to.‘falling.off.the.wagon.’. He.found.a.PRI.brochure.in.his.door.and.called.Iowa.Concern.for.help..He.said.he.was.relieved.to. find.the.brochure;.it.was.the.answer.he.had.been.looking.for”.(Iowa.Department.of.Human.Services. 2009,.292).

Another.programmatic.element.that.facilitated.the.provision.of.disaster.substance.abuse.services. was. the. importance. given. to. ongoing. needs. assessment.. Early. in. the. program,. Project. Recovery. Iowa.used.a.“pyramid.diagram”.to.target.services.in.which.about.80.percent.of.a.community.ben- efited. from. services. that. were. preventive. and. psychoeducational. in. nature,. about. 15. percent. of. a. community.benefited.from.services.targeted.to.at-risk.populations,.and.about.5.percent.of.commu- nity.members.required.more.intensive.services.based.on.significant.behavioral.health.adjustment. needs.(Iowa.Department.of.Human.Services.2009)..Community.and.at-risk.population.needs.were. continually.assessed.throughout.the.life.of.the.program,. leading.to.observed.variances.over.time. as.well.as.differences.from.one.community.to.another..Such.ongoing.needs.assessment.activities. helped. to. ensure. that. individuals. with. substance. abuse. issues. continued. to. be. among. those. who. merited.special.consideration.throughout.the.program.

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329Disaster and Substance Abuse Services

Project.Recovery.Iowa’s.experience.illustrates.several.important.ways.disaster.substance.abuse. services.can.be.effectively.incorporated.into.a.large-scale.disaster.behavioral.health.response.and. recovery.program..First,.disaster.substance.abuse.services.fit.nicely.within.the.service.parameters. of.the.CCP.and.should.be.viewed.as.a.critical.partner.of.mental.health.services..Second,.valid.and. reliable.substance.abuse.screening.tools.for.both.adults.and.youth.should.be.completed.whenever. mental. health. screening. tools. are. used. and. at. other. times. as. indicated.. Third,. crisis. counselors. should. receive. appropriate. substance. abuse. training. at. the. beginning. of. a. CCP. to. assist. them. to. identify.individuals.with.substance.abuse.problems..And,.finally,.state.disaster.mental.health.and. disaster. substance. abuse. coordinators. should. be. encouraged. to. collaborate. during. the. writing. of. the.CCP.application.in.order.to.maximize.effective.behavioral.health.outreach.efforts,.as.well.as. develop.a.program.responsive.to.both.disaster.mental.health.and.substance.abuse.needs.

As.a.disaster.behavioral.health.response.and.recovery.program.that.has.evolved.over.the.course. of. its. 35-plus-year. history,. the. CCP. is. increasingly. addressing. disaster-related. substance. abuse. issues.. State. public. mental. health. and. substance. abuse. prevention. and. treatment. systems,. which. have.often.operated.independently.of.each.other,.have.continued.to.move.toward.a.unified.behav- ioral.health.model.in.recent.years..As.a.result,.CCPs.will.most.likely.continue.to.engage.providers. with.substance.abuse.expertise..The.Project.Recovery.Iowa.CCP.demonstrated.that.disaster-related. substance.abuse.issues.can.be.addressed.through.the.inclusion.of.substance.abuse.providers,.as.well. as.the.incorporation.of.substance.abuse.trainings,.screenings,.supportive.services,.partnerships,.and. referrals.across.CCP.service.providers.

18.6.2  colorado disasTer response

The. following. disaster. substance. abuse. field. reports. are. based. on. a. questionnaire. sent. to. Katie. Wells,. Disaster. Response. Coordinator. for. Substance. Abuse. with. the. Colorado. Department. of. Human.Services,.Division.of.Behavioral.Health,.and.a.follow-up.interview..The.Colorado.reports. highlight.how.substance.abuse.professionals.can.make.important.contributions.to.the.local.or.state. jurisdiction’s.disaster.behavioral.health.response;.how.collaborative.education.and.cross-training.of. mental.health.and.other.partner.organizations’.workers.can.raise.awareness.of.the.effects.of.disaster. on.substance.use.and.abuse;.and.the.special.role.and.utilization.of.peers.in.recovery.and.12-step. programs.in.disaster.response..The.importance.of.outreach.to.at-risk.populations,.the.building.of. rapport.and.trust.with.survivors.with.substance.use.problems,.and.the.need.to.address.psychological. triggers.that.can.threaten.recovery.and.sobriety.are.also.discussed.

18.6.2.1  2008: Severe Storms and Tornadoes After.a.powerful.tornado.struck.north-central.Colorado.in.May.2008.(FEMA-1762-DR-CO;.FEMA. 2009),. efforts. were. made. to. link. the. Crisis. Counseling. Assistance. and. Training. Program. (CCP). with. a. local. substance. abuse. prevention. coalition,. with. an. increased. focus. on. helping. youth. in. school.settings..The.response.consisted.mostly.of.information.sharing.on.the.location.of.providers,. crisis.intervention.for.individuals.who.were.struggling.with.relapse.and.trauma,.and.basic.support- ive.services.for.those.in.varying.stages.of.recovery..For.individuals.requiring.substance.abuse.treat- ment,. referrals. and. assessments. were. provided,. and. collaborative. partnerships. helped. to. provide. transportation.to.treatment.providers..Many.survivors.were.very.reluctant.to.identify.their.need.for. substance.abuse.services,.so.it.was.a.slow.process..Psychological.First.Aid.was.provided.by.mental. health.staff,.and.substance.abuse.providers.were.consulted.when.a.substance.use.issue.was.discov- ered.. Many. substance. abuse. professionals. helped. by. listening. and. providing. simple,. supportive. interventions.

18.6.2.2  2005: Hurricane Katrina Colorado.was.one.of.many.states.that.received.Hurricane.Katrina.evacuees,.under.a.program.entitled. Colorado.Safe.Haven..Although.the.state.administered.a.CCP.for.the.Katrina.evacuees,.a.substantial.

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330 Behavioral Health Response to Disasters

portion.of.the.substance.abuse.services.provided.was.outside.the.CCP..Evacuees.began.arriving.in. Colorado.on.September.4,.2005;.some.arrived.by.plane.and.were.assisted.by.the.Federal.Emergency. Management.Agency,.and.others.came.on.their.own.using.different.modes.of.transportation..The. state. provided. dormitory. housing,. medical. services,. services. for. pets,. crisis. counseling,. and. all. other. necessities. for. the. evacuees. in. a. 550-room. dormitory. on. Lowry. Air. Force. Base.. Evacuees. were.not.allowed.to.use.alcohol.or.other.drugs.while.at.the.base.

In.addition.to.certified.addiction.counselors.at.the.site.to.provide.support.and.guidance.for.those. seeking.treatment.services.or.access.to.recovery.support.meetings,.the.participation.of.recovering. individuals. from. 12-Step. programs. was. a. key. factor. in. the. substance. abuse. response. to. support. Hurricane.Katrina.evacuees..Approximately.10–12.substance.abuse.responders.from.local.provider. agencies.and.25–30.individuals.from.Alcoholics.Anonymous.and.Narcotics.Anonymous.provided. outreach,. support,. screenings. and. assessment,. and. referrals. to. community. services. for. substance. abuse.treatment..Outreach.included.literature.distribution;.brochures.were.left.at.the.site.for.families. who. needed. referrals. for. medication-assisted. therapy,. detoxification,. or. ongoing. substance. abuse. treatment.services..Educational.materials.were.also.distributed.to.local.schools.where.adolescent. evacuees.attended.to.raise.awareness.of.substance.abuse.problems.and.community.resources..It.was. expected.that.the.first.6–12.months.after.relocation.would.be.the.most.challenging.time.for.evacuees. with.substance.abuse.problems..

Substance. abuse. professionals. and. paraprofessionals. integrated. their. services. within. the. larger. disaster.response.effort.and.worked.effectively.alongside.other.behavioral.health.response.partners. such.as.the.American.Red.Cross.and.the.Colorado.Organization.for.Victim.Assistance..Substance. abuse. workers. explained. the. services. that. recovering. individuals. would. need. and. their. own. roles. and. responsibilities.. They. were. especially. helpful. with. the. referral. process. due. to. their. expertise. and.knowledge.of.community.substance.abuse.treatment.and.detoxification.services..Having.peers- in-recovery.onsite.was.invaluable,.as.they.provided.an.important.support.role.as.evacuees.made.the. transition.to.their.new.location..They.provided.trucks.to.help.evacuees.move,.donated.items.evacuees. needed.in.order.to.get.settled,.and.provided.transportation.to.12-Step.recovery.support.meetings.

18.6.2.3  2002: Wildfires In.Colorado’s.2002.wildfire.disaster.(FEMA-1421-DR-CO;.FEMA.2004),.a.substance.abuse.treat- ment. provider. participated. in. the. CCP. to. help. the. families. impacted. by. the. disaster.. One. of. the. program’s.crisis.counselors.reported.conversations.with.different.survivors.with.substance.use.dis- orders.after.the.fires..One.of.these.survivors.had.lost.everything.and.was.living.in.a.tent..Each.time. the. crisis. counselor. spoke. to. him. he. was. intoxicated. and. refused. help.. Consequently,. behavioral. health. workers. must. face. the. fact. that. survivors. with. substance. abuse. or. mental. health. issues. do. not.always.seek.nor.will.they.accept.help..However,.outreach.workers.can.sometimes.motivate.such. individuals.to.seek.help.by.providing.supportive.interventions,.which.contribute.to.relationships.of. trust.in.which.confidentiality.and.safety.are.assured.

For.the.survivors.who.needed.medication-assisted.therapies,.the.substance.abuse-funded.provid- ers,.known.as.the.Managed.Service.Organizations,.offered.the.assessments.and.services.required. outside.the.CCP..There.was.significant.outreach,.including.door-to-door.canvassing,.to.older.adults. and.non-English-speaking.populations.after.the.fires..Workers.provided.information.in.both.English. and. Spanish. regarding. disaster. preparedness. and. stress. management,. including. how. to. deal. with. painful. reminders. such. as. the. disaster’s. anniversary.. Such. trigger. events. can. test. the. resolve. of. individuals.in.recovery.

The.Division.of.Behavioral.Health.discovered.that.both.large-and.small-scale.disaster.substance. abuse.responses.include.the.importance.of.planning.ahead.of.time.and.knowledge.of.services.avail- able.in.any.given.community..Whatever.can.be.done.to.elevate.the.need.for.an.awareness.of.the.role. substance. abuse. can. have. on. survivors. would. be. helpful.. Due. to. lack. of. training. and. awareness,. nonbehavioral.health.emergency.responders.do.not.often.consider.the.mental.health.and.substance. abuse.issues.with.which.some.survivors.struggle..Therefore,.there.is.a.need.to.train.nonbehavioral.

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331Disaster and Substance Abuse Services

health workers. in. other. disaster. response. agencies. to. increase. their. knowledge. of. the. potential. impact.of.disaster.on.people.in.recovery.or.in.active.addiction..Interagency.collaborations.and.train- ings.should.occur.regularly.so.that.in.the.future,.no.matter.what.the.disaster,.a.community.response. team.would.know.immediately.if.substance.abuse.services.have.been.interrupted.and.to.ensure.a. substance.abuse.professional.is.always.available.and.involved.in.the.disaster.response..Distributing. literature.to.help. responders. and.survivors.alike.recognize.when.an.individual’s.use.is.becoming. problematic.is.an.important.aspect.of.outreach.education..Furthermore,.there.is.greater.recognition. of.the.necessity.for.mental.health.services.postdisaster.than.substance.abuse.services..Training.on. the. stigma. of. substance. abuse. is. important. to. help. mental. health. outreach. workers. to. talk. confi- dently.about.the.subject.of.substance.use.and.abuse.with.disaster.survivors.

18.6.3  MassachuseTTs disasTer response

The. following. disaster. substance. abuse. response. field. report. is. based. on. a. questionnaire. sent. to. Rodrigo.Monterrey,.All-Hazards.Coordinator.for.the.Massachusetts.Department.of.Public.Health,. Bureau.of.Substance.Abuse.Services.(BSAS),.and.a.follow-up.interview..The.field.report.describes. the.experiences.of.substance.abuse.workers.who.assisted.Hurricane.Katrina.evacuees.who.relocated. to.Massachusetts.after.the.storm..Their.experiences.illustrate.the.importance.of.effective.substance. abuse. screening. and. referral. of. survivors;. interagency. collaboration. and. cross-training;. medica- tion.maintenance;.surge.capacity.and.worker.stress.issues..Furthermore,.the.provision.of.disaster. behavioral.health.services.must.occur.within.the.context.of.the.local.or.state.jurisdiction’s.overall. response. to. disaster.. Contrary. to. posing. a. barrier. to. substance. abuse. workers,. such. collaborative. efforts.provide.opportunities.to.raise.awareness.of.survivor.substance.abuse.problems.

18.6.3.1  2008: Hurricane Katrina Evacuees and Response On.August.29,.2005,.Hurricane.Katrina.impacted.the.southeast.Louisiana.coast.with.severe.flood- ing,.damaged.levees,.and,.ultimately,.causing.flooding.and.loss.of.life.in.New.Orleans..Assisted.by. the. Federal.Emergency. Management. Agency,. approximately. 200.evacuees. from. the. greater. New. Orleans.area.began.arriving.in.Massachusetts.by.plane.on.September.8,.2005..Another.100.evacu- ees.arrived.by.other.means.of.transportation..Under.a.program.entitled.Operation.Helping.Hands,. the.state.welcomed,.triaged,.and.temporarily.housed.the.evacuees.at.Otis.Air.National.Guard.Base. on.Cape.Cod,.with.the.BSAS.playing.an.integral.role.in.the.effort..The.newcomers.were.referred.to. as.“guests”.instead.of.the.more.impersonal.term.“evacuees.”

All.guests.arriving.at.Otis.Air.National.Guard.Base.were.given.a.brief.substance.abuse.screen- ing..The.screening.documented.substance.use.history.with.a.focus.on.current.withdrawal.risks..It. included.simple,.straightforward.questions.about.medications.guests.were.taking.or.typical.alcohol. and.other.drug.intake,.in.order.to.prevent.survivors.from.experiencing.withdrawal.symptoms.while. at.the.base..Drinking.or.illegal.drug.use.was.not.allowed.“on.campus.”.Guests.were.instructed.on. the.rules.of.conduct,.compliance.with.which.was.a.prerequisite.for.remaining.in.the shelter.

BSAS. substance. abuse. outreach. workers. primarily. provided. interventions. consistent. with. Psychological.First.Aid,.in.addition.to.ongoing.recovery.support.and.relapse.prevention.interven- tions. for. evacuees. in. recovery.. However,. substance. abuse. education,. screenings,. and. referrals,. as. well. as. transportation. to. and. from. formal. treatment,. were. also. part. of. their. roles.. Specific. tools. were. developed. for. Department. of. Mental. Health. staff. to. conduct. substance. abuse. assessments. effectively.. Based. on. the. substance. abuse. screenings,. three. guests. were. immediately. referred. to. the. State’s. Acute. Treatment. Services. (ATS). or. a. detoxification. facility. following. arrival.. Others. were. monitored. and. offered. support. throughout. their. stay. by. substance. abuse. outreach. workers. who.were.trained.to.engage.clients.who.are.homeless.or.otherwise.unable.or.unwilling.to.access. traditional.office-based.services..A.number.of.other.guests.were.subsequently.referred.to.substance. abuse.treatment.during.the.course.of.their.stay..Additionally,.Alcoholics.Anonymous.was.invited.to. establish.regular.meetings.on.campus..

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332 Behavioral Health Response to Disasters

Guests.on.medication-assisted.therapy.for.opioid.dependence.were.identified.through.the.initial. medical.screening.given.to.all.guests.upon.their.arrival.at.the.base.and.referred.to.a.substance.abuse. provider. for. an. assessment. to. ensure. treatment. continuity.. BSAS. arranged. for. a. licensed. opioid. treatment. provider. to. be. on. the. base. during. the. first. 24. hours. of. guest. intake. to. take. referrals. if. needed..Methadone.was.not.available.on.the.base,.but.several.times.a.day,.shuttle.buses.took.guests. off.the.base.to.collect.their.medications.or.other.needs..There.was.also.a.medical.station.on.the.base. where.guests.could.collect.their.prescription.medications.as.needed..After-action.reports.noted.staff. concerns. about. medication. dosages. as. guests’. preexisting. diagnoses. and. medical. histories. were. typically.inaccessible.after.the.disaster.

Although.the.Massachusetts.substance.abuse.prevention.and.treatment.infrastructure.did.not.suf- fer.physical.damage.due.to.Hurricane.Katrina,.the.influx.of.guests.with.substance.abuse.treatment. needs.tested.the.state’s.surge.capacity..To.mitigate.against.secondary.traumatic.stress,.the.outreach. workers.were.offered.counseling..They.were.also.briefed.and.then.debriefed.at.the.beginning.and. end.of.their.shifts.as.part.of.the.clinical.supervision.and.self-care.support.to.ensure.work.continuity. and.worker.effectiveness.f

The.guests.came.from.a.very.different.culture,.in.many.cases.without.any.local.support.networks. such.as.family,.friends,.neighbors,.spiritual.advisors,.or.work.colleagues..Consequently,.the.BSAS. deployed.a.number.of.bilingual.substance.abuse.outreach.workers..Additional.interpreters.were.also. available.on.campus.and.on.call,.if.needed..Older.adults.were.accommodated.on.the.ground.floors. of.the.residences.and.provided.with.wheelchairs.and.canes,.as.well.as.other.assistive.devices..Many. guests.brought.their.pets.and,.with.the.exception.of.certain.exotic.pets,.most.were.allowed.to.keep. them. in. the. residences.. Families. with. children. were. kept. together. in. a. separate. building.. Sexual. offender/criminal.background.checks.were.completed.to.ensure.guest.safety.

The.Massachusetts.BSAS.operated.within.the.state’s.Incident.Command.System.in.response.to. receiving.evacuees..Most.of.the.nonbehavioral.health.disaster.agency.workers.had.little.knowledge. of. substance. abuse. problems. and. services.. Many. of. them. saw. the. BSAS. as. the. “alcohol. or. drug. police.”.Much.education.was.necessary.as.the.response.was.taking.place.with.nearly.every.entity. involved.with.the.response.and.recovery.coordination.effort..These.collaborations,.however,.raised. awareness.of.substance.abuse,.typical.signs.and.symptoms.of.use.or.abuse,.and.available.commu- nity.resources,.which.contributed.to.greater.resilience.within.the.emergency.management.commu- nity.for.future.disaster.response.

18.7  LESSONS LEARNED

There.are.a.number.of.important.takeaway.points.for.individuals.involved.in.disaster.substance.abuse. planning. and. response.. Research. to. date. and. anecdotal. field. observations. support. that. the. issue. of. substance.abuse.should.be.included.in.any.jurisdiction’s.overall.behavioral.health.response.to.disaster.. Individuals.in.recovery,.especially.early.recovery,.may.relapse.after.disaster.and.need.supportive.inter- ventions.to.maintain.their.sobriety..Additionally,.survivors.who.are.borderline.addicts.or.individuals. in.active.addiction.may.increase.their.consumption.of.substances.after.disaster,.sometimes.with.life- threatening.results..Since.it.appears.that.loss.of.residence.and.lack.of.social.support.are.significantly. related.to.substance.use.problems,.the.homeless.may.need.extra.support.to.prevent.substance.use.from. spiraling.out.of.control..Likewise,.disaster.response.should.incorporate.measures.to.mitigate.against. trigger.events.that.may.impede.the.best.efforts.of.individuals.in.recovery.to.preserve.their.sobriety.

Substance. abuse. professionals. and. paraprofessionals. should. be. included. in. both. the. jurisdic- tional.disaster.behavioral.health.response.and.preparedness.efforts.because.they.are.trained.to.pro- vide.initial.screenings.and.assessments.to.identify.addiction.issues.and.will.be.the.most.familiar. with.available.resources.in.the.impacted.community..Their.actions.should.reflect.an.appreciation. for.cultural.diversity.and.how.culture.can.impact.survivors’.response.to.disaster..Substance.abuse. workers.should.also.be.proactive.in.reaching.out.to.and.collaborating.with.other.partner.organiza- tions.active.in.the.response,.including.providing.education.and.training.to.mental.health.workers.

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333Disaster and Substance Abuse Services

and.nonbehavioral.health.partners.on.the.effects.of.stigma,.recognizing.signs.and.symptoms.of.sub- stance.abuse,.and.building.rapport.and.trust.with.survivors.who.may.be.struggling.with.addiction.

Further,.the.demonstrated.ability.of.peers-in-recovery.to.regroup.quickly.after.disaster.and.their. willingness.to.provide.support.to.survivors.facing.similar.issues.should.not.be.overlooked..Disaster. planners. would. be. wise. to. engage. in. discussion. with. groups. such. as. Alcoholics. Anonymous. or. Narcotics.Anonymous.and.to.augment.the.jurisdictional.disaster.response.and.develop.Memoranda. of.Understanding.with.other.recovery.support.organizations.

Catastrophic.disasters.pose.special.concerns.because.they.can.destroy.or.indefinitely.delay.sub- stance. abuse. infrastructure. and. services.. Even. when. disasters. do. not. destroy. or. delay. use. of. the. substance.abuse.infrastructure,.providers.need.to.have.surge.capacity.and.sufficient.ability.to.con- tinue.medication-assisted.therapies.to.avoid.dangerous.consequences.for.survivors..Therefore,.the. emergency. planning. needs. of. opioid. treatment. providers. should. be. factored. into. local. and. state. preparedness.activities..Further,.opioid.treatment.providers.need.to.have.protocols.for.guest-dosing. in.place.prior.to.disaster.because.medical.records.may.be.unavailable.afterwards.

18.8  NATIONAL DEVELOPMENTS

Fortunately,.some.of.the.disaster.substance.abuse.lessons.learned.are.being.applied.on.the.national. level.. Since. the. events. of. 9/11,. disaster. substance. abuse. responses. benefited. from. several. initia- tives. and. developments.. State. and. territory. planning. for. the. substance. abuse. impact. of. disasters. increased.and.is.becoming.more.integrated.with.mental.health,.emergency.management,.and.public. health.planning..In.addition,.experience.with.the.impact.of.terrorism.and.large-scale.disasters.led.to. efforts.to.ensure.that.patients.receiving.medication-assisted.therapy.can.get.medication.safely.and. effectively.after.a.disaster..Finally,.there.is.a.substantial.increase.in.the.number.of.identified.state. and.territory.disaster.substance.abuse.or.behavioral.health.coordinators.over.the.last.several.years.

18.8.1  disasTer suBsTance aBuse planning

Effective.response.to.the.substance.abuse.impact.of.disasters.depends,.in.large.part,.on.best.practice. disaster. substance. abuse. preparedness. and. planning. efforts. at. the. state,. territory,. and. local. levels.. This.promotes.further.integration.of.disaster.substance.abuse.planning.with.overall.state.and.territory. disaster.mental.health,.emergency.management,.and.public.health.plans..One.important.catalyst.for. increased.and.coordinated.disaster.substance.abuse.planning.was.the.SAMHSA.Targeted.Capacity. Expansion. Grants. to. Enhance. State. Capacity. for. Emergency. Mental. Health. and. Substance. Abuse. Response,.also.known.as.the.State.Capacity.Expansion.(SCE).grants,.which.were.initiated.in.2003.and. ended.in.2006.for.most.states.participating.in.the.initiative..These.grants.were.a.direct.outgrowth.of.the. 9/11.terrorist.attacks,.which.highlighted.the.need.for.coordinated.mental.health.and.substance.abuse. responses.to.disasters.that.are.integrated.with.the.larger.emergency.management.and.public.health. responses..Thirty-four.states.and.the.District.of.Columbia.received.the.grants,.a.primary.deliverable. of.which.was.the.development.of.a.state.all-hazards.plan.that.required.“coordinated.mental.health.and. substance.abuse.emergency.planning.and.capacity.development.activities”.(Donato.and.Mosser.nd,.2).

Prior.to.the.SCE.grants,.only.four.states.participating.in.the.SCE.grant.initiative.had.a.unified. disaster.behavioral.health.plan.that.addressed.both.disaster.mental.health.and.substance.abuse.pre- paredness,.with.an.additional.three.states.holding.a.disaster.substance.abuse.plan.that.also.addressed. mental. health. concerns.. A. final. review. of. the. state. all-hazards. plans. submitted. under. the. grants. indicated.improved.disaster.substance.abuse.planning.evidenced.by.26.states.with.a.unified.disaster. behavioral.health.plan,.two.states.with.separate.disaster.mental.health.and.substance.abuse.plans,. four. states. with. disaster. mental. health. plans. that. also. addressed. substance. abuse,. and. one. state. with. a. disaster. substance. abuse. plan. that. also. addressed. mental. health. (Donato. and. Mosser. nd).. SAMHSA. is. continuing. to. promote. integrated. best-practice. disaster. substance. abuse. all-hazards. planning.for.states.and.territories.that.is.compliant.with.the.National.Incident.Management.System.g

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334 Behavioral Health Response to Disasters

18.8.2  digiTal access To MedicaTion

One. important. program. that. resulted. from. lessons. learned. from. the. 9/11. terrorist. attacks. is. the. SAMHSA. Center. for. Substance. Abuse. Treatment’s. (CSAT). Digital. Access. to. Medication,. or. D-ATM.initiative..The.attacks.led.to.the.destruction.of.one.opioid.treatment.provider.(OTP).and.the. closure.of.several.others.in.lower.Manhattan..The.disruption.in.medication-assisted.therapies.and. the.subsequent.impact.on.roughly.1,000.patients.is.well.documented.in.the.Frank.and.Owens.(2002). report.mentioned.earlier.in.this.chapter..As.a.result,.SAMHSA.CSAT.collaborated.with.stakehold- ers,. including. the. Committee. of. Methadone. Program. Administrators. and. patient. representatives,. to. plan. for. a. secure,. Web-based. database. that. would. allow. a. patient. to. be. effectively. and. safely. guest-dosed.at.an.OTP.other.than.their.home.clinic.in.an.emergency..Later,.the.arrival.of.Hurricane. Katrina.evacuees.at.guest.OTPs,.many.of.whom.came.with.no.identification,.reinforced.the.need. for. both. effective. guest-dosing. protocols. and. the. development. of. the. D-ATM. project,. which. was. initiated.in.the.fall.of.2005..D-ATM.utilizes.a.biometric.identifier.based.on.a.patient’s.finger.scan. so.that.a.guest.OTP.can.verify.that.the.patient.is.in.treatment.at.another.D-ATM.participating.OTP. and.can.receive.information.on.the.patient’s.medicinal.history..The.home.OTP.is.also.notified.of.the. patient’s.request.for.guest.dosing,.the.dosage.provided,.and.the.frequency.of.guest.dosing..Patient. participation.in.D-ATM.is.strictly.voluntary.and.the.system.is.designed.with.a.high.degree.of.secu- rity.to.protect.the.patient’s.personal.information,.which.is.only.accessed.at.the.request.of.the.patient.. Currently,.D-ATM.is.in.phase.III.pilot.testing.with.plans.to.eventually.make.the.project.available. to.OTPs.nationwide.h

18.8.3  disasTer suBsTance aBuse preparedness and response coordinaTion

Many.states.and.territories.have.increased.their.personnel.resources.devoted.to.the.coordination.of. disaster.substance.abuse.preparedness.and.response..Known.as.disaster.substance.abuse.coordina- tors,.virtually.no.states.or.territories.held.such.a.position.before.9/11..However,.by.2006,.at.least.six. states.had.coordinators.serving.in.this.role,.and.as.of.this.writing,.17.state.or.territory.disaster.sub- stance.abuse.coordinators.were.identified.by.the.SAMHSA.Disaster.Technical.Assistance.Center,. with.an.additional.29.state.or.territory.disaster.behavioral.health.coordinators.holding.responsibili- ties.for.both.mental.health.and.substance.abuse.disaster.preparedness.and.response.

18.9  CONCLUSION

This.chapter.used.several.methods.to.raise.awareness.of.disaster.substance.abuse.including.a.review. of.recent.literature,.field.observations.from.several.state.responses.to.disaster,.and.discussion.of.sev- eral.important.state.and.federal.initiatives.that.incorporated.some.of.the.lessons.learned.from.prior. disasters..Although.the.practice.of.disaster.substance.abuse.is.a.relatively.new.field.of.study,.current. research.suggests.that.use.of.substances.after.disaster.increases.and.survivors.in.recovery.may.be.at. greater.risk.of.relapse..We.believe.the.information.presented.in.this.chapter.will.stimulate.the.appe- tites.of.both.readers.and.behavioral.health.researchers..Much.more.research,.including.longitudinal. studies.in.particular,.is.needed.to.understand.the.relationship.between.disasters.and.substance.use. and.abuse..It.is.our.hope.that,.having.shed.light.on.disaster.substance.abuse,.others.will.continue.to. refine.interventions.and.practices.that.will.improve.the.health.and.well-being.of.disaster.survivors. with.substance.use.problems.

NOTES

. a.. Meals.Ready.to.Eat.(MREs).are.prepackaged,.individual.meals.bought.by.the.U.S..military.for.use.in. combat.and.other.field.deployments.where.food.facilities.may.be.unavailable.

. b.. PL-104-321;. see. http://www.fema.gov/pdf/emergency/nrf/EMACoverviewForNRF.pdf. for. additional. information.about.the.EMAC.

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335Disaster and Substance Abuse Services

. c.. See.the.Centers.for.Disease.Control.(CDC).Web.site.at.http://www.cdc.gov/phpr/stockpile.htm.for.infor- mation.about.the.Strategic.National.Stockpile.(SNS).

. d.. State.Mental.Health.Authority.(SMHA),.42.U.S.C..§.201.

. e.. The.term.in-services.refers.to.intraorganizational.trainings.offered.by.CCP.staff.

. f.. The.debriefings.were.not.based.on.Critical.Incident.Stress.Debriefing,.however.(see.Mitchell.1983).

. g.. Information. concerning. the. National. Incident. Management. System. can. be. found. at. http://www.fema. gov/emergency/nims/.

. h.. See. the. SAMHSA. D-ATM.Web. site. for. additional. information. on. this. important. project:. http://datm. samhsa.gov.

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