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Testimony on SAMHSA Oversight Hearing by Camille Barry, Ph.D., R.N.
Deputy Director, Center for Substance Abuse Treatment
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Before the House Committee on Government Reform, Subcommittee on Criminal Justice, Drug Policy, and Human Resources
February 17, 2000

Good morning Mr. Chairman and Members of the Subcommittee. I am Camille Barry, Deputy Director of the Substance Abuse and Mental Health Services Administration's (SAMHSA) Center for Substance Abuse Treatment (CSAT). I am accompanied today by George Gilbert, Director of CSAT's Office of Policy Coordination and Planning.

The Substance Abuse and Mental Health Services Administration was established (as a successor to the Alcohol, Drug Abuse, and Mental Health Administration) by Congress under Public Law 102-321 on October 1, 1992. Our mission is to strengthen the Nation's health care capacity to provide quality substance abuse and mental health prevention, diagnosis, and treatment services. While an agency of national scope, SAMHSA prides itself on its deep state and local roots. We work in partnership with States, communities, and private organizations to address the needs of people with substance abuse problems and mental illness where they live. While we support the local implementation and evaluation of treatment initiatives, we also have a keen interest in helping States and communities understand and work with the individual and community risk factors that contribute to these illnesses or protect against them.

To achieve these priorities and to improve the quality and availability of substance abuse prevention, addiction treatment and mental health services in the U.S., SAMHSA has developed a balanced four part strategy that supports the agency's Government Performance and Results Act (GPRA) goals. SAMHSA strategy is to work to: 1) support and maintain State service systems through block and formula grants; 2) cultivate a system responsive to current and emerging needs through Targeted Capacity Expansion (TCE) grants; 3) improve system performance and service quality through Knowledge Development and Application (KD&A) grants; and, 4) provide accountability through data collection.

Put in its simplest terms, SAMHSA programs put research findings into practice ­ bringing new science-based knowledge to community-based prevention, identification, and treatment services. The results are being measured by the marked improvement in how this Nation is responding to substance abuse and mental illness. The results are being measured in health care dollars saved, workplace absenteeism reduced, and educational opportunities reclaimed. Perhaps most important, the results of our efforts are being measured in human lives changed for the better -- parents and children, elders and youth.

In general, we agree with the findings of the year-long GAO survey of our drug abuse treatment efforts. Clearly, at the individual, community, and national health policy levels, treatment is both a cost-effective and beneficial response to substance abuse. Treatment does lead to recovery. Treatment does help people triumph over addiction. Our aim is to ensure that more people have access to what we know are effective treatments.

Despite the clear cost-effectiveness of substance abuse treatment, not everyone in need of care receives it. According to the National Household Survey on Drug Abuse (NHSDA), 5.7 million Americans abusing or dependent on drugs need treatment. Today's publicly funded treatment system can meet the needs of only 2.1 million of them. The result ­ 3.6 million people in severe need of substance abuse treatment are left with few, if any, options. These individuals all too often end up in other publicly funded, but far more expensive systems, including the welfare and criminal justice systems, where mental health and substance abuse problems are not adequately addressed, if dealt with at all. SAMHSA is working to make every door, including primary care, and the welfare and criminal justice systems, an open portal to substance abuse services for people in need.

Without continued aggressive investment in prevention and treatment we can predict a coming tidal wave. We often think of substance abuse as the province of adolescence and early adulthood. However, trends in substance abuse across the age span may well change as the baby boomer generation ages. As these youth of the 1960s age, the number of older persons who abuse illicit drugs and alcohol may increase simply because the rates of substance abuse for this age group are higher than they are for previous generations of elders. In fact, if we combine the aging of current drug users with the continuation of current rates of first-time drug use, we project a 57 percent increase in the need for drug abuse treatment by 2020. To maintain a level demand for treatment, we would need an immediate 50 percent reduction in first time drug use. These predictions argue strongly for increased attention and investment in substance abuse treatment capacity.

That's why we help educate dedicated substance abuse and mental health professionals about best practices in treatment. That's why we work to ensure that treatments are targeted toward the specific culture and needs of various populations. And that's why we undertake continuous evaluation and improvement of treatment interventions.

SAMHSA is no less determined than you, or the GAO, are to ensure that Federal monies for treatment are both well spent and yield results. To this end, our efforts to promote monitoring of treatment outcomes will continue unabated. Our resolve to provide the most efficient accountability for the Federal funds over which we are stewards is unswerving. SAMHSA's balanced four-part action strategy that supports our Government Performance and Results Act (GPRA) goals serves as the bedrock upon which these efforts are built.

Our strategy is beginning to reap dividends. The encouraging findings from SAMHSA's 1998 National Household Survey on Drug Abuse (NHSDA) coupled with several even more recent reports show that drug use among teens is no longer on the rise; in fact, it may be declining for the first time in decades. The news has energized both SAMHSA and the field. We know that what we do is making a difference. For that reason we know we must not rest; we cannot rest.

The President's drug control strategy has set an aggressive target to reduce drug use to the lowest levels ever recorded by 2007. If we are to hit the mark, we must continue our strategic deployment of programs proven to reduce substance abuse nationwide. SAMHSA's achievements to date attest to the effectiveness of federally supported drug abuse treatment programs; the achievements highlight the fact that our programs offer States and communities models of more effective and efficient ways to accomplish results.

We know that substance abuse treatment is effective. The National Treatment Improvement Evaluation Study (NTIES), a congressionally mandated 5-year evaluation of substance abuse treatment programs funded by CSAT, found a 50 percent reduction in drug use among clients one year after treatment. The clients included in this evaluation study were from vulnerable and underserved populations (minorities, pregnant and at-risk women, youth, public housing residents, welfare recipients, and those in the criminal justice system). They may well have been among the most difficult-to-treat people abusing substances. NTIES also reported up to an 80% reduction in criminal activity, decreases in homelessness (down 43 percent), and increases in employment (up almost 20%). High-risk sexual behaviors were lowered by 56%; health care visits for alcohol- or drug-related purposes also declined following substance abuse treatment.

SAMHSA's Services Research Outcomes Study (SROS), a national representative sample of treatment programs, found similar outcomes five years following treatment. SROS reported a 21 percent decrease in the use of any illicit drug, a 14 percent decrease in alcohol use, a 28 percent decrease in marijuana use, a 45 percent decrease in cocaine use, and a 14 percent decrease in heroin use.

The NTIES findings are also corroborated in other studies, among them, a National Institutes on Health study of over 10,000 clients who received treatment in 96 programs in 11 large U. S. cities. This study ­ the Drug Abuse Treatment Outcomes Study (DATOS) ­ found that following treatment patients dramatically reduced their drug use, reduced drug-related criminal activities, and improved their physical and mental health. Treatments included the four most common types of programs--outpatient methadone, outpatient non-methadone, short-term inpatient, and long-term residential care. According to DATOS, heroin use by clients enrolled in methadone treatment dropped 70 percent, and clients enrolled in both long-term residential and outpatient drug free treatment reported a 50 percent decrease in cocaine use at the 1-year follow up interview.

Even more striking, substance abuse treatment is among the most cost effective of all medical treatments. Returns on investments range from $4 to over $11 saved in other medical and social costs. In just one year, the State of Minnesota saved $28.7 million in medical, hospital, psychiatric, driving under the influence (DUI), and justice costs, recovering over 67 percent of its investment in treatment. Washington State reported a 50 percent decrease in medical expenses for individuals who received substance abuse treatment compared to those not getting treatment ¯ down from $9,000 per year to $4,500 per year. Oregon, found that each dollar invested in substance abuse treatment produced savings of $5.60.

Stop to consider the relative effectiveness of treatments for other chronic illnesses ­ for example, diabetes, cancer, heart disease. The successes in our field rival -- if not surpass -- the successes in other fields of medicine. Just as this Nation should never give up on the fight against cancer, we cannot rest in our endeavor to bring even more effective treatment to those in need. Nor must we rest in our effort to deter substance abuse in the first place.

To capitalize on the cost-effectiveness of substance abuse treatment and to close the gap between need and availability, SAMHSA's CSAT has launched a new initiative Changing the Conversation: The National Plan to Improve Substance Abuse Treatment. This initiative is designed to: 1) close the treatment gap, 2) reduce stigma and change attitudes, 3) improve and strengthen treatment systems; 4) connect services and research, and 5) address workforce issues. A series of stakeholder meetings were held, bringing research and treatment professionals together, and six regional public hearings which were held across the nation received testimony from more than 425 witnesses. This effort will lead to a comprehensive report that will be the foundation to guide subsequent program planning for CSAT and future action for the treatment field. While the final report for the National Treatment Plan is not expected until early this summer, CSAT has received a wealth of information and innovative recommendations that we have already begun to address in our activities and programs, and will continue to build into future strategies for improving substance abuse treatment.

The Substance Abuse Prevention and Treatment (SAPT) Block Grant remains the primary tool the Federal government utilizes to support and expand substance abuse prevention and treatment services. Due to the leveraging-effect the Block Grant has on State and local governments, total treatment capacity through publicly-funded programs in FY 2001 will serve an estimated 900,000 persons. Federal funding for public substance abuse treatment facilities ranges from a low of 11 percent in one State to a high of 84 percent in another. The gap between need and services will grow absent increased funding to accommodate higher service costs and provide additional services capacity. In addition to the direct support of services, a portion of the 5 percent set-aside under the Block Grant is used for targeted technical assistance to help States improve service delivery systems and the quality of services delivered. In 1999, technical assistance resulted in 66 percent of States making systems, program or practice improvements ­ 16 percent above our 1999 goal.

The words of State Substance Abuse Authority Directors speak volumes about the impact of our technical assistance efforts:

"First it increased collaboration across multiple systems for one of our counties. Also, the data integration technical assistance helped us demonstrate the efficiency of our system. This led to a budget increase by the legislature of $30 million dollars. This happened because we had good research that proves that what we are doing saves lots of acute care and psychiatric care. For every 2.5 million spent by us, the state saves 4.8 million in other health care costs."
"It has improved our ability to improve services to Medicaid populations and has bolstered our changes that are underway."
"The technical assistance has helped to get training which has helped us get results."

SAMHSA has worked with the States to develop a core set of outcome indicators applicable to the SAPT Block Grant. OMB recently approved our proposed changes to the Block Grant uniform application to permit voluntary collection of treatment outcome data from States beginning with Fiscal Year 2000. States are being asked to collect and submit client outcome data in four areas or domains: criminal activity, employment status, living status, and alcohol and drug use.

In addition, through its Treatment Outcomes and Performance Pilot Studies (TOPPS I) program, CSAT supported a 14-state series of pilot studies to analyze performance and outcomes for specific components of selected state substance abuse treatment systems. Oklahoma, for example, found that two-thirds of those with DUI convictions 18 months before treatment had no DUI convictions within 18 months following treatment; 62 percent of treatment clients in another study improved their economic status. Preliminary results from Maryland show that over 40% percent of clients successfully completed treatment, more than 70% were employed at discharge, and nearly 3/4 were reported to be substance use free at discharge.

Through TOPPS II, we are supporting a 19-state effort to develop a standardized approach to measure block grant client outcomes. The participating states have developed a 31-item core data set to measure specific outcomes across the states, and data collection has begun on representative samples of over 19,000 clients. Common indicators include number of clients served and functional outcomes in the areas of increased employment and decreased involvement with the criminal justice system.

Legislation reauthorizing SAMHSA has been adopted in the Senate and is pending actoin in the House. This legislation permits further development, implementation, and evaluation of performance and outcome measures under the Block Grant. In exchange it gives States greater flexibility by reducing set-asides and enhancing their ability to direct services to underserved populations within the State, in accord with States' needs assessment activities and community input.

While vital to the support and maintenance of State systems, block grant funds are only part of the comprehensive approach needed to help communities address emerging drug use and related public health problems, including HIV/AIDS and Hepatitis C, at the earliest possible stages.

SAMHSA's Targeted Capacity Expansion program gives States and communities the tools needed to aggressively contain emerging problems before they intensify. Mayors, town and county officials, the Congressional Black and Hispanic Caucuses and Indian Tribal Governments all emphasized to us the need for Federal leadership in providing this rapid and strategic response capacity to the demand for services that are regional or local in nature.

CSAT's Targeted Capacity Expansion grants for substance abuse treatment address the regional and local nature of drug abuse by targeting states, cities, counties, tribes or other entities that identify a need for and can rapidly put into place effective treatment services for emerging drug epidemics. For example, these grants may be used to respond to the outbreak of methamphetamine use that has spread across the West and Southwest, as well as dramatic heroin use increases reported in localized areas.

At the proposed FY 2001 funding level, we anticipate awarding about 100 new grants to help communities target services for their vulnerable populations, including substance abusing women and their children, youth, the homeless, people with both substance abuse and mental disorders, and rural populations. We are also targeting improved substance abuse treatment services for African Americans and Hispanics with or at risk for HIV/AIDS.

We are also proposing to expand the scope of CSAT's program to include a new focus on making it easier to enter treatment. Large proportions of alcohol and drug users are found in populations served by a variety of health and human service agencies. Primary care organizations, social service agencies, mental health, welfare, and child welfare agencies, jails and detention centers each contain significant numbers of drug- and/or alcohol-dependent individuals. Evidence suggests that many people seeking treatment do so outside of specialized substance abuse treatment programs. The FY 2001 proposal would implement inter-organizational models to improve access to substance abuse services from other health, human service, and criminal justice organizations.

The dividend in terms of people served and positive outcomes achieved from Block Grant and Targeted Capacity Expansion investments can be amplified still further with the application of knowledge gleaned from SAMHSA's Knowledge Development and Application (KDA) program. Investments in KDAs allow us to determine even more efficacious and cost-effective ways to deliver substance abuse and mental health services. KDAs are also critical for connecting the findings from laboratory research funded by the National Institutes on Health and others, to the needs of our citizens through the delivery of everyday health care services. Without the bridge that SAMHSA provides, the benefits from federal investments in bench science and biomedical-behavioral research will not reach our citizens or achieve full potential in a timely manner.

For example, CSAT has launched an initiative to determine the effectiveness of available methamphetamine addiction treatments for various populations and the cost effectiveness of the various treatment approaches. CSAT is also investing in improving treatment services available for adolescents and adults dependent on marijuana. Because the effectiveness of current treatment models is not well established for adolescents, we are working to identify effective treatment interventions for adolescents who abuse alcohol and those who have become alcoholics.

We have made significant strides in learning from our KDA activities how to provide better treatment for women and children through our Pregnant and Postpartum Women (PPW) and Residential Women and Children's (RWC) programs, as well as our marijuana treatment grants. Preliminary findings from CSAT's KDA-supported cross-site evaluation of the RWC/PPW program strongly support the value of residential substance abuse treatment for pregnant women in reducing adverse birth outcomes and infant mortality. The rate of low weight births among PPW clients was 5.7 percent, far lower than the 30 percent average rate for drug-exposed infants and below the national rate of 7.5 percent. Perhaps the most startling finding was that the percentage of reported infant deaths among PPW clients was 1.5 percent, twice the national average of 0.7 percent, prior to entering treatment. The rate of infant mortality after treatment was 0.3 percent, far below the expected rate for substance-abusing women, and lower than the national average.

The Marijuana Treatment Project shows that brief treatment of two sessions produces a significant reduction in smoking behavior and extended treatment of nine sessions produces a significant proportion of abstinence and smoking reduction as well. Both brief and extended treatment interventions are more effective than no treatment. In a similar assessment of marijuana treatment for adolescents, preliminary pilot studies have demonstrated reduction in marijuana use with five interventions. In untreated adolescents, marijuana use typically accelerates until age 20, with out-patient treatment reducing or leveling the slope of increasing use.

Based on the recommendations of the Institute of Medicine, SAMHSA is working with the Food and Drug Administration and the National Institutes of Health to increase access to, and improve the quality and accountability of methadone and levo-alpha-acetyl-methadol (LAAM) treatment for people with heroin addiction. Improving access and quality of treatment will be accomplished by moving from the current regulatory environment to a system that will combine program accreditation with statutory requirements. What is most important is that SAMHSA is moving from a system of process oversight to one that requires performance and outcome measures for more comprehensive and effective substance abuse treatment.

SAMHSA's extraordinary progress during the past few years in understanding addiction treatment is already having an impact. It is clear, however, that much work is ahead of us in the areas of improving system performance and service quality. We also must pursue the answers to such questions as: why people become involved in substance abuse; what causes people to avoid or delay seeking treatment for substance abuse; which treatments are the most effective in the real world as compared to research settings; why treatment is effective for some, but not for others; how to improve access to quality care for those individuals with both a mental and addictive disorder; and how we can make treatment more relevant to individual needs, cultures and situations.

One other important activity I want to mention is the concept of improving the dissemination of research in practical terms that can be used by clinicians and counselors in the real world. This is carried out in CSAT through several major efforts. For example, the Practice/Research Collaborative program brings together researchers, providers, and other community leaders to identify and prioritize the problems that need to be researched to meet community needs. Another component of this effort is the expansion and broadening of an existing network of curriculum developers, trainers, and consultants that is regionally-based and sensitive to the needs of that region. This activity is known as the Addiction Technology Transfer Centers (ATTCs) program. It provides training and technical assistance resources and generally enhances the capacity of the service system to provide effective treatment.

Also in this area, CSAT has embarked upon a major dissemination effort through the Knowledge Application Program (KAP), which, in part, will continue and enhance the development of our highly successful Treatment Improvement Protocols (TIPs) that provide best practice models to the treatment field.

Finally, we will continue to inform the President, the Congress and the American people on program performance. Our Government Performance and Results Act (GPRA) Plan incorporates programmatic goals that encompass all of SAMHSA's activities, including the area of treatment outcomes and accountability. We continue to invest considerable staff, time, and dollar resources to ensure that data are available to evaluate the results of our efforts and to help us improve our services.

In particular, a significant investment is being made to expand the National Household Survey on Drug Abuse. The expanded survey, already underway, will provide enhanced national estimates of substance abuse and, for the first time, comparable State-level estimates of substance abuse. The analysis of trends from the expanded Household Survey, in combination with other data sources, will: provide an invaluable tool to help direct future investments, especially through the Substance Abuse Block Grant; measure outcomes of the National Drug Control Strategy; and report our progress to Congress.

SAMHSA's ongoing strategy is the balanced, tested, and proven approach needed to improve the quality and availability of substance abuse treatment in the U.S.

Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. Mr. Gilbert and I will be pleased to answer your questions regarding SAMHSA's substance abuse treatment activities and programs.

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