Good morning Mr. Chairman and Members of the Subcommittee. I want to thank you for the opportunity to testify and provide the Subcommittee with information on the operation and effectiveness of SAMHSA's programs.
It is an exciting time for the fields of substance abuse and mental health. We have established SAMHSA over the past seven years as a critical component of our Federal health and human service system and have improved substance abuse prevention and treatment, and mental health service programs across the country. Never before has the potential been so great and pride in our efforts so strong.
In particular, I want to thank Department of Health and Human Services Secretary Donna Shalala for her leadership, guidance and support. Her commitment to ensuring that substance abuse and mental health services are a visible and vital part of comprehensive health and human services for children, youth and families is unsurpassed. In the area of substance abuse, we welcome the added leadership and support the Director of the Office of National Drug Control Policy (ONDCP), General Barry McCaffrey, has brought to our work. SAMHSA and ONDCP staff work together daily to coordinate Federal demand reduction efforts to achieve the goals of the President's National Drug Control Strategy. In the area of mental health, we are pleased that the Surgeon General, Dr. David Satcher, has focused the spotlight on our work to improve mental health and provide services for mental illness. Through the publication of the first ever Surgeon General's Report on Mental Health, he has made mental health services a national priority.
We also acknowledge and appreciate the work of our State partners and the organizations representing the State agencies responsible for substance abuse and mental health services: the National Association of State Alcohol and Drug Abuse Directors (NASADAD) and the National Association of State Mental Health Program Directors (NASMHPD). Their efforts have helped guide and shape SAMHSA's work to fulfill its mission. We further appreciate the recognition of the importance of our work by the U.S. Conference of Mayors, American Public Health Association, Council of State Governments, National League of Cities and the many other groups that have supported this Agency and helped it exercise its leadership role.
SAMHSA ROLE AND RESPONSIBILITY
To understand the role and responsibility of SAMHSA, it is important to examine the Agency's history. As Federal investments have advanced the fields of substance abuse prevention, addiction treatment and mental health, the organizational structure of Federal programs responsible for continuing the progress has changed. Most recently, SAMHSA was created in 1992 as a result of the growing recognition by our Nation's leaders that increasing access to quality substance abuse and mental health services is central to improving national health and productivity. Before 1992, the major Federal substance abuse and mental health services delivery and research activities were combined under one agency, the Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). Through bipartisan legislation, Congress created SAMHSA under Public Law 102-321 on October 1, 1992. This reorganization of ADAMHA moved the research institutes - National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA), and the National Institute of Mental Health - that were part of ADAMHA to the National Institutes of Health. The service components of ADAMHA were configured to create SAMHSA.
To achieve SAMHSA's mission - to improve the quality and availability of substance abuse prevention, addiction treatment and mental health services in the U.S. - we have developed a balanced, four-part strategy:
- Support and maintain State service systems through block and formula grants;
- Cultivate a system responsive to current and emerging needs through Targeted Capacity Expansion (TCE) grants;
- Improve service system performance and quality through Knowledge Development and Application (KDA) grants; and
- Provide accountability through evaluation and data collection.
Consistent with your request, most of the examples in my remarks on the implementation of our four-part strategy focus on SAMHSA's substance abuse programs. I'm sure you will agree, the findings of the recent year-long GAO survey of our drug abuse treatment efforts provides a good place to start. Let me summarize. Clearly, at the individual, community and national health policy levels, Federal investments in prevention and treatment are both a cost-effective and beneficial response to substance abuse. Prevention does reduce substance abuse. Treatment does help people triumph over addiction and lead to recovery. And, SAMHSA's staff is to be commended for working in partnership with the States, communities and public and private sector organizations to achieve national goals and to develop model programs; to coordinate Federal policy related to providing prevention and treatment services; and to evaluate the process, outcomes, and community impact of prevention and treatment services. That is why SAMHSA was established by Congress and that is what SAMHSA is accomplishing.
NATIONAL STRATEGY TO REDUCE DRUG USE IS WORKING
As the data attest, our four-part strategy is reaping dividends. The encouraging findings from SAMHSA's 1998 National Household Survey on Drug Abuse (NHSDA), coupled with findings from NIDA's Monitoring the Future Survey, show that drug use among teens is no longer on the rise; in fact, it may be declining. 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, SAMHSA must continue a balanced deployment of resources into each one of our four program areas - Block Grant, TCE, KDA and evaluation. SAMHSA's achievements to date confirm the importance of federally supported drug abuse prevention and treatment programs; the achievements of our TCE and KDA program highlight the fact that our programs offer States and communities models of more effective and efficient ways to accomplish results.
For example, the National Treatment Improvement Evaluation Study (NTIES), a congressionally mandated, 5-year evaluation of substance abuse treatment programs, funded by SAMHSA's Center for Substance Abuse Treatment (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 percent reduction in criminal activity, decreases in homelessness (down 43 percent), and increases in employment (up almost 20 percent). High-risk sexual behaviors were lowered by 56 percent; health care visits for alcohol- or drug-related purposes also declined following substance abuse treatment.
SAMHSA's Services Research Outcomes Study (SROS), based on a nationally 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 corroborated by other studies, among them, a NIDA study of over 10,000 clients who received treatment in 96 programs in 11 large U. S. cities. In the study the Drug Abuse Treatment Outcomes Study (DATOS) NIDA 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;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.
Substance abuse treatment is among the most cost effective of all medical treatments. Returns on every dollar invested in treatment 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.
Our achievements in substance abuse prevention are also substantial. Just this year, SAMHSA's Center for Substance Abuse Prevention (CSAP) released findings from its landmark 48-community study with almost 80,000 participants that found statistically significant reductions in drug and alcohol abuse among males in communities with anti-drug partnerships funded by CSAP. Findings from our High-Risk Youth Demonstration Grants Program show ways to achieve significant reductions in alcohol, tobacco and illicit drug use among the youth. These results highlight that positive change can be achieved related to youth substance abuse. These changed include: enhanced ability to refuse drugs and resolve conflicts, reduced school failure and improved attendance; and improved communications between parents and their children. We have joined forces with Boys and Girls Clubs of America to use what we have learned to reach millions of young people and their families across the country with effective prevention programs.
Despite the Nation's recent successes in preventing and treating substance abuse, we are far from declaring victory. Unfortunately, the stigma of substance abuse and mental disorders persists. Lack of health insurance parity for substance abuse and mental health services, combined with limited government resources, prevent people in need from receiving treatment. The result, according to SAMHSA's National Household Survey on Drug Abuse, is that 3.6 million people in severe need of substance abuse treatment do not receive the help they need. These individuals all to often end up in other publicly funded, but far more expensive systems, including the welfare and criminal justice systems, where substance abuse and mental problems are not addressed adequately, if at all.
The demographics of substance abuse are also changing. We often think of substance abuse as the province of adolescence and early adulthood, of boys and not girls. Well, girls have caught up to boys and trends in substance abuse across the age span may well change as the baby boomer generation ages. As the youth of the 1960s grow older, 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 were for previous generations. In fact, if we combine the aging of current drug users with the continuation of current rates of first-time drug use, we can 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. Our current systems are not prepared for an aging group of drug users. At the same time treatment for teenagers, male or female, is far from its potential. These projections and unmet needs combined with the potential costs to society argue strongly for a prevention and treatment approach that balances the need to simply fund prevention and treatment services with the need to improve and target those services.
The Federal role is clear. The findings from Knowledge Development and Application (KDA) grants offer service providers and purchasers of prevention and treatments services, including Federal, State and local government access to improved, more efficient and effective prevention and treatment models. Targeted Capacity Expansion (TCE) grants offer a way to target prevention and treatment services to the areas of greatest need. Block Grants provide a way to help support States and to maintain their prevention and treatment delivery systems.
SUPPORTING STATE PREVENTION AND TREATMENT SYSTEMS
Among the Nation's most important tools available to increase the capacity to deliver quality services and to implement new findings are the Substance Abuse Prevention and Treatment (SAPT) and Mental Health Block Grants. To increase State flexibility, SAMHSA has proposed to transform these Block Grants into Performance Partnerships. The proposal developed in collaboration with the organizations representing State agencies responsible for substance abuse and mental health services, NASADAD and NASMHPD would increase State flexibility by allowing States to set their own priorities for expenditures and management of Block Grant funds.
For example, we propose consolidating 12 required criteria for the Mental Health Services Block Grant plan into five. This will make it easier for the States to complete their plans, and reduce administrative expenditures, while still focusing on the important aspects of community-based mental health services for adults with serious mental illness and children with serious emotional disturbance.
For the SAPT Block Grant, we are proposing to increase flexibility by reducing the number of mandatory requirements and by creating conditional waiver authority for the Secretary of the Department of Health and Human Services for some provisions, such as tuberculosis services, the set aside for pregnant addicts and mandatory treatment for intravenous drug users. To maintain the focus on services for the particular populations specified in the statute, a State waiver would be conditioned on meeting criteria established by the Secretary in cooperation with the States and published in the Federal Register. Legislation to reauthorize SAMHSA and to implement these changes in the Block Grants has been adopted in the Senate and is pending action in the House.
Part of the 5 percent SAPT Block Grant set aside is used by SAMHSA for targeted technical assistance to help States improve service delivery systems and the quality of the services delivered. In 1999, technical assistance resulted in 66 percent of States making systems, program or practice improvements 16 percent above SAMHSA's 1999 goal. The words of State Substance Abuse Authority Directors speak volumes about the value of SAMHSA's 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.
Technical assistance offered by SAMHSA is based on requests from the States. SAMHSA does not determine what States need. States specify the topics of interest and, sometimes, who should do the training. To ensure that States have access to requested training and services, SAMHSA draws on a nationwide network of top-notch trainers. From the kinds of technical assistance requested by the States, it is very clear that the States vary in their ability to collect and analyze data on cost, organization, human resources and, especially, outcomes data. So, 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 driving under the influence (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 percent were employed at discharge, and nearly 75 percent were reported to be substance use- free at discharge.
Through TOPPS II, a 19-State effort to develop a standardized approach to measure block grant client outcomes is underway. 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, including number of clients served and functional outcomes in the areas of increased employment and decreased involvement with the criminal justice system, will both support SAMHSA and State efforts to increase their flexibility in the use of Block Grant funds and provide enhanced accountability for the expenditure of these funds.
CULTIVATING A SYSTEM RESPONSIVE TO CURRENT AND EMERGING NEEDS
While vital to the support and maintenance of State systems, Block Grant funds are based on a formula set by Congress that does not allow the flexibility to target funds based on need. Therefore the Block Grant funds are only part of a comprehensive Federal 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 (TCE) 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 have emphasized the need for Federal leadership to provide a rapid and strategic response to the demand for services that are regional or local in nature.
CSAT's TCE grants do just that. They target cities, counties, tribes and other entities that have identified a need and are rapidly able to 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. Targeted Capacity Expansion grants already are providing treatment for women in three rural regions of Colorado, outpatient methadone treatment in Chicago, detoxification services in Philadelphia, and 147 additional treatment slots for heroin users in Orlando. One major requirement of this grant program is that services must be coordinated with State efforts to target 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.
Through CSAP's State Incentive Grants for Community-based Action program we are now working with Governors in 20 States and the Mayor of the District of Columbia to develop state/city-wide strategies and deliver science-based substance abuse prevention services. A full 85 percent of funds provided by this program are being directed to community prevention programs, resulting in the funding of approximately 1500 communities in the 21 jurisdictions. Three High-Risk Youth prevention programs developed by CSAP are identified as among the top 10 programs implemented by these communities. Others are implementing family strengthening approaches for substance abuse prevention developed by NIDA.
IMPROVING SERVICE SYSTEM PERFORMANCE AND QUALITY
We can multiply the Block Grant and TCE dividend in terms of people served and positive outcomes by applying the new knowledge learned from SAMHSA's Knowledge Development and Application (KDA) grant program. Investments in KDAs allow us to determine more effective and efficient ways to deliver substance abuse and mental health services. KDAs also play a key role in connecting the findings from research funded by the National Institutes on Health and others, to the delivery of everyday health care services.
For example, CSAT has launched an initiative to determine the effectiveness of the MATRIX program, a model methamphetamine treatment program developed and proven to be efficacious for various populations by a NIDA grantee. CSAT is also investing in improving treatment services available for adolescents and adults dependent on marijuana. The Marijuana Treatment Project shows that brief treatment two sessions produces a significant reduction in smoking behavior and that extended treatment nine sessions produces significant levels of both abstinence and smoking reduction. 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 reductions 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.
Thanks to SAMHSA KDA activities, significant strides were made in learning how to provide better treatment for women and children through our Pregnant and Postpartum Women (PPW) and Residential Women and Children's(RWC) programs. 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 after treatment was 0.3 percent, far below the expected rate for substance-abusing women, and lower than the national average of 0.7 percent.
Because the effectiveness of current treatment models is not well established for adolescents, CSAT is currently working with NIAAA to identify effective treatment interventions for adolescents who abuse alcohol and for those who have become alcoholics. SAMHSA's Center for Substance Abuse Prevention is also working with NIAAA to examine the effects of alcohol advertising on underage drinking and to develop effective interventions to prevent and reduce alcohol-related problems, including deaths, among colleges students.
SAMHSA is working with the Food and Drug Administration and NIDA to increase access to, and improve the quality and accountability of methadone and levomethadyl acetate hydrochloride (ORLAAM) treatment for people with heroin addiction. Improving access to and quality of treatment will be accomplished by moving from the current regulatory environment to a system that combines program accreditation, based on standards developed by CSAT, with statutory requirements.
Several mechanisms are used by CSAT to disseminate findings from research and KDAs. 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 our Addiction Technology Transfer Centers (ATTCs). To improve treatment services, ATTCs develop curricula, provide regionally-based training and consultants, sensitive to area needs. CSAT also continues to develop its highly successful Treatment Improvement Protocols (TIPs) publication series that provide best practice models to the treatment field.
The extraordinary progress during the past few years in understanding substance abuse prevention, addiction treatment and mental health services is clearly having an impact. However, just as Federal investments are needed to continue to improve services available for the prevention and treatment of cancer, HIV/AIDS, heart disease, diabetes and other chronic conditions, continued investments are needed to improve services available for the prevention and treatment of substance abuse and mental illnesses. Thus, Federal investments are needed to continue evaluation, to improve efficiency and effectiveness of prevention and treatment models, to help educate substance abuse and mental health professionals about the best practices available, and to ensure that prevention and treatment strategies are relevant and focused on the specific cultural needs of our increasingly diverse population. These and other service delivery issues are being addressed at the request of States and others through SAMHSA's KDA grant program.
The fourth part of our strategy is used to inform the President, the Congress and the American people on our program performance. Our Government Performance and Results Act (GPRA) plan incorporates the four-part strategy that encompass all of SAMHSA's budget activities. We continue to invest considerable staff, time, and dollars to ensure that data are available to assess the results of our efforts and to help us improve our services in these four areas. 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 and national information on mental health. The analysis of trends over time from the expanded Household Survey, in combination with other data sources, will provide an invaluable tool to direct future investments, especially through the SAPT Block Grant; to measure outcomes of the National Drug Control Strategy; and to report our progress to Congress.
We are always working to ensure SAMHSA management and program resources are being optimized. Since SAMHSA was established, a number of changes have occurred in SAMHSA staff allocation that have improved efficiency and emphasized support for our programs and initiatives. The most significant of these occurred during Fiscal Year 1996. The House Appropriations Committee, in its report on the 1996 SAMHSA budget request (House Report 104-209), noted the following:
"...the Committee is concerned about the level of duplication of activities supported with program management resources. For instance, each of the three operating agencies as well as the Office of the Administrator retain budget, public relations and congressional affairs operations - functions which should more appropriately be centralized within the Office of the Administrator. Accordingly, the Committee directs SAMHSA to reexamine its administrative structure and to streamline management of the agency to improve efficiency, reduce duplication of effort, and contain costs."
In response, SAMHSA undertook a significant restructuring effort. The majority of administrative functions that were spread across the Agency were consolidated within the Office of Program Services (OPS), a new SAMHA-level unit outside of the Office of the Administrator responsible for servicing all SAMHSA components. Duplication of effort was eliminated as a result. Staff dedicated to contracts management, grants management, administrative services and certain aspects of financial management were combined with those administrative services that already had been centralized in Fiscal Year 1993 (Human Resources and Information Resources Management). Economies achieved through consolidation permitted substantial FTE savings; a 25-30 percent staff reduction accrued from the resulting economies of scale; and the number of administrative offices was reduced from 20 to only 7. Through these administrative consolidations, 44 FTEs were saved which were then transferred back to the Centers for program purposes. The reorganization also reduced the size of the immediate Office of the Administrator to its present size of 7 staff members.
The FY 1997 House Appropriations Committee Report noted that:
"The Committee commends the agency for the difficult decisions it has taken to downsize and streamline its operations to improve productivity and efficiency with limited resources."
Beyond the centralization of administrative functions and transfer of 44 FTEs to the Centers for program purposes in 1996, there have been no real or relative staffing increases for any offices outside of the Centers. Neither have there been any formal changes in oversight practices or operational controls resulting in amendments to the delegations of authority accorded Center Directors. In fact, SAMHSA has a record of excellent internal controls and has not been cited as deficient in this regard in any of its audit findings or in reports of the Inspector General or the General Accounting Office.
It is clear that each new generation of American youth presents us with new challenges. Each new scientific advance in substance abuse prevention, addiction treatment and mental health services provides new options. And these options need to be translated and applied to every-day, real-life practices in order to improve the quality and availability of substance abuse prevention, addiction treatment and mental health services. SAMHSA's Knowledge Development and Application program is the Federal tool specifically designed to make progress and improve services in our Nation's communities. Our Targeted Capacity Expansion program is working to cultivate a system responsive to current and emerging needs. Our Block Grants are the vehicles available to leverage adoption of best practices and to support and maintain the quality services provided by the States. In summary, SAMHSA's unique role in the Federal government results in benefits to the American people.
I'm optimistic and enthusiastic about what the future holds for our ability, with the Congress's help, to address some of the Nation's most costly and devastating problems. Again, Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. I'll be pleased to answer any questions you may have.
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