March 30, 2004
Mr. Chairman and Members of the Subcommittee, good morning. I am Charles G. Curie, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (HHS).
In this testimony, I will describe how SAMHSA and its State and community partners are working to provide effective substance abuse treatment to people who want and need it. Key to that effort is how we are measuring the effectiveness of those efforts.
The need for substance abuse treatment services in our Country cannot be overstated. According to SAMHSA's National Survey on Drug Use and Health, in 2002, 22.8 million people age 12 and older needed treatment for a serious alcohol problem or a diagnosable drug problem. Only 2.3 million of them received specialized treatment for an alcohol or illicit drug problem.
Over 85 percent of people with untreated alcohol and drug problems felt they did not require care. Further, of the 1.2 million people who reported that they did feel they needed treatment for their alcohol or drug problem but did not receive it, 446,000 reported that they made an effort but were unable to get treatment; 744,000 reported making no effort to get treatment. The result of these findings is continued substance addiction; potential loss of health, employment and education; and possible criminal involvement, all at significant human and economic cost. All of this requires us to acknowledge that we need to build more capacity while using the existing treatment infrastructure to better serve those who seek and need substance abuse treatment. With a historic focus on this objective by the President, Congress responded to this call and funded an innovative new program - Access to Recovery. Your focus now on quality of the system as a whole is both timely and important.
We have compelling data that show that Federal investments in prevention and treatment are 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. For example, SAMHSA's National Treatment Improvement Evaluation Study (NTIES), a congressionally mandated, 5-year evaluation of substance abuse treatment programs, found a 50 percent reduction in drug use among clients one year after treatment. Clients included in this evaluation study were from underserved populations and included minorities, pregnant and at-risk women, youth, public housing residents, welfare recipients, and those in the criminal justice system. NTIES also reported a nearly 80 percent reduction in criminal activity, a 43 percent decrease in homelessness, and a nearly 20 percent increase in employment.
SAMHSA's Services Research Outcomes Study (SROS), with a nationally representative sample, found similar outcomes five years following treatment.
Our findings are corroborated by other studies, among them, the Drug Abuse Treatment Outcomes Study (DATOS), a National Institute on Drug Abuse (NIDA) study of over 10,000 clients who received treatment in 96 programs in 11 large U. S. cities. NIDA found that, following treatment, patients dramatically reduced their drug use, reduced drug-related criminal activities, and improved their physical and mental health.
As we acknowledge the state of the science with respect to addiction, we have come to the inexorable conclusion that addiction is indeed a disease. It is unlike many diseases in that a significant challenge to its diagnosis and successful treatment is denial. We also know that the earlier we diagnose the problem of addiction, the more cost-effective and successful are the outcomes. To help overcome that denial, SAMHSA has begun to invest in a program of early detection and treatment, a regimen of Screening, Brief Intervention, and Referral to Treatment. We know treatment works, and it is cost-effective. We also know that innovation in treatment is necessary to increase effectiveness, quality, and efficiency.
While substance abuse treatment is clearly effective, we must also work to prevent substance abuse in the first place. As you know, the President set aggressive goals to reduce drug use in America. Today, with effective prevention efforts, rates of substance use among the Nation's youth are dropping. The data confirm that the President's two-year goal has been exceeded. According to the HHS Monitoring the Future Survey, released this past December by NIDA, drug use declined 11% over the past two years among students in 8th, 10th and 12th grades. That finding translates into around 400,000 fewer teen drug users over the two-year period. This decline in substance use among our Nation's youth suggests that our work, joined with that of the Office of National Drug Control Policy, and the extensive community-based work of schools, parents, teachers, law enforcement, religious leaders, and local anti-drug coalitions, together, is having an effect.
THE SAMHSA ROLE
SAMHSA is working to improve how we approach substance abuse treatment and prevention, not only at the Federal level, but also at the State and community levels. During my tenure, we have restructured our work around the vision of a life in the community for everyone and our mission of building resilience and facilitating recovery.
To focus and to guide our program development and resources, we have developed a Matrix of program priorities and cross cutting principles that pinpoints SAMHSA's leadership and management responsibilities. These responsibilities were developed as a result of discussions with members of Congress, our advisory councils, constituency groups, people working in the field, and people working to obtain and sustain recovery.
The Matrix priorities are also aligned with the priorities of President Bush and HHS Secretary Tommy Thompson whose support for our vision of a life in the community for everyone we appreciate.
THE ACE PRINCIPLES
To accomplish our priorities SAMHSA is building our programs around three key principles: accountability, capacity, and effectiveness - ACE. These are the very issues at the heart of the hearing today.
To promote accountability, SAMHSA tracks national trends, establishes measurement and reporting systems, develops standards to monitor service systems, and works to achieve excellence in management practices in addiction treatment and substance abuse prevention. We are demanding greater accountability of our grantees in the choice of treatment and prevention interventions they set in place and in the ways in which program outcomes meet the identified needs for services. We will promote accountability from States that receive funds from the largest single funding source for treatment dollars, SAMHSA's Substance Abuse Block Grant, through the Performance Partnership Grants.
By assessing resources, supporting systems of community-based care, improving service financing and organization, and promoting a strong, well-educated workforce that is grounded in today's best practices and known-effective interventions, SAMHSA is enhancing the Nation's capacity to serve people with or at risk for substance use disorders
SAMHSA also helps assure service effectiveness by assessing delivery practices, identifying and promoting evidence-based approaches to care, implementing and evaluating innovative services, and providing workforce training. For example, our National Registry of Effective Programs - with over 50 known-effective programs in prevention and early intervention - provides a foundation on which States and communities can build to meet prevention needs and reduce treatment needs. And our Treatment Improvement Protocols (TIPS) bring the latest knowledge about effective interventions, including treatment for adolescents, co-occurring disorders, and treatment for older adults, to professionals in the field. By utilizing, in the broadest way possible, the medical infrastructure of the Nation to diagnose and refer those addicted to drugs and alcohol, we ensure that those who suffer from the disease of addiction are identified and treated as early as possible, thus increasing the likelihood of a successful recovery.
To measure our effectiveness and be accountable, we must have the capacity to gather and analyze data about our programs. We are continuing to build on our national surveys, such as the National Survey of Drug Use and Health, the Drug Abuse Warning Network and the Drug and Alcohol Services Information System, to measure our programs' effectiveness, and, at the same time, we are working with States to build the infrastructure to capture and evaluate those measures.
NATIONAL OUTCOME DOMAINS
Working in collaboration with States and other stakeholders, SAMHSA has reviewed our discretionary and block grant programs, examining their ability to capture and assess treatment and prevention outcomes. The result has been the identification of and global agreement on seven key outcome domains that emphasize real results for people with or at risk for mental and substance use disorders, instead of focusing on outcomes related to the effects on systems needs or regulatory requirements.
By using the same outcome domains and their measures over time to assess progress, States and SAMHSA can foster continuous program and policy improvement. By using the same national outcome domains across all of SAMHSA's State and community-based programs, we will be able to report nationally aggregated data in standard periodic and special reports. We will know, as will you, OMB, and the public, with significant precision, whether the service system is improving and whether we are meeting the President's goals to reduce substance abuse nationwide. Moreover, we will be able to identify - and you will be able to know about - gaps or issues that need to be addressed at the national level through program, regulation, or statute. Our grantees, and SAMHSA, in turn, will be accountable for positive results. Perhaps most critically, we will be able to see just how well we are promoting recovery and the vision of a life in the community for everyone.
Let me share, briefly, each of the seven domains on which we will gather outcome information related to substance abuse prevention and treatment:
Each domain represents an outcome that you, SAMHSA, and the American people expect from successful substance abuse treatment systems. More important, these are the outcomes that help people obtain and sustain recovery.
ACCESS TO RECOVERY
Providing people with the opportunity to obtain and sustain recovery is at the heart of the President's Access to Recovery Initiative. Access to Recovery, a new substance abuse treatment-related discretionary grant program, will foster consumer choice, improve service quality, and increase treatment capacity by providing individuals with vouchers to pay for the substance abuse clinical treatment and recovery support services they need. This program was funded at nearly $100 million in FY 2004, and the President has requested $200 million in his FY 2005 budget. Vouchers, coupled with other State-operated programs, such as the Block Grant program, provide an unparalleled opportunity to create profound change in substance abuse treatment financing, service delivery and accountability in America. Change will also be driven by the first time use at the Federal level of the seven domains previously discussed to measure and manage performance of this grant program.
Clearly, moving forward with these measures is a challenge for a variety of reasons. However, we already have identified and resolved many of the potential obstacles, in large part through the deliberate, iterative process between SAMHSA and the States. By keeping the number of key domains to a minimum - seven in this case - and by using domains for which measures already are in place in many States, we have relieved a potential burden on States and communities in providing performance outcome data.
OUTCOME DOMAINS IN REAL-TIME: KEY SAMHSA PROGRAMS
The utility of these seven domains extends across all SAMHSA grant programs, from the Substance Abuse Prevention and Treatment Block Grant program - the largest portion of SAMHSA's budget - to our discretionary grant programs.
We are looking at what data we now are collecting. We are asking why we are collecting it. And, we are asking how are we using it to manage and measure performance. If we do not use it, we need to lose it. Let me mention a few examples of just how we are changing our focus on measuring performance and accountability for substance abuse services.
Performance Partnership Grants: As you are aware, SAMHSA has been working at the request of Congress to move its Substance Abuse Prevention and Treatment Block Grant program into Performance Partnership Grants, with an emphasis on performance outcomes. Rather than design a stand-alone Performance Partnership program, SAMSHA is committed to improving the management of the block grant programs - and both State accountability to SAMHSA and our accountability to you - by focusing data collection and outcome assessment on the seven core domains described earlier and providing States with clear, but limited, requirements and standards for National outcome data collection.
Critically, States have shared in the identification of these domains, and, to a large degree, consensus on their use has been achieved. Clearly, State reporting on these outcome domains will need to be phased in over time. A careful and full assessment of State capacity in this area is being undertaken, as are ways to set State outcome goals and targets. At the same time, SAMHSA is providing targeted technical assistance on data collection, reporting, and analysis. During this transition, States will be encouraged to report outcome data on each of the seven domains on a voluntary basis.
Discretionary Grant Programs: As measures of program effectiveness, the seven domains also will be used to assess the performance of existing discretionary grant programs. Critically, this includes the new Access to Recovery substance abuse treatment program for which grant applications are now being solicited from States, Territories, the District of Columbia, and Tribal Organizations.
SAMHSA is firmly committed to bringing accountability for performance into each and every one of its programs. We concur with Congress that such accountability is at the heart of good program design and program management. We will judge our programs on their progress in achieving positive outcomes across each of these domains and hope you will judge SAMHSA's work similarly.
Concurrent with these efforts, SAMHSA is shifting from cohort data collection to client-matched data for all of its grant programs, whether block or discretionary, collecting this data on a real-time basis. Consistent with applicable information technology architecture and privacy parameters, we have been building a data infrastructure at SAMHSA and are continuing to work with States to build their data infrastructures to promote better accountability not just for where the dollars are being spent, but how effectively those dollars are being used.
We have invested significant resources to help prepare SAMHSA and the States to report on these measures in substance abuse treatment and prevention, including prevention's Minimum Data Set and State Incentive Grant programs, and treatment's Treatment Outcomes and Performance Pilot Studies (TOPPS I and II), which built upon States' systems reporting data via the Treatment Episode Data Set (TEDS).
SAMHSA's Data Strategy Group is now developing final recommendations on these and other data investments to help ensure that our dollars and programs are working to achieve their intended goals of resilience and recovery for people with or at risk for substance use disorders.
By assessing program effectiveness and performance with the proposed seven domains of recovery, SAMHSA, States, communities and this Subcommittee can gain a powerful tool to guide future policies and program direction, thus serving as a key feedback loop to inform both program and policy. Only through performance measures can States be assured that the community-based substance abuse prevention, addiction treatment, and mental health services programs that they are supporting are working, and working well. Only through performance measures can SAMHSA know that it is working successfully to achieve its vision of a life in the community for everyone and its mission of building resilience and facilitating recovery. Only through performance measures can you assess whether SAMHSA is using its resources wisely to reduce the toll of substance abuse on the Nation.
Thank you for the opportunity to appear before the Subcommittee. I would be pleased to respond to any questions you may have at this time.
Last Revised: November 1, 2004