April 26, 2005
Mr. Chairman and Members of the Subcommittee, as Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA) within the U.S. Department of Health and Human Services (HHS), I am pleased to present SAMHSA's role in achieving the demand reduction goals contained in the President's National Drug Control Strategy.
We have an aggressive agenda at SAMHSA that is driven by our vision and mission. Our vision of "a life in the community for everyone" and our mission to "build resilience and facilitate recovery" are clearly aligned with the priorities of both President Bush and Health and Human Services (HHS) Secretary Michael Leavitt.
Our collaborative efforts with our Federal partners, States and local communities, and faith-based organizations, consumers, families and providers are central to achieving both our vision and mission and at the same time upholding fiscal responsibility and good stewardship of the people's money. Together, we are working to ensure that the 22.2 million Americans with a serious substance abuse problem, the 19.6 million Americans with serious mental illness, and the 4.2 million Americans with co-occurring serious mental illness and substance abuse problems have the opportunity for fulfilling lives that include a job, a home, and meaningful relationships with family and friends.
It is abundantly clear that many of our most pressing public health, public safety, and human services needs have a direct link to mental and substance use disorders. The obvious link is why HHS has a strong focus on prevention efforts and building treatment capacity. By one estimate, substance abuse, including alcohol, illicit drugs, and tobacco use, costs our Nation more than $484 billion per year. (Dorothy P. Rice, Sc.D., University of San Francisco, 1995, as updated by the National Institute on Drug Abuse (NIDA) and the National Institute on Alcoholism and Alcohol Abuse (NIAAA), 1998.)
The good news is, in the 21st Century, we have compelling data that demonstrate prevention and treatment work. And recovery should be the expectation, not the exception. At SAMHSA we have aligned our resources to provide solutions to urgent public health problems while building systemic change.
SAMHSA's direction is clearly depicted on our Matrix of program priorities and cross-cutting management principles that guide program, policy, and resource allocations of the Agency. The priorities on the SAMHSA Matrix 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. Among its many purposes, the Matrix guides our critical efforts in prevention as well.
A NATIONAL PROBLEM - A NATIONAL STRATEGY
Substance abuse prevention and treatment are clear priorities for Secretary Leavitt. The Administration has embarked on a strategy that has a three-pronged approach: stopping drug use and addiction before they start, healing America's drug users, and disrupting the market for illegal drugs. SAMHSA has a lead role to play in the demand reduction side of the equation - that is - to help stop drug use before it starts - through education and community action and healing America's drug users by getting treatment resources where they are needed.
I am pleased to report that our strategy is working. By focusing our attention, energy, and resources, we as a nation have made real progress. The most recent data from the 2004 Monitoring the Future Survey, funded by NIDA, confirms that we are steadily accomplishing the President's goal to reduce teen drug use by 25 percent in five years. The President set this goal with a two-year benchmark reduction of 10 percent. Last year we met and exceeded that goal. Now at the three-year mark, we have seen a 17 percent reduction and there are now 600,000 fewer teens using drugs than there were in 2001.
Additionally, the most recent findings from SAMHSA's 2003 National Survey on Drug Use and Health clearly confirm that more American youth are getting the message that drugs are illegal, dangerous, and wrong. For example, 34.9 percent of youth in 2003 perceived that smoking marijuana once a month was a great risk, as opposed to 32.4 percent of youth in 2002. This is an indication that our partnerships and the work of prevention professionals, schools, parents, teachers, law enforcement, religious leaders, and local community anti-drug coalitions are paying off. Yet, we can and must do more to reduce illegal drug use, alcohol abuse and tobacco use in America.
Fortunately, we know more about what works in prevention, education and treatment than ever before. Over the years, we have shown prevention programs produce results. The evidence continues to mount. Prevention reduces the numbers of individuals who become dependent on drugs, and it deters substance abuse in the first place. We know that when we push against the drug problem it recedes, but we also know our work is far from over. In addition to our ongoing work to reduce the use of illicit drugs and abuse of prescription drugs, we continue to be very concerned about underage use of alcohol. In particular, rates of underage drinking have not changed much at all over the years; these rates have remained stubbornly persistent at unacceptably high levels.
In 2003, about 10.9 million young people ages 12 to 20 reported current alcohol use. That is almost 30 percent of all children and youth in that age group. Of them, nearly 7.2 million were binge drinkers; 2.3 million were heavy drinkers. And they drank even though we all know underage drinking is unhealthy, dangerous, and illegal.
We also all know that it is never too early to begin educating about the dangers of underage alcohol use. For example, more than one-quarter, 1.8 million, of alcohol-dependent adults, age 21 or older in 2003, had first used alcohol before age 14. Over eighty percent, 5.1 million, had first used before they were age 18. Ninety-six percent, 6.0 million, had first used before age 21.
To address this problem, HHS has formed the Interagency Coordinating Committee on the Prevention of Underage Drinking, which has conducted a thorough review of existing Federal efforts and has identified opportunities for collaboration to address this problem. Our goal is to implement appropriate steps to create and sustain a strong national commitment to prevent and reduce underage drinking.
As we acknowledge the state of the science and research with respect to addiction, we have come to the conclusion that addiction is indeed a disease. And as with other diseases, like diabetes, heart disease, and cancer, much can be done to prevent the onset of illness - in this case, addiction - from occurring in the first place. For example, our new Screening, Brief Intervention, Referral, and Treatment (SBIRT) program allows States to intervene early with nondependent users and stop drug use before it leads to addiction. SBIRT is designed to expand the continuum of care available to include screening, brief interventions, brief treatments, and referrals to appropriate care. By placing the program in both community and medical settings such as emergency rooms, trauma centers, health clinics, and community health centers, the program can reach a broad segment of the community at large. In addition, SAMHSA has recently designed and implemented its Strategic Prevention Framework.
STRATEGIC PREVENTION FRAMEWORK
President Bush has called upon the U.S. Department of Health and Human Services to realize his vision of a Healthier US, in which its citizens use the power of prevention to help them live longer, healthier lives. Whether we speak about abstinence or rejecting drugs, tobacco, and alcohol; promoting exercise and a healthy diet; preventing violence; or promoting mental health, we really are all working towards the same objective - reducing risk factors and promoting protective factors.
SAMHSA's Strategic Prevention Framework is based on the risk and protective factor approach to prevention. For example, family conflict, low school readiness, and poor social skills increase the risk for conduct disorders and depression, which in turn increase the risk for adolescent substance abuse, delinquency, and violence. Protective factors such as strong family bonds, social skills, opportunities for school success, and involvement in community activities can foster resilience and mitigate the influence of risk factors. People who work in communities with young people and adults understand the need to create an approach to prevention that is citizen centered, cuts across existing programs, system levels, and funding streams, and share common outcome measures.
I have seen the results of operating without a framework numerous times, firsthand. I have had the privilege to visit many cutting-edge prevention programs. I have been tremendously impressed, but I also have walked away frustrated time and again. I see prevention programs competing for dollars from multiple Federal, State, local, public and private sector funding streams - all of which have specific and, very often, competing requirements. Each alone provides a stream of funding; if combined under the framework, together they can produce an ocean of change.
To align and focus prevention resources at the State and local level, SAMHSA awarded 5-year Strategic Prevention Framework grants to 19 States and 2 territories last year. We expect to continue these grants and fund new grants in FY 2006 for a total of $93 million. These grants are working with our Centers for the Application of Prevention Technology to systematically implement a risk and protective factor approach to prevention across the Nation.
The success of the framework rests in large part on the tremendous work that comes from grass-roots community anti-drug coalitions. That is why we are pleased to be working with ONDCP to administer the Drug-Free Communities Program. This program supports approximately 750 community coalitions across the country.
Consistent with the Strategic Prevention Framework and the Drug Free Communities grant programs, we are transitioning our drug-specific programs to a risk and protective factor approach to prevention. This approach provides States and communities with the flexibility to target their dollars in the areas of greatest need.
Moving the Framework forward has required and will continue to require the Federal Government, States, and communities to work in partnership. Under the new grant program, States will provide leadership, technical support, and monitoring to ensure that participating communities are successful in implementing the five-step public health process that is known to promote youth development, reduce risk-taking behaviors, build assets and resilience, and prevent problem behaviors across the life span. The five steps are:
First, communities assess their mental health and substance abuse-related problems including magnitude, location, and associated risk and protective factors. Communities also assess assets and resources, service gaps, and readiness.
Second, communities must engage key stakeholders, build coalitions, organize and train, and leverage prevention resources.
Third, communities establish a plan that includes strategies for organizing and implementing prevention resources. It must be based on documented needs, build on identified resources, and set baselines, objectives, and performance measures.
Fourth, communities implement evidence-based prevention efforts specifically designed to reduce the risk and promote protective factors identified.
Finally, communities will monitor and report outcomes to assess program effectiveness and service delivery quality, and to determine if objectives are being attained or if there is a need for correction.
The success of the Strategic Prevention Framework will be measured by specific national outcomes that are true measures of whether our programs are helping people achieve our vision of a life in the community. These National Outcome Measures (NOMs) emphasize ten domains that were based on a history of extensive dialogue with our colleagues in State mental health and substance abuse service agencies and, most importantly, the people we serve.
The ten key domains are: (1) abstinence from drug use and alcohol abuse, or decreased mental illness symptomatology/improved functioning; (2) increased or retained employment and school enrollment; (3) decreased involvement with the criminal justice system; (4) increased stability in housing conditions; (5) increased access to services; (6) increased retention in services for substance abuse treatment or decreased utilization of psychiatric inpatient beds for mental health treatment; (7) increased social connectedness to family, friends, co-workers, and classmates; (8) client perception of care; (9) cost effectiveness of services; and (10) use of evidence-based practices.
These NOMs are already being implemented through the Strategic Prevention Framework grants, and we are rapidly moving to implement the consistent use of these measures across all of SAMHSA's programs. The NOMs will allow us to identify what is and is not working, assist in the targeting of resources, and more easily and readily translate into action what is proven to work in prevention.
SCIENCE TO SERVICE
To speed the delivery of science into the prevention and treatment service delivery systems, SAMHSA developed a Science to Service Initiative in 2002. The overarching goal is to facilitate the rapid implementation of effective, evidenced-based mental health and substance abuse interventions into routine clinical practice, and to strengthen feedback from the field to influence and frame services research programs.
Over the past two years, SAMHSA has partnered with the National Institutes of Health, including NIDA, NIAAA, and the National Institute of Mental Health, as well as the Agency for Healthcare Research and Quality to advance a Science to Service agenda. As an example of this collaboration, in FY 2004, NIDA began contributing $2.5 million per year to support a comprehensive evaluation of the Strategic Prevention Framework.
Another key component of the Science to Service agenda is SAMHSA's expansion of its National Registry of Evidence-based Programs and Practices, or NREPP. NREPP is a voluntary rating and classification system for mental health and substance abuse prevention and treatment interventions - a system designed to categorize and disseminate information about programs and practices that meet established evidentiary criteria.
NREPP began in 1998 as the National Registry of Effective Prevention Programs within SAMHSA's Center for Substance Abuse Prevention (CSAP). From 1998 through 2004, NREPP reviewed over 1,100 prevention programs, with over 150 programs being recognized as promising or effective.
In 2004, SAMHSA began expanding the NREPP to include reviews of programs and practices for the treatment of mental and substance use disorders and the promotion of mental health. Ultimately, NREPP will become the leading national resource for contemporary and reliable information on the scientific basis and practicality of interventions to prevent and/or treat mental and addictive disorders. Information on these efforts is currently available on the Internet at www.modelprograms.samhsa.gov.
Increasingly, SAMHSA-funded technical assistance centers, such as the Addiction Technology Transfer Centers, the Centers for the Application of Prevention Technology, the Older Americans Technical Assistance Center, and the Suicide Prevention Resource Center, will be positioned to provide assistance both to organizations wishing to implement an NREPP intervention, as well as program developers wishing to improve the quality of their interventions.
Improving the quality of prevention and treatment services on a national scale is the very essence of SAMHSA's mission to build resilience and facilitate recovery. Addiction's toll on individuals, their families, and the communities they live in carries with it a devastating and cumulative impact on American society. This ripple effect leads to costly social and public health issues, including HIV/AIDS, domestic violence, child abuse and crime in general, accidents, teenage pregnancies, co-occurring mental health disorders, and other adverse outcomes.
SAMHSA will continue to do our part. We will continue to more effectively and efficiently align and focus prevention resources while creating greater flexibility for States and communities to target their dollars in the areas of greatest need. We will also continue our efforts to make it possible for even more Americans who are already battling addiction and struggling with mental illness to live, work, learn, establish themselves, and enjoy themselves in communities across the Nation.
Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. I look forward to continuing to work with you in partnership toward a healthy and addiction-free America. I will be pleased to answer any questions you may have.
Last Revised: April 27, 2005