Statement by
W. Westley Clark, M.D., J.D., M.P.H.
Center for Substance Abuse Treatment
Substance Abuse and Mental Services Administration
U.S. Department of Health and Human Services

SAMHSA's Substance Abuse Prevention and Treatment Programs

Committee on Health, Education, Labor and Pensions
United States Senate

Thursday, March 23, 2006

Mr. Chairman, good afternoon. I am Westley Clark, Director of the Center for Substance Abuse Treatment within the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (HHS). Our Administrator, Charles Curie, would have come to participate, but he was committed to go to Cairo, Egypt, for a meeting on providing mental health services to the people of Iraq.

I greatly appreciate the opportunity to testify today in your home state on a disease that is not only affecting the people of Wyoming but millions of people across the United States. According to SAMHSA's National Survey on Drug Use and Health, in 2004, 19.1 million people age 12 and older had used an illicit drug in the past month. Whether they use heroin, marijuana, methamphetamine, cocaine, or abuse prescription drugs, the health, social, and economic costs are substantial, including continued substance addiction, lost productivity, premature death, unemployment, homelessness, diminished educational advancement, and possible criminal involvement.

We have compelling data that show the 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, a congressionally mandated, five-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. The study also reported a nearly 80 percent reduction in criminal activity, a 43 percent decrease in homelessness, and a nearly 20 percent increase in employment.

Our findings are corroborated by other studies, among them, the Drug Abuse Treatment Outcomes Study, 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.

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. This decline in substance use among our Nation's youth suggests that our work, joined with the work of our Federal partners, and the extensive community-based work of schools, parents, teachers, law enforcement, religious leaders, and local anti-drug coalitions, is having an effect.

I was asked to testify this afternoon on SAMHSA's programs to address the prevention and treatment of substance abuse and about our efforts to hold our grantees and ourselves accountable.

I would like to start by discussing how SAMHSA is weaving accountability into our substance abuse prevention and treatment efforts.

To focus and guide our program development and resources, we have developed a Matrix of program priorities that pinpoint SAMHSA's leadership and management responsibilities. These responsibilities were developed as a result of discussions with members of Congress, SAMHSA's National 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 the Administration and HHS Secretary Leavitt, whose support for our vision of a life in the community for everyone we appreciate. They guide us as we make policy and budget decisions.

To accomplish our priorities SAMHSA is building our programs around three key principles: accountability, capacity, and effectiveness - ACE.

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.

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.

National Outcome Domains
Working in collaboration with States and other stakeholders, we have identified and received global agreement on ten key national outcome domains that emphasize real results for people with or at risk for substance use disorders.

The first and foremost domain is abstinence from drug use and alcohol abuse. Four domains focus on resilience and sustaining recovery. These include getting and keeping a job or enrolling and staying in school; decreased involvement with the criminal justice system; securing a safe, decent, and stable place to live; and social connectedness to and support from others in the community such as family, friends, co-workers, and classmates. Two domains look directly at the treatment process itself in terms of available services and services provided. One of these measures increased access to services for both mental health and substance abuse, and another looks into increased retention in services for substance abuse treatment. The final three domains examine the quality of services provided. These include client perception of care, cost-effectiveness, and use of evidenced-based practices in 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.

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 with significant precision, as will you, the Administration, and the public, 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 rectified at the national level. 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.

While grantees under our discretionary grant programs are providing this data now, it has been and continues to be more of a challenge with our block grant program, largely because we are talking about change to systems of care and not just to a specific grant. Despite this, States are committed to provide outcome data by the end of 2007.

We are very pleased with the progress we have made with the States and look forward to not only gathering the data but using it to make decisions and to improve services.

SAMHSA Programs
Now let me discuss some of the major programs that SAMHSA funds to assist States and communities in addressing substance abuse in their communities.

For Fiscal Year (FY) 2007 the President has requested nearly $1.8 billion for the Substance Abuse Prevention and Treatment Block Grant. These funds are distributed to States using a formula dictated in statute. While there are some requirements that States must meet as a condition of receiving the funds, States have great flexibility in their use of the funds. Across the United States, Block Grant funds account for just over 40 percent of all State funding on substance abuse prevention and treatment. One requirement of the program is that the State must spend at least 20 percent of its allotment on primary prevention. This amounts to $334 million across all States. Wyoming this year received $3.3 million under the Substance Abuse Prevention and Treatment Block Grant program.

Besides the Block Grant, SAMHSA has funds for which public and non-profit private entities are eligible to compete. SAMHSA publishes notices about the availability of program funds. Entities submit applications which are reviewed and scored by experts from outside Federal employment, and SAMHSA funds those with the best scores. This year we have $592 million in appropriated funds for discretionary grants and an additional $80 million for Drug Free Community Programs, which are discussed below. Most of these funds will be used to continue grants that were awarded in previous years. To learn what new funds are available, interested people can go to our website at www.samhsa.gov and click on "Grants." For FY 2005, Wyoming received $5.3 million in substance abuse prevention and treatment discretionary funding. For details on who is receiving those funds, one can go to our website and click on State Funding.

I want to take a moment to highlight just a few of the programs that we have.

Providing people with the opportunity to obtain and sustain recovery is at the heart of the President's Access to Recovery (ATR) Initiative. This program fosters consumer choice, introduces greater accountability and flexibility, and increases treatment capacity by providing individuals with vouchers to pay for the substance abuse clinical treatment and recovery support services they need. In 2004, 44 States and 22 American Indian tribes submitted applications. Fourteen States and one American Indian Tribe received a three year grant under this program. As you know, Wyoming received an award of $2.9 million over three years to address methamphetamine abuse in the State.

Despite requesting additional funding for the program in both Fiscal Years 2005 and 2006, the program was level funded, and all those funds were used to continue the existing grants. For FY 2007, the President has requested $98.2 million for the ATR program to continue to implement the President's commitment to expand consumer choice and access to effective substance abuse treatment and recovery support services by including Faith and Community-based providers.

Of the $98.2 million, $25 million will be targeted to help individuals recover from methamphetamine abuse. The $25 million will fund approximately 10 grants of almost $2.5 million a year for three years. The program will focus on applicants from those States whose epidemiological data and treatment data indicate high methamphetamine prevalence and treatment prevalence.

ATR funding for FY 2007of $70 million is proposed for a Voucher Incentive Program, which will provide up to 25 grant awards of between $1 million and $5 million to applicant States and Tribal Organizations to expand consumer choice through the use of vouchers. Vouchers provide an unparalleled opportunity to create profound change in substance abuse treatment financing, service delivery, and accountability in America.

The Strategic Prevention Framework (SPF) program helps move the President's vision of a healthier U.S. to State- and community-based action. The SPF state incentive grants provide funding to States to establish and implement a statewide comprehensive prevention strategy. At the end of this year, 40 States and American Indian Tribes will have received a SPF grant of $2.3 million a year for five years. Wyoming has a SPF grant which will continue with SAMHSA support through FY 2009.

The success of the framework is and will be determined in large part on the tremendous work that comes from grass-roots community anti-drug coalitions. SAMHSA will continue working with the Office of National Drug Control Policy throughout 2006 to support 720 grantees funded through the Drug Free Communities grant program. Under this program, local coalitions receive $100,000 a year for five years to continue community-based efforts to prevent drug abuse. Grants awarded in 2006 will have a particular emphasis on underage drinking. Wyoming currently has four such grants, including one here in Casper - Natrona County School District.

SAMHSA's Targeted Capacity Expansion (TCE) grants, for which the Administration has requested $21 million for FY 2007, are to expand and/or enhance the community's ability to provide a comprehensive, integrated, and community-based response to a targeted, well-documented substance abuse treatment capacity problem and/or improve the quality and intensity of services. For example, a community might seek a TCE grant to add state-of-the-art treatment approaches or new services to address emerging trends or unmet needs.

As we financially support State and local providers in their efforts to prevent and treat substance abuse, we are working to ensure that consumers and providers of substance abuse services are aware of the latest interventions and treatments. One important tool being used to accelerate the "Science to Service" agenda is SAMHSA's National Registry of Evidenced-based Program and Practices. Last week we released a Federal Register Notice about the registry and how it has been and will continue to provide guidance to States and local community organizations in choosing prevention and treatment modalities.

Education and dissemination of knowledge are key to combating substance abuse. SAMHSA's Addiction Technology Transfer Centers are providing training, workshops, and conferences to the field regarding drug use. It is an ATTC that developed the discs outlining cognitive behavioral approaches to the treatment of methamphetamine abuse and in particular the MATRIX model.

SAMHSA develops Treatment Improvement Protocols (TIPs) on various subjects related to substance abuse. For example, in 1999, SAMHSA first published TIP #33, entitled "Treatment for Stimulant Use Disorders," which has been reprinted twice. Every two years, we take another look at each TIP to update it as needed.

I would be remiss if I did not mention that on April 5-7, SAMHSA is sponsoring a conference on methamphetamine in Los Angeles for all States west of the Mississippi River. We are paying for each State to bring up to 15 individuals, including State officials and providers. The States on the east side of the Mississippi will have their conference in Orlando the week of May 23.

Again, Mr. Chairman, I thank you for the opportunity to discuss SAMHSA and its programs. We look forward to working with you on expanding the services we provide and in improving the accountability systems currently in place to ensure that Federal funds are being used effectively and efficiently.

Last Revised: March 24, 2006