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Testimony on Oversight of Agency Efforts to Prevent and Treat Drug Abuse by Joseph Autry, M.D.
Acting Deputy Administrator
Substance Abuse and Mental Health Services Administration
U.S. Department of Health and Human Services

Before the House Government Reform Committee, Subcommittee on Criminal Justice, Drug Policy and Human Resources
March 18, 1999

Mr. Chairman and Members of the Subcommittee. On behalf of the Administrator of theSubstance Abuse and Mental Health Services Administration(SAMHSA) I want to thank you for the opportunity to testify this afternoon. Your interest in drug control policy and your commitment to bipartisan support of a comprehensive response to the Nation's drug abuse problem are much appreciated. I am accompanied today by Dr. Westley Clark, Director of SAMHSA's Center for Substance Abuse Treatment (CSAT) and Dr. Karol Kumpfer, Director of SAMHSA's Center for Substance Abuse Prevention (CSAP). Both are available to address questions you may have later in the hearing.

I am pleased to present to you today the role and responsibilities of SAMHSA in achieving the goals and objectives of the President's National Drug Control Strategy. As you know the strategy provides the Nation a long-term, balanced approach that focuses on prevention, treatment, research, law enforcement, protection of our borders, international cooperation and policy development. As the Federal Government's lead agency for improving the quality and availability of substance abuse prevention and addiction treatment services, SAMHSA's mission directly supports Goal 1 - "Educate and enable America's youth to reject illegal drugs as well as alcohol and tobacco" and Goal 3 - "Reduce health and social costs to the public of illegal drug use" of the strategy. Within these two goals, SAMHSA supports a number of programs, many in partnership with other Federal agencies, including the Office of National Drug Control Policy, Department of Education, Department of Justice and the Department of Transportation and private sector organizations. All are targeted towards achieving objectives detailed under the respective goal of the strategy.

The importance of our work in substance abuse prevention, addiction treatment and mental health services cannot be overstated. Drug and alcohol abuse ravage the lives of millions and fuel crime, domestic violence, disease and premature death. When the link is made between substance abuse and other headline grabbing problems -- unintended pregnancy, HIV/AIDS, crime, welfare, violence, school drop-out, suicide, homelessness, and injuries, substance abuse is clearly one of our most costly public health problems.

As with any other public health problem, we must achieve public health solutions. Study after study has shown, drugs are dominating the public's concern about the future of children in this country. A survey of American adults found 56 percent listed drugs as the top problem facing American children. Crime was second, at 24 percent.

The relationship between crime and drugs and the cost of drugs and crime to our country is clear. More than 1.7 million people are behind bars in America at an annual cost to the taxpayer of $38 billion. Seventy percent or 1.2 million of them have histories of drug and alcohol abuse and addiction. For hundreds of thousands of these individuals drug abuse and addiction is the core problem that prompted their criminal activity. Our prison and punishment approach to substance abuse is not sufficient by itself. Instead we need to approach drug abuse as a public health issue and invest our resources in reaching adults, adolescents, and children in need of substance abuse prevention and treatment services before they reach the criminal justice system.

In the area of prevention - Goal 1 of the Strategy - our investments seems to be paying off. Each year we release SAMHSA's National Household Survey on Drug Use. While we are cautiously optimistic that the recent increase in drug use Maybe leveling off among youth, we are concerned that our young people continue to use drugs and drink alcohol at an unacceptable rate. To ensure our programs are keeping up with current issues and trends, over the past three years at SAMHSA we have re-engineered our programs, widened our circle of partners and adopted a long term public health approach. With this shift in strategy we have redirected our efforts from narrowly focused drug prevention efforts to a more comprehensive coordinated community approach that identifies and addresses family, school, and mental health problems that may lead to substance abuse and other destructive behaviors.

For example our new State Incentive Grant Program offers technical and financial support to Governors in 19 states to help them deliver research-based substance abuse prevention services. A full 85 percent of these funds are being directed to community prevention programs, resulting in the funding of approximately 500 community based programs in the 19 States. The "incentive" nature of the State Incentive Grants, encourages Governors to mobilize and coordinate state-wide efforts in preventing drug use among youth. In developing this program, we asked Governors to take a fresh look at all the funding streams focused on preventing substance abuse in their state and identify the needs and gaps. Then we asked for innovative plans that leverage resources to reach youth, parents and families in their homes, schools, and workplaces with proven substance abuse strategies. In addition to adapting effective prevention models to local situations and their needs the State Incentive Grant program requires states to account for, coordinate, and strategically manage all substance abuse prevention funding streams in the state, including the 20 percent prevention set-aside of the Substance Abuse Prevention and Treatment Block Grant, Safe and Drug Free Schools and Communities Programs and other Federal programs.

I'm pleased that we've been able to award grants to states with the best proposals and to work with them to help move their programs forward through the establishment of 6 Regional Centers for the Application of Prevention Technology. The Regional Centers are focusing their efforts on the application of National Institute on Drug Abuse (NIDA), National Institute on Alcohol Abuse and Alcoholism (NIAAA) and SAMHSA proven and promising research-based substance abuse prevention practices, methods, and policies in the states that receive incentive grants. These regional centers are critically important. They will identify and reach out to practitioners and programs to ensure they are using the latest science based prevention knowledge available to reduce substance abuse at the community and individual level.

To continue to improve services that are available to very young children, SAMHSA has initiated the Starting Early-Starting Smart collaborative effort. I say collaborative because SAMHSA is collaborating with The Casey Family Program, the Department of Education and other HHS operating divisions to develop new knowledge, demonstrate what works, and create collaborative community-based partnerships that will sustain improved health and health care services for children from birth to age 7 and their families or caregivers. SAMHSA initiated the Starting Early-Starting Smart program because so many social and economic factors impact children's mental health and their potential for substance abuse. This interagency collaboration will bring all the available resources to bear on providing coordinated, quality services for children and their caregivers. I clearly see this collaboration as just the beginning of a much needed effort to improve the lives of children and, ultimately, as our first line of defense in preventing drug use.

Research has shown that with co-occurring mental and addictive disorders, the mental disorder often occurs first, during adolescence and 5 to 10 years before the addictive disorder. While this provides a "window of opportunity" for targeted substance abuse prevention interventions and needed mental health services, two-thirds of young people in this country who suffer from a mental disorder are not receiving the help they need. Without that help these problems can lead, in addition to alcohol and illicit drug abuse, to school failure, family discord, violence and even suicide. SAMHSA is leading a vigorous effort to help families, educators, and others who work with children and adolescents, as well as young people themselves - to recognize mental health problems and seek appropriate services. This is a key goal of our Children's Mental Health Services Program and our Caring for Every Child's Mental Health: Communities Together initiative.

We are also very pleased with the initial response to the National Youth Anti-Drug Media Campaign. While the corporate "in kind"contributions of free public service announcements have exceeded expectations and the goal for reaching target audience members continues to be surpassed, the first measures of impact are coming from SAMHSA. The national phone number used to obtain more information is SAMHSA's National ClearingHouse for Drug and Alcohol Information. In cooperation with the Office of National Drug Control Policy (ONDCP), we have expanded our hours of operation to 7 days a week, 24 hours a day. We are receiving about 2000 calls a day as a result of the media campaign. Approximately half are parents looking for ways to start a conversation about drugs with children in their care. Since the campaign started to run nationally last July, SAMHSA has distributed over 600,000 copies of the publication "Keeping Youth Drug Free"which includes suggested conversations for parents and other caregivers to increase their confidence and knowledge.

SAMHSA's Center for Substance Abuse Prevention (CSAP) is also working with other federal agencies on a number of targeted areas, including underage drinking, family-focused prevention programs, and children of substance-abusing parents to improve system performance and service quality. For example, CSAP and NIAAA have a study underway to examine the effects of alcohol advertising on underage drinking. We are also working with NIAAA to identify, test and develop effective interventions to prevent and reduce alcohol-related problems, including death, among college students.

When it comes to our families, there are many effective strategies for preventing substance abuse among children in the home. Our efforts at SAMHSA are focusing on improved implementation of appropriate family strengthening substance abuse prevention strategies. Also of great concern are the 8.3 million American children who live with at least one parent who is alcoholic or using drugs and in need of substance abuse treatment. These children face a significantly higher-than-average risk for early substance abuse, addiction and the development of a variety of physical and mental health problems. To address this high risk population, CSAP is developing prevention interventions specifically designed for these children and families as part of an interagency Strengthening Families Initiative.

In the area of alcohol and drug treatment - Goal 3 of the Strategy - SAMHSA has repeatedly demonstrated the effectiveness of Federally supported programs. For example, an evaluation of treatment programs funded by the Center for Substance Abuse Treatment (CSAT) found a 50 percent reduction in drug use among their clients one year after treatment. Additional outcomes include improved job prospects, increased incomes, and better physical and mental health. Clients are less likely after treatment to be homeless and less likely to be involved in criminal activity and risky sexual behaviors. Our Services Research Outcomes Study, released in September 1998, produced similar findings. This national sample of substance abuse treatment programs showed that participating individuals sustained reductions in substance abuse for at least five years following treatment. Similar findings have been produced by NIDA and in the States of California, Oregon and Minnesota and by RAND corporation. We have achieved successful results that parallel or exceed the results of patients receiving treatment for other chronic illnesses like diabetes, hypertension and asthma. Yet, we are living in an America where substance abuse treatment is stigmatized and private insurance coverage for treatment is not equal to coverage for treatment of other medical conditions. According to the National Household Survey on Drug Abuse (NHSDA) 63 percent of people with a severe drug problem, about 3.6 million people in need of treatment, did not receive the care they needed in 1997. With the Congress's leadership we can help others understand that drug abuse is a serious public health issues that must be addressed and can be addressed successfully.

To help support and maintain State substance abuse treatment and prevention services, SAMHSA is providing $1.6 billion in funds through the Substance Abuse Prevention and Treatment Block Grant in FY 1999. While block grant investments that support and maintain state systems are vital, they represent only one part of the comprehensive approach needed to improve access to quality substance abuse prevention and addiction treatment services in the U.S. To increase access and reduce waiting times for services, Federal investments in targeted capacity expansion and development and application of new more effective and efficient interventions are essential to improve system performance and service quality as well as cultivate a system that is responsive to current and emerging needs. These investments help to connect the laboratory research funded by the National Institutes for 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 research will not reach our citizens or achieve full potential.

Wise investments in improving performance and quality of services through SAMHSA's Knowledge Development and Application (KD&A) grant program stimulate the discovery of new and more cost effective ways to deliver services paid for through block grant funding, Medicaid, Medicare and private sector insurance. 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. Additionally, CSAT has also initiated a program to identify currently existing and potentially exemplary adolescent treatment models and to produce short-term evaluation of outcome measures and cost-effectiveness of such models with a special emphasis on models that focus on treatment for adolescent heroin abusers. Because the effectiveness of current treatment models for adolescents is still being developed, CSAT is working with NIAAA to identify effective treatment interventions for adolescents who abuse alcohol and those who have become alcoholics. CSAT is also working with the Department of Justice to support the Drug Court Program and through this effort we are piloting three Family Drug Courts projects in which alcohol and other drug treatment, combined with intervention and support services for child and family, are integrated with the legal processing of the family's case. And, 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.

While the drug problem is national in scope, our data provides us the ability to gauge the regional nature of emerging trends. In addition, Mayors, town and county officials, the Congressional Black and Hispanic Caucuses and Indian Tribal Governments experiencing the effects of drug use in their communities have appreciated Federal leadership in helping them address emerging drug trends and the related public health problems, including HIV/AIDS. SAMHSA's Targeted Treatment Capacity Expansion program is key to these efforts. These grants, already in 41 communities, are providing rapid and strategic responses to the demand for services that are more regional or local in nature. For example, the outbreak of methamphetamine use that has spread across the Southwest or dramatic heroin use increases reported in localized areas can be more rapidly addressed as a result of this program.

Finally, we are continuing to provide information to the President, the Congress and the American people on the performance of treatment and prevention programs. SAMHSA's Government Performance and Results Act (GPRA) plan is linked to ONDCP "Performance Measures of Effectiveness," which are derived from the goals and objectives of the National Drug Control Strategy. We are also making a significant investment in data collection by expanding the National Household Survey on Drug Abuse. The expanded survey, which is 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 over time from the expanded Household Survey in combination with other data sources will provide an invaluable tool for reporting to Congress; directing future investments, especially through the Substance Abuse Prevention and Treatment Block Grant; and for measuring outcomes for the National Drug Control Strategy.

Improving accountability for Substance Abuse Prevention and Treatment Block Grant funds is a priority for SAMHSA. Through reauthorization we are proposing to transition our block grants into Performance Partnerships. Our proposal increases state flexibility by allowing states to set their own priorities for expenditures and management of block grant funds and at the same time holding them accountable for achieving capacity, process and outcomes measures agreed upon through negotiations.

Mr. Chairman, we are confident the long-term National Drug Control Strategy will meet its goals through continued collaboration of Federal agencies and the support of the Congress. I assure you SAMHSA will continue to be a vital partner in achieving Goal 1 and Goal 3 that will bring about a 50 percent reduction in drug use and availability and reduce the health and social costs associated with drug abuse by 25 percent by 2007. Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. We will be pleased to answer any questions you may have.

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