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MEASURING THE EFFECTIVENESS OF DRUG

ADDICTION TREATMENT

HEARING

BEFORE THE

SUBCOMMITTEE ON CRIMINAL JUSTICE,

DRUG POLICY AND HUMAN RESOURCES

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

SECOND SESSION

MARCH 30, 2004

Serial No. 108–222

Printed for the use of the Committee on Government Reform

(

Available via the World Wide Web: http://www.gpo.gov/congress/house

http://www.house.gov/reform

(II)

COMMITTEE ON GOVERNMENT REFORM

TOM DAVIS, Virginia, Chairman

DAN BURTON, Indiana

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

DOUG OSE, California

RON LEWIS, Kentucky

JO ANN DAVIS, Virginia

TODD RUSSELL PLATTS, Pennsylvania

CHRIS CANNON, Utah

ADAM H. PUTNAM, Florida

EDWARD L. SCHROCK, Virginia

JOHN J. DUNCAN, JR., Tennessee

NATHAN DEAL, Georgia

CANDICE S. MILLER, Michigan

TIM MURPHY, Pennsylvania

MICHAEL R. TURNER, Ohio

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

——— ———

——— ———

HENRY A. WAXMAN, California

TOM LANTOS, California

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

CAROLYN B. MALONEY, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

WM. LACY CLAY, Missouri

DIANE E. WATSON, California

STEPHEN F. LYNCH, Massachusetts

CHRIS VAN HOLLEN, Maryland

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

JIM COOPER, Tennessee

——— ———

———

BERNARD SANDERS, Vermont

(Independent)

MELISSA WOJCIAK, Staff Director

DAVID MARIN, Deputy Staff Director/Communications Director

ROB BORDEN, Parliamentarian

TERESA AUSTIN, Chief Clerk

PHIL BARNETT, Minority Chief of Staff/Chief Counsel

SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY AND HUMAN RESOURCES

MARK E. SOUDER, Indiana, Chairman

NATHAN DEAL, Georgia

JOHN M. MCHUGH, New York

JOHN L. MICA, Florida

DOUG OSE, California

JO ANN DAVIS, Virginia

JOHN R. CARTER, Texas

MARSHA BLACKBURN, Tennessee

PATRICK J. TIBERI, Ohio

ELIJAH E. CUMMINGS, Maryland

DANNY K. DAVIS, Illinois

WM. LACY CLAY, Missouri

LINDA T. SANCHEZ, California

C.A. ‘‘DUTCH’’ RUPPERSBERGER, Maryland

ELEANOR HOLMES NORTON, District of

Columbia

——— ———

EX OFFICIO

TOM DAVIS, Virginia HENRY A. WAXMAN, California

J. MARC WHEAT, Staff Director

NICOLE GARRETT, Clerk

TONY HAYWOOD, Minority Counsel

(III)

C O N T E N T S

Page

Hearing held on March 30, 2004 ............................................................................ 1

Statement of:

Curie, Charles, Administrator, Substance Abuse and Mental Health Services Administration; and Nora D. Volkow, National Institute on Drug

Abuse, National Institutes of Health .......................................................... 12

McLellan, Thomas, Ph.D., director, Treatment Research Institute, Philadelphia, PA; Charles O’Keeffe, Virginia Commonwealth University,

Richmond, VA; Karen Freeman-Wilson, executive director, National

Drug Court Institute, Alexandria, VA; Jerome Jaffe, M.D., professor,

University of Maryland, Baltimore, MD; Catherine Martens, senior

vice president, Second Genesis, Silver Spring, MD; and Hendree Jones,

Ph.D., research director, Center for Addiction and Pregnancy, Baltimore, MD ....................................................................................................... 44

Letters, statements, etc., submitted for the record by:

Cummings, Hon. Elijah E., a Representative in Congress from the State

of Maryland, prepared statement of ............................................................ 9

Curie, Charles, Administrator, Substance Abuse and Mental Health Services Administration, prepared statement of ............................................... 15

Freeman-Wilson, Karen, executive director, National Drug Court Institute, Alexandria, VA, prepared statement of .............................................. 74

Jaffe, Jerome, M.D., professor, University of Maryland, Baltimore, MD,

prepared statement of ................................................................................... 83

Jones, Hendree, Ph.D., research director, Center for Addiction and Pregnancy, Baltimore, MD, prepared statement of ........................................... 96

Martens, Catherine, senior vice president, Second Genesis, Silver Spring,

MD, prepared statement of .......................................................................... 88

McLellan, Thomas, Ph.D., director, Treatment Research Institute, Philadelphia, PA, prepared statement of ............................................................. 46

O’Keeffe, Charles, Virginia Commonwealth University, Richmond, VA,

prepared statement of ................................................................................... 56

Souder, Hon. Mark E., a Representative in Congress from the State

of Indiana, prepared statement of ............................................................... 3

Volkow, Nora D., National Institute on Drug Abuse, National Institutes

of Health, prepared statement of ................................................................. 25

(1)

MEASURING THE EFFECTIVENESS OF DRUG

ADDICTION TREATMENT

TUESDAY, MARCH 30, 2004

HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY AND

HUMAN RESOURCES, COMMITTEE ON GOVERNMENT REFORM, Washington, DC.

The subcommittee met, pursuant to notice, at 2 p.m., in room

2247, Rayburn House Office Building, Hon. Mark E. Souder (chairman of the subcommittee) presiding.

Present: Representatives Souder, Cummings, Blackburn and

Davis.

Staff present: Marc Wheat, staff director and chief counsel; Alena

Guagenti, legislative assistant; Nicole Garrett, clerk; Tony Haywood, minority counsel; and Jean Gosa, minority assistant clerk.

Mr. SOUDER. The subcommittee will come to order. Good afternoon, and I thank you all for coming. Today we will continue our

subcommittee study of drug addiction treatment, or as President

Bush refers to it in the National Drug Control Strategy, ‘‘Healing

America’s Drug Users.’’ It is estimated that at least 7 million people in the United States need treatment for drug addiction. Getting

effective help to those 7 million people and getting them to accept

that help is one of America’s greatest public health challenges.

Everyone agrees that we should help drug addicts get effective

treatment. What is far more difficult is to find a consensus on how

to measure what effective treatment is, but it is vital that we find

that consensus because in an era of tight budgets, we must be able

to focus our limited resources on the most effective treatment

methods.

Last year, President Bush took what I believe to be a very significant step in that direction when he unveiled the Access to Recovery Initiative. Beginning this fiscal year, the President’s initiative will provide $100 million to the Substance Abuse and Mental

Health Services Administration [SAMHSA], to supplement existing

treatment programs. That amount of money is intended to pay for

drug treatment for most Americans who want it but can’t get it,

many of whom can’t afford the cost of treatment and don’t have insurance to cover it.

If fully funded at $200 million per year as requested by the

President, it could help up to 100,000 more addicts get treatment.

The program also has enormous potential to open up Federal assistance to a much broader range of treatment providers than are

used today. Through the use of vouchers, the initiative will support

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and encourage variety and choice in treatment and could open up

and support a significant number of new options for drug users to

get treatment. Finally, and most important for our purpose today,

the emphasis on accountability should help us make significant

progress in the most difficult issues of drug treatment policy, finding and encouraging programs that truly work, helping and healing

the addicted, as well as ensuring a meaningful and effective return

on taxpayers’ dollars spent on treatment.

Earlier this month, SAMHSA published a request for applications spelling out the qualifications for programs to administer the

new funds and inviting those programs to apply. The RFA, request

for application, contains new performance measures designed to

help us determine what programs are working for the patients and

which ones aren’t. I am especially looking forward to discussing Access to Recovery Initiative with the person most responsible for implementing it, my fellow Hoosier, SAMHSA administrator Charlie

Curie.

With SAMHSA up for reauthorization this year, I’m also eager

to discuss with him the agency’s plans for the future of drug treatment. We are also pleased to be joined by Dr. Nora Volkow, director of the National Institute on Drug Abuse at the National Institutes of Health, which is the Federal Government’s pre-eminent

authority on the nature of drug addiction and the science of drug

treatment. We are pleased to be joined in the second panel by a

number of experts in the field of drug addiction treatment.

We welcome Dr. A. Thomas McLellan, director of the Treatment

Research Institute in Philadelphia, PA; Mr. Charles O’Keeffe at the

Virginia Commonwealth University in Richmond, VA; the Honorable Karen Freeman-Wilson, executive director of the National

Drug Court Institute in Alexandria, VA; Dr. Jerome Jaffe, professor

at the University of Maryland in Baltimore, MD; Ms. Catherine

Martens, senior vice president of Second Genesis in Silver Spring,

MD; and Dr. Hendree Jones, research director at the Center For

Addiction and Pregnancy in Baltimore, MD. We look forward to

discussing these issues with you.

[The prepared statement of Hon. Mark E. Souder follows:]

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Mr. SOUDER. Now I will now yield to our distinguished ranking

member, Mr. Cummings, for his opening statement.

Mr. CUMMINGS. Thank you very much, Mr. Chairman, for holding this important hearing on measuring the effectiveness of drug

treatment. I have often said it is one thing to treat drug addiction.

It is another thing to be effective in treatment. As you know, Mr.

Chairman, drugs kill 20,000 Americans each year, and drug abuse

and the illegal drug trade contribute to most of the violent crime

and social problems we experience here in the United States. Providing effective treatment to people who have become drug dependent is necessary to reduce the demand for illegal drugs that drives

consumption and fuels crime and social dysfunction. The President

has proposed substantial increases in drug treatment funding, including increases for the substance abuse prevention and drug

treatment block grant, which accounts for 40 percent of public

funding for drug treatment, and the new Access to Recovery Voucher Initiative for which State applications are being accepted this

spring.

Under both, the block grant and Access to Recovery, drug treatment funding is being accompanied by new requirements for outcomes measurement and reporting in an effort to increase accountability and effectiveness in drug treatment programs funded with

taxpayers’ dollars. I have often said that the one thing that Republicans and Democrats appear to agree on is that the taxpayers’ dollar must be spent effectively and efficiently. These are appropriate

goals in addition to expanding the capacity of the drug treatment

system to ensure that treatment is accessible to those in need. We

should seek to ensure that the treatment we fund is the very best

that it can be. The value of treatment cannot be overstated. Numerous studies attest to the effectiveness of treatment in reducing

not only the consumption of drugs and alcohol, but also the social

harms associated with addiction, including violent crime, property

crime, unemployment, risky health behaviors contributing to HIV

and hepatitis infection and so on.

And yet, public funding for drug treatment has been derided by

some critics who view drug treatment programs as a revolving door

for addicts who lack a moral commitment to abstinence. Addiction

research tells us, however, that relapse is a component of the disease of addiction and a part of the recovery process for most recovering addicts. Moreover, temporary abstinence and reduced consumption are beneficial for the patient and the community in

which the patient lives and treatment contributes to these intermediate steps as well as the ultimate goal of permanent abstinence. The National Institute on Drug Abuse publication, ‘‘Principles of Drug Addiction Treatment,’’ a research-based guide, cites

several conservative estimates showing that every $1 invested in

addiction treatment programs yield a return of between $4 and $7

in reduced drug-related crime, criminal justice costs and theft

alone. When savings related to health care are included, total savings can exceed costs by a ratio of 12 to 1. The guide further states

that drug addiction is a complex illness that nonetheless is just as

treatable as other chronic diseases in which patient behavior is a

factor, including diabetes, asthma and hypertension.

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Evaluations of treatment programs must take into account not

only the complexity of the illness, but also the very different life

circumstances patients in a variety of treatment settings in which

patients receive treatment. The diversity and types of treatment

programs poses a challenge to efforts to establish criteria that will

allow for meaningful comparisons. Applying criteria in a manner

that is fair and that yields useful evaluations is critical. We have

two very distinguished panels of witnesses who will offer their insights on this important subject today, and I am happy that my

State of Maryland is so well represented.

We are fortunate to have both NIDA and SAMHSA before us on

this panel. And I want to thank you, Mr. Chairman, in particular

for allowing Dr. Hendree Jones and Catherine Martens to testify

today as minority witnesses on the second panel. Dr. Jones is research director for the Center For Addiction and Pregnancy at

Johns Hopkins Bayview Medical Center in Baltimore. Ms. Martens

is senior vice president of Second Genesis, a therapeutic communities program in Silver Spring, MD. Taking into account the perspectives of treatment providers is critical to the development of

evaluation methods that will yield meaningful and useful information, leading to more effective treatment. And I am glad that we

will hear these important perspectives today.

With that said, Mr. Chairman, I look forward to hearing the testimony of our distinguished witnesses and I hope that this hearing

helps to move us forward toward the goal of reducing drug abuse

and dependency in this great country. With that, I yield back.

[The prepared statement of Hon. Elijah E. Cummings follows:]

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Mr. SOUDER. I thank you for your statement. I ask unanimous

consent that all Members have 5 legislative days to submit written

statements and questions for the hearing record and that any answers to written questions provided by the witnesses also be included in the record. And without objection, it is so ordered. I also

ask unanimous consent that all exhibits, documents and other materials referred to by Members and the witnesses may be included

in the hearing record and that all Members be permitted to revise

and extend their remarks. Without objection, it is so ordered. Now

it is the policy of this committee and the full Government Reform

Committee to swear in our witnesses, so if you would stand and

raise your right hands.

[Witnesses sworn.]

Mr. SOUDER. Let the record show that the witnesses have answered in the affirmative. I apologize. I wasn’t paying attention. Do

you have an opening statement?

Mrs. BLACKBURN. No.

Mr. SOUDER. I was so intent on reading the materials in front

of me, I apologize. We will start with Mr. Curie.

STATEMENTS OF CHARLES CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION; AND NORA D. VOLKOW, NATIONAL INSTITUTE ON

DRUG ABUSE, NATIONAL INSTITUTES OF HEALTH

Dr. CURIE. Thank you, Mr. Chairman and members of the subcommittee. Good afternoon. I am Charles Curie, Administrator of

the Substance Abuse and Mental Health Services, part of the U.S.

Department of Health and Human Services. At this time, I ask

that my formal written testimony be included in the record of this

hearing. In the time I have with you today, I will describe how

SAMHSA is working to promote and provide effective substance

abuse treatment to people nationwide, and I will describe how we

are measuring the effectiveness of those efforts. The importance of

substance abuse treatment prevention services is undeniable. And

I am pleased to be appearing here today with my colleague, Dr.

Nora Volkow of NIDA, where partnership is critical in us accomplishing that goal.

According to our 2002 national survey on drug use and health,

of the 22.8 million people aged 12 and older who needed treatment

for alcohol or drugs, only 2.3 million of them received specialized

care. Over 85 percent of people with untreated alcohol or drug

problems said they didn’t think they needed care. Of the 1.2 million

people who felt they did need treatment, 446,000 tried but were

unable to get treatment.

The result, continued addiction, lost health, employment and

education and often criminal involvement. That is a huge human

and economic cost. Yet we know Federal investments in substance

abuse treatment and prevention are cost effective and beneficial.

Treatment is effective. Recovery is real. SAMHSA’s national treatment improvement evaluation study found a 50 percent reduction

in drug use 1 year after treatment. It reported up to an 80 percent

reduction in criminal activity, a 43 percent drop in homelessness

and a nearly 20 percent rise in employment. Our findings are corroborated by other SAMHSA and NIDA studies. We are also workVerDate 11-MAY-2000 10:31 Dec 03, 2004 Jkt 000000 PO 00000 Frm 00016 Fmt 6633 Sfmt 6633 D:\DOCS\96744.TXT HGOVREF1 PsN: HGOVREF1
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ing to prevent substance abuse in the first place. The President set

aggressive goals to reduce youth drug use in America.

With effective prevention efforts, rates are dropping; 11 percent

in the past 2 years among 8th, 10th and 12th-grade students, according to NIDA’s most recent monitoring the future survey. That

is roughly 400,000 fewer teen drug users in these 2 years. And that

means the President’s 2-year goal has been exceeded. Let me remind everyone what SAMHSA is all about.

In contrast to NIH, SAMHSA is not a research agency. We don’t

conduct or fund research. SAMHSA is a services agencies. That

means taking our work and our substance abuse prevention and

treatment services programs to where people are in communities

nationwide. That’s where our programs, policies and budget priorities are driven by the vision of a life in the community for everyone. That’s why they’re driven by a mission of building resilience

and facilitating recovery one person at a time. And that is why

each and every one of our program outcomes is being measured

against the yardstick of recovery, resilience and that life in the

community for every man, woman and child. Our vision and mission are aligned with those of President Bush and Health and

Human Services Secretary, Tommy Thompson. We appreciate their

leadership and support for our vision of a life in the community for

everyone. Three concepts at the heart of today’s hearing guide our

work: Accountability, capacity and effectiveness [ACE]. We assess

ACE by gathering and analyzing data about our programs. But we

are not collecting data for the sake of collecting data.

Today we are asking why we are collecting the data and whether

they measure outcomes that are meaningful for real people working to make recovery a reality. If they don’t, they simply won’t be

collected. That’s why we have been working with the States to

change the ways in which we assess our discretionary and block

grant programs. It is an approach that focuses questions and expectations on success and substance abuse treatment and prevention, measured in real-time outcomes for real people. The result

has been the identification of and agreement on seven outcome domains, the very outcomes that help people obtain and sustain recovery.

First and foremost is abstinence from drug use and alcohol

abuse. Without that, recovery and a life in the community are impossible. Two other domains, increased access to services and increased retention and treatment, relate directly to the treatment

process itself. We measure whether our programs are helping people who want and need treatment get the care they need, over the

duration they need it and with the social supports that are most

beneficial to each individual.

The remaining four domains focus on sustaining treatment and

recovery, increasing employment or a return to school, decreasing

criminal justice involvement, increasing in stabilized family and

living conditions and an increase in support from and

connectiveness to the community. These measures are true measures of recovery. They measure whether our programs are helping

people achieve and sustain recovery. By focusing our program outcome data collection on just these seven domains over time, we can

foster continuous program and policy improvement. We can know

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whether our efforts to move new scientific knowledge from NIDA

to the front lines of service delivery or science to services efforts

are working for people.

SAMHSA’s addiction technology transfer centers are an example.

They encourage the adoption of evidence based practices by alcohol

and drug abuse treatment programs and providers. We work with

NIDA to disseminate new knowledge specifically related to the results of NIDA research. We will know whether these efforts are

paying dividends in reaching recovery and promoting and abstinence from drugs, giving people an opportunity to obtain sustained

recoveries at the heart of the President’s Access to Recovery Initiative. That is the first place we will use the seven domains to assess

our outcomes.

As you know and has been indicated, Access to Recovery is a new substance abuse treatment grant program funded at $100 million

in fiscal year 2004, and for which the President is seeking $200

million in fiscal year 2005. ATR fosters consumer choice, improved

service quality and increases treatment capacity by providing individuals with vouchers to pay for substance abuse treatment they

need. At the same time, SAMHSA has been working with the

States to transform its substance abuse prevention and treatment

block grant program into a performance-based system. To begin,

States will be asked to voluntarily submit data on the seven domains as we integrate performance accountability into the system.

SAMHSA has invested significant resources to help States build

their State data infrastructures. We will work with them to promote better accountability not just for where the dollars are being

spent, but how effectively those dollars are being used.

By focusing program measurement and management on the

seven outcome domains, SAMHSA, States and communities and

this subcommittee can gain a powerful tool to guide the policies

and program directions of today and tomorrow. For the first time,

we can paint a picture of the effectiveness of drug treatment as it

relates to recovery. We will ensure that our programs remain focused on the real-time needs of people working toward recovery

and a life in the community. Thank you for the opportunity to appear before the subcommittee. I will be pleased to respond to any

questions at the appropriate time. Thank you.

Mr. SOUDER. Thank you very much.

[The prepared statement of Dr. Curie follows:]

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Mr. SOUDER. We will hear from Dr. Nora Volkow, Director of the

National Institute for Drug Abuse at NIH.

Ms. VOLKOW. Good afternoon. Thank you for inviting the National Institute on Drug Abuse to join with our colleagues at

SAMHSA and others to participate in this very important hearing.

I am pleased to be here at my very first hearing before Congress.

What I would like to do today is share with you what science is

teaching us about the chronic relapsing nature of addiction and the

impact it has had on how we treat patients and how we measure

treatment effectiveness. Every one of us in this room is here because we want to do something about the tremendous burden that

drug abuse has on our society. Illicit drug use costs our Nation

$161 billion a year. But that number is very small compared to the

impact that drugs can have on individuals, families and communities. Drug abuse can lead to crime, domestic violence, child

abuse, among others. It is also a leading factor for many diseases,

including HIV-AIDS, and hepatitis.

Fortunately, our investments in biomedical research to improve

the health of all Americans are paying off especially how we approach and treat addiction. Research shows that addiction is a

chronic relapsing disorder associated with long-lasting changes in

the brain that can affect all aspects of a person’s life. New advances are beginning to increase our understanding of the developmental nature of addiction. Addiction is a disease that starts in

adolescence and sometimes even in childhood. The urgency to combat substance abuse and addiction is highlighted by the numbers;

2.9 million 12 to 17-year-old individuals are currently using illicit

drugs. This is a time when the brain is undergoing major changes

in both structure and function. If we do not intervene early, drug

problems can last a lifetime.

For this reason, NIDA is encouraging new research such that pediatricians and other primary care physicians have the tools, skills

and knowledge to screen every patient as early as possible. We are

also working with our colleagues from SAMHSA and others to rapidly bring new treatments to providers. For example, a little over

a year ago with the help of many of you in this room, we were able

to bring the new medication buprenorphine to qualified physicians.

For the first time, doctors can treat patients who are addicted to

opiates such as heroin and Oxycontin in their own offices. Over 3

decades of research demonstrate that treatment works. We have

summarized these findings in one of our most popular publications

to date, the principles of drug addiction treatment, commonly referred to as the Blue Book. This Blue Book has been distributed

to over 12,000 providers and provides the basic principles that research studies have shown to be necessary for successful treatment.

As with other chronic illnesses, treatment for drug addiction in

most cases is a long-term process. In fact, the effectiveness of treatment for addiction is similar to that of other chronic relapsing disorders such as diabetes, asthma, hypertension and heart disease

and many forms of cancer. Indeed, treatment compliance, drop out

rates and relapse are similar for all of these chronic diseases.

The chronic nature of drug addiction dictates the need for ongoing care. The importance of this strategy is illustrated by stories

of after care in criminal justice settings. Studies in California and

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Delaware have shown that when treating drug abusers while they

are in prison and continuing to provide treatment and other services while they transition to the community reduces drug use by 50

to 70 percent. It also reduces the likelihood that their return to

prison by about 50 percent.

However, without the after-care component, the effects of treatment largely disappear. In addition, because drug addiction is associated with disruption across multiple dimensions of a person’s life,

treatment requires that not just the drug use but also its consequences be treated, which can include medical complications such

as HIV-AIDS and hepatitis, mental illness such as depression, anxiety, suicide, criminal justice involvement, unemployment and problems with family and social functioning among others.

Conceptualizing drug addiction as a chronic relapsing disease

that requires ongoing treatment and that affects multiple dimensions of an individual’s life that need to be addressed for recovery

will require that we change the way we measure treatment effectiveness. We particularly applaud SAMHSA for focusing on the

multiple dimensions of drug abuse outcomes because this is consistent with our scientific understanding of the complexities of this illness. Like other areas of health care, standardized measures of

drug abuse treatment effectiveness have not yet been developed

and I commend this committee for addressing this important topic.

Thank you very much. I would be happy to answer any questions

you may have.

[The prepared statement of Ms. Volkow follows:]

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Mr. SOUDER. I thank you both for your testimony. I believe your

statement was very clear, Mr. Curie, but I want to ask it again for

the record because as the administration moved in to several of

these new initiatives, one of the most common questions was, were

new grantees going to be treated differently in accountability than

previous grantees? As I understood your statement, you said

whether or not it was discretionary or block granted, you were

looking for a continuity of measurement where all would be measured in similar ways?

Dr. CURIE. That is correct. We are able to operationalize Access

to Recovery and we are asking States or tribal entities who are responding to that request for applications [RFA] to demonstrate how

they will either entice or assure measurement from providers who

are eligible providers to receive the voucher. At the same time, as

we move ahead with performance measures on the block grant and

other targeting capacity expansion grants, we are looking at the

seven domains of common measurements to be required of all

grantees. The primary reason is there has been consensus in the

field that these seven domains represent recovery and represent

measurement of someone who is in recovery, and that is really the

goal of all of our services that we are funding.

Mr. SOUDER. Dr. Volkow just talked in her written testimony

about the impact of comprehensive treatment. And in the written

testimony, it also says that in the studies in Delaware and California, that offenders who are treated in prison are less likely, if they

have comprehensive treatment, to end up back in prison. But if

they do not receive after care despite receiving in prison treatment

they have poorer outcomes. My question to you is, are we interconnecting the different programs at this point in the Department

of Justice in what you are doing and what can we do to encourage

more of that type of cooperation? I know, for example, in the Fort

Wayne area, we both know well, they have Justice Department

grants for continuum of care.

And Congressman Davis has a bill that I support on housing

questions. But are we seeing these things coming together, because

so many of us see people who have been in a treatment program

and they go right back in and the question is how can we integrate

and look at this more holistically from the Federal Government

level.

Dr. CURIE. I think the answer is yes, we are making great

progress in that area. We do have joint programs with the Department of Justice. For example, we are funding the treatment components of reentry courts. Fort Wayne is an example of a reentry

court. And we have an understanding, a relationship with Justice,

that our responsibility is to fund community-based treatment for

individuals who are coming out of the justice system, and to collaborate on drug courts. And again, we have a commitment between both departments to continue to foster that relationship. I

think we are all in agreement that the treatment and recovery support systems on the community based side of things need to be integrated, and you don’t want to see a separate criminal justice and

community-based system of care. But if we truly are working for

individuals to have that life in the community, it needs to be part

of the overall public health focus.

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Mr. SOUDER. Before I followup with Dr. Volkow on that particular question, when you give block grant money to the States, is

there any guidance to them that says we want this integrated with

the drug courts, with other reentry programs and not just OK, we

are pursuing this thing at the Federal level and these different

agencies and you’re pursuing this?

Dr. CURIE. For the block grant there are various directives and

statute that are on the block grant. The States do have a lot of latitude. That’s the very thing we are examining as we move to PPGs

is how we can measure and incent, if you will, a system with further integration.

The other thing I might mention, there are block grant dollars,

I know, in a wide range of States that are going toward treating

individuals who are coming out of the criminal justice system. Also

with Access to Recovery, nothing precludes the State, in fact, we

have encouraged this one scenario, a State or a tribal organization

may want to use the vouchers in connection with the drug court

or the reentry court program and actually begin their voucher program with that specialty population. And we anticipate we are

going to see those types of models proposed.

Mr. SOUDER. Dr. Volkow, have you seen any of these integrated

studies? Are you setting up any tracking to see whether or not we

are getting the results when we have a drug court, a reentry program and a prison treatment program or community-funded program? Are you able to see enough of these that you can start to

research it and to see whether what was suggested in the State

studies might, in fact, be true?

Ms. VOLKOW. One of our priority areas is how to actually develop

knowledge that optimizes the way that we bring the prisoners back

into the community. We have a strategy that, for lack of a better

term, we are calling an ‘‘NIDA goes to jail’’ and it has multiple

components. One of them is to generate the knowledge and to create the infrastructure. One of the things that we have started is

what we call the Criminal Justice Drug Abuse Treatment Studies

[CJDATS] and these are seven of our criminal justice systems

working with academic centers to develop research protocols to optimize our reentry of the prisoner back into the community. Another component is to interact with SAMHSA, and also to interact

with the Department of Justice to bring education about the signs

of addiction and the treatments that are available. So that is the

educational component.

And finally, the other aspects we are working with, which we are

also addressing is the issue on research that unfortunately is common in the substance abuse area. Many of the individuals that end

up in prison are frequently associated with co-morbid mental illnesses.

So that is another area where we don’t have sufficient research.

And in parallel to this initiative, there is also parallel one for the

criminal juvenile offenders.

Mr. SOUDER. Can I ask one supplemental question? I know all

the members are interested in this as well. I didn’t mention, and

nor did you, the Labor Department or the Education Department.

Are we looking at any attempts to look at vocational education and/

36

or employment as part of this rehab where that would be integrated as well?

Dr. CURIE. Yes. In fact, one of the major domains, employment

and education which reflect a dimension of recovery, we are looking

at collaborating with labor. We are looking at potentially—I know

a reentry program was proposed by the President which would be

focused on just that and with the efforts between Justice and HHS

at this point around bringing individuals back into the community

to succeed. It would make a lot of sense to be engaged in that process to make sure we have a comprehensive approach. Also on a related side of the equation, on the mental health agenda side, we

have an action agenda around transforming the mental health system, which will address co-occurring disorders which has a clear

connect to addictive disorders. And with that, we have Labor at the

table collaborating with us around models that work to help people

gain employment.

Mr. SOUDER. Mr. Cummings.

Mr. CUMMINGS. Thank you all very much for being here. Ms.

Volkow, tell me exactly what you mean—what is your definition of

after-care? You said it is important that you have after-care. And

I want to know what are the essential ingredients for what you

deem to be effective after-care?

Ms. VOLKOW. The after-care for someone who has been in jail or

after-care for any drug abusing person that ends up in a health

care facility seeking treatment.

Mr. CUMMINGS. Both?

Ms. VOLKOW. What it basically requires is that it starts, and this

is actually one of the things that has been clearly summarized in

the principles of drug addiction and what has been, there is consensus that in the initial reentry of the person you are focusing on

stopping the drug use while at the same time starting to engage

the patient on realizing what are the positive and negative aspects

of taking drugs. Once that individual recognizes his position on this

stance, he is taken to the next step, which is to teach that individual what are the actions that he needs to do in order to optimize

his chances to not take drugs.

So that is the first stage. Once that is achieved, the patient goes

into what we call after-care and the patient is released into the

community and that requires that there has to be followup and

there are several programs that can be utilized. There is nothing

like a recipe that works for everyone.

So the first thing that has to be realized is that the treatments

have to be tailored for the unique circumstance and characteristics

of the patient, and that will require that the several aspects that

SAMHSA is focusing on are addressed. You need to address not

just the substance abuse, but the integration of the individual and

the support of the community, which ideally should include the

family. And if the family doesn’t exist, what does the integration

require? If it is an adult, that they have employment. And if it is

a younger person, that they are able to continue in the educational

system.

At the same time, what science has taught us is that self-help

groups are usually very beneficial. And in certain instances, the noVerDate 11-MAY-2000 10:31 Dec 03, 2004 Jkt 000000 PO 00000 Frm 00040 Fmt 6633 Sfmt 6633 D:\DOCS\96744.TXT HGOVREF1 PsN: HGOVREF1
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tion of medication can help drug-addicted persons stay away from

drugs.

And finally, but not because it is least important, unfortunately

substance abuse is frequently coupled with morbid mental illness.

And if the issue of mental illness is not addressed, they are very

unlikely to succeed in getting that person out of drugs. That is

what the after-care entails, being able to monitor all of these different dimensions that have unfortunately been affected by the

drug addiction process.

Mr. CUMMINGS. I was waiting for you to say and you finally did

say it, a job is helpful, isn’t it?

Ms. VOLKOW. One of the things we have come to realize is that

we are human beings. One of the most important aspects that motivates our behavior is to be part of a group; to be part of a community, and to feel that we are appreciated and we can contribute to

that community. It is one of the most important aspects that motivates our actions in life. So when you bring a person into community and you make him feel he is part of it, you actually achieve

a great deal through that process.

Mr. CUMMINGS. Mr. Curie, you were with us in Fort Wayne?

Dr. CURIE. Yes, I was.

Mr. CUMMINGS. If you recall when we were in Fort Wayne with

the chairman, a lot of those judges came forward and talked about

how they were so upset that State law—that is what they were

talking about, I think—because somebody had a drug offense on

their record, it had precluded them from getting so many jobs. And

when I go to the inner city of Baltimore, I talk about that because

they think it is only a problem in the inner city. And so then I just

heard Ms. Volkow talk about how jobs are a part of getting that

person back into society.

Are there any efforts to try and look at some of these State laws

on the part of either of you? And I don’t know if that comes under

your purview, so we can get people to have some hope and able to

get back and circulate in society, since that is such a crucial part

of recovery.

Dr. CURIE. I am not aware of any formal reviews of looking at

that. I think it would be a worthwhile endeavor to consider, especially since we are using recovery now as our framing of service delivery. Historically, and I think Dr. Volkow was, when she is talking about after-care, historically, I think from the public sector side

of things, as we finance services, we have focused primarily on the

treatment or the treatment intervention and not on the whole recovery picture. We have begun focusing on the whole recovery picture recognizing that relapse is less likely to occur if people are attaining those real life goals of employment, education, stable housing, connectiveness to family and friends, and connectiveness to the

community. So as we are basically embarking, I would say, in a relatively new chapter as we look at what we are financing. I think

the type of review you described would be worthwhile because historically you never heard us talking necessarily to labor or to education about how we help individuals build a life. We used to think

that if we provided access to care and some forms of care, we are

done with our mission. We are recognizing today that we are not

finished with our mission.

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Mr. CUMMINGS. Just one other thing. When I talk to people in

my district who are recovering addicts, one of their biggest concerns is a job. And the more I think about it combined with what

you just said, I mean, it really makes sense. One, they need another family. In other words, the family that got them on drugs,

they need to get away from that group or they will be right back

where they started. Two, I guess it does give them a sense of

worth. Three, it gives them a whole lot more eyes looking over

their shoulder, like the woman who is their boss or the person that

they become familiar with and becomes a friend that they eat

lunch with or people that go out and play baseball after work.

So basically what we are talking about is sort of a shifting from

one lifestyle and trying to shift them over to another lifestyle, that

includes new people and new opportunities to change and get away

from what sent them there in the first place.

Dr. CURIE. Exactly. Goals, aspirations, you mentioned hope earlier. It is all part of it. Your experience parallels mine. When I ask

a question of people what they need, people who have an addictive

disease or disorder, they don’t define that they need a clinical program. They define that they are looking for a job, a home and a

date on the weekends to build a new life. And a job also strikes

not only giving someone a sense of worth, but in our society, the

basic question you’re asked when you enter a neighborhood is what

do you do? And if you don’t have an answer to that question, already you’re on a slippery slope in terms of acceptance in that community. So a job goes to basically identity in this society.

Mr. CUMMINGS. Just as a footnote when you are at a party and

a fellow is talking to a young lady, she wants to know what do you

do, do you work and have job.

Mr. SOUDER. Congressman Blackburn has been very involved in

this before she came to Congress, and we had an excellent hearing

in her district as well, a number of remarkable people in Tennessee.

Mrs. BLACKBURN. That is exactly right. Thank you, Mr. Chairman and to my colleague. He was speaking in terms of family and

I was sitting here making some notes before he started speaking

on that issue, abouit the importance of a family or an extended

family or well-placed mentors. I do applaud our President in the

fact that he has developed mentoring programs and that he is a

supporter of faith-based initiatives. As the chairman mentioned,

the hearing we did in our district and the very active work and

participation that is taking place on that.

So I agree with what he is saying, that those life skills that

many times our educational system no longer teaches. It is important that we have families and mentors to fill that void and to

teach those skills to young people. I thank you both for being here

and appearing before us. I appreciate it.

Dr. Volkow, I want to thank you specifically for using the front

and back of your paper. We conservatives like to see that. It is

wonderful that we doubled up there. You know just think what we

could do to cut the use of paper in half if we used the front and

back of the paper, so we thank you for that. A couple of questions

that I do have looking through your testimony, Dr. Curie. I want

to start with you first, please. As you reference the programs in the

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studies that you have done, one of the things I am not seeing is

the complete universe of individuals in your programs. I am going

to ask these questions in bulk just to save time and let you answer

them.

Out of the individuals in the program and the length of time they

were in their programs, one of the things from the State level that

we have learned is that short programs don’t work, longer programs do work. Out of this universe, what is the recidivism rate

and do you have any documented evidence on tying the length of

the program to the recidivism rate? In looking at your accountabilities, and I appreciate your spelling out the seven domains, I think

that is really excellent, do we know how much we are spending per

individual to move them through this program?

And let me go ahead and finish here. When we look at the

States, and both of you mentioned working with the States, as you

move them through this, have you developed some type of software

that you or some type of program that they are going to be able

to submit this accountability data to you? And our grantees, if they

are not accountable, is there a process for withholding money or

moving them out of the program? I know that is a lot to throw out,

but I have got 5 minutes, so I wanted to be sure I got out of all

of these things before you.

Dr. CURIE. Understood. I can share with you information about

specific programs and the link between longevity within the program and relapse and we have that mainly on specific programs,

sometimes by State. There is no real comprehensive national picture of that and that is one reason we want the seven domains to

be consistent among all grants because we think that will help us

begin to paint more of a national picture.

Mrs. BLACKBURN. Mr. Chairman, I would like to request that we

have that submitted for the record and for our review.

Dr. CURIE. And as we move ahead in terms of working with the

States, State data infrastructure is a real critical issue. When you

speak to the States, you understand that there are many demands

on their particular State budget. At the same time, they have State

legislators and Governors who want to have this information for

them to make informed decisions. So there is an alignment of goals.

We are providing both resources and technical assistance to States

to help and develop the data infrastructure. Also working with

States, there are certain States that have excellent data information systems that can be used as models for other States.

We are also looking to work with the National Association of

State Alcohol and Drug Abuse Directors to accommodate that. But

that is a priority and it is going to be essential in order for us to

gain the data we need to measure performance.

Mrs. BLACKBURN. Thank you, sir. Go ahead. Thank you, Mr.

Chairman.

Mr. SOUDER. Mr. Davis.

Mr. DAVIS. Thank you very much, Mr. Chairman and I thank you

for calling this hearing. I have gotten very much into this whole

business. In fact, I am leading an initiative effort in Illinois to get

a referendum on the November ballot calling for drug treatment on

demand. We have to get 300,000 signatures and we have gotten

about 60,000 that I have in my office in a safe right now. Let me

40

tell you the headlines in the Chicago Sun Times on Monday, saying

that Chicago is now No. 2 in the Nation in drug overdoses. Philadelphia is No. 1. Chicago is No. 2. And of course lots of folks

thought that the increase would be in the inner city area of Chicago, but it is actually more prevalent in the suburban communities outside of Chicago and especially with teenagers using heroin.

And so it is a big issue and a big problem. One of the questions

we find people are asking as we deal with our referendum effort

is how effective is treatment, that is, if individuals get treated,

then so what? What is the difference between the recidivism rate

for those who are treated and those who are not? And we got into

it really because there is such a close relationship between crime

and drug use and abuse. I mean, most of the crime that we encounter is in some way, shape, form or fashion drug related or drug connected. And so we got to thinking that if we could reduce drug use,

we also could reduce crimes and save ourselves a tremendous

amount of money and human misery and other problems associated

with it.

Is there a discernible difference in different kinds of treatment

and their effectiveness? Do we have enough data to suggest that

people who treat it one way, the recidivism rate might be one

thing. If they are treated another way, it may be something different?

Ms. VOLKOW. Yes, there is some data for certain drug addictions,

particularly for heroin, where we have compared the relapse rate

for one type of treatment versus the other. And in the case of heroin we of course have methadone and buprenorphine, and indeed,

studies have shown very, very clearly and cogently that treatment

with these medications significantly reduces relapse and also the

relapse reduction is significantly greater than basically other types

of treatment intervention.

For heroin addiction, that is definitely the case. For other types

of addictions, there is not enough research to compare one modality

versus another. There are two aspects that I think are very, very

relevant. When you compare one modality versus the other, you

have to consider that not every addict is the same nor are their circumstances. And that’s why I made the point that you have to be

able to tailor the treatment accordingly to the needs of the individual. It is not going to be a transparent comparison in one versus

the other.

Another thing I want to reiterate because it is extremely important and it has carried the field tremendously, is the notion that

when you provide treatment and there is relapse, automatically it

is felt that there was failure when, in fact, relapse may not be failure. When you are treating someone for hypertension, if the blood

pressure has been stabilized for 6 months and 1 day it goes up, did

you fail? You did not fail. You restart treatment. Even though relapse is part of the process, it does not necessarily mean that our

medications have failed and that is one of the aspects that we have

to start to change in the way we evaluate treatment. We are setting up the comparisons of different treatment modalities. We have

the clinical trials network whose function it is to do exactly what

41

you are asking, to compare the different modalities and to optimize

what is best for a given individual.

Mr. DAVIS. Thank you, Mr. Chairman. I have to run to another

hearing, but I would like to ask one additional question if I could,

and that is, is there enough information that we have been able to

evaluate relative to faith-based efforts? And I mean we had an

event Saturday and I had about 400 people in recovery and since

I have been working so closely with them, I have learned so many

things that I haven’t really thought about in terms of who is addicted.

A lot of people seem to think that a lot of individuals who are

addicted are thrill seekers and macho people and that many of the

people who become addicted are lacking in self-esteem and somehow or another, whatever it is, they end up using. We were doing

role playing and all of that to get them ready to go out and help

get these signatures. And there were some individuals who simply

could not ask a person to sign a petition because they could not

look at them. And even when they would be talking they would be

looking away. And of course, the faith-based stuff seemed to help

with that somewhat. Is there any data related to the effectiveness

of faith-based efforts?

Ms. VOLKOW. The answer is that there has not been enough research in this area. We are currently funding several grants that

are specifically addressing the role of spirituality in the recovery

process because most of the treatments that are available for drug

addiction incorporate faith-based approaches into their systems.

We are specifically requesting in all of our program announcements

and request for proposals that faith-based organizations, we are encouraging them to apply for these funds.

Unfortunately, there is not enough research that has been done,

but we are actually encouraging the community to come and request grants so that we can start to look at these questions that

you are asking.

Mr. DAVIS. Thank you very much, Mr. Chairman, and I appreciate your leadership in this area.

Mr. SOUDER. If you have additional written questions that you

want to submit, you can do that as well. If I could ask a followup

on that faith-based point. We have been doing a series of field hearings around the country, both on narcotics and on faith-based. And

one of the things we heard in San Antonio as well as Los Angeles

and a few other places is that in faith-based drug treatment programs, one of the things that has been an effective measure, and

disagree with me if this is incorrect, but I think most people agree

that the more inclined a person is to want to get off their addiction,

the more success there is, not saying that you have to have voluntary compliance or speaking about the program to make it more

successful. But the more one is prepared to have a life changing experience, the more likely you are for success. And one of the roles

of the faith based organizations is preparing their heart for a

change in their life that prepares them for the drug treatment.

Is that one of the things you might be looking at in the research,

and has that come up before?

Because that is a little different than saying it is precisely a drug

treatment program. It is saying that because they are willing to

42

make a life change and they are transforming their life, that has

prepared them now mentally to go through a drug program.

Dr. VOLKOW. What you are saying is correct. It is a basis of a

therapy called transcendental therapy, and it has been shown to be

effective not just for drug addiction but other types of behavioral

disorders, where the main element is to make the person aware

that they want to really incorporate the sense that they want to

make a change in their life. This is an extremely important component of whether a person will succeed or not.

Yet at the same time, you also state that what we have shown,

it does not necessitate treatment be voluntary, but the motivation

of the person to change is indispensable.

As for your question about what is the role of faith-based organizations in helping drive the person to really accept and incorporate

that need to change and willingness to change is one of the items

that may indeed be playing a role. But we have to do the stories

to demonstrate it.

The question scientifically is, what are the active ingredients

that determine the benefits for faith-based approaches? And it is

likely that one of them may be, but that is why we are doing the

work. And we do not have answers yet. So one can just predict.

From previous research, it does make sense that this is one of the

variables.

Mr. CURRIE. I would say one common denominator among all

programs, whether they are faith-based or they’re not faith-based,

could, again, be the seven domains being a way of judging outcome

and effectiveness over time as well. And I think those domains can

be utilized with a wide range of interventions.

Also, I think with faith-based approaches, recovery is such an individualized process. As Congressman Davis said, if there were 400

people in the room, there will probably be 400 different stories of

recovery, some with common elements.

But the role that faith plays, sometimes, it is an upfront role as

you just described. Sometimes, it’s a role that, once they’ve been

through a medically based program in order to sustain recovery in

the 12-step program, the spiritual component of that helps them

sustain recovery.

So I think faith can play a role at different levels in an individual’s life, and again, I think the biggest challenge for us in using

recovery as we are framing both public policy and public finance

is that it is such an individualized process.

Mr. SOUDER. I want to ask one other question. The most spectacular failure, certainly in North America and possibly the world,

is Vancouver, British Columbia, right now in their needle-exchange

program. And now on top of having the world’s highest HIV infection rate, they have this huge expanded market of actual heroin

addicts. And now this high-THC marijuana, it has now corrupted

several officials in their government. They are being prosecuted,

going down the path of Colombia, more or less, and what happened

in Mexico before those governments started to tackle it.

In Vancouver, they started this program in 1988. They are now

up to 2 million needles that they are distributing on the street. And

people call that harm reduction. And I wanted to have two clarifications here.

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One is, there is a difference between harm reduction defined that

way, which is more of a maintenance question. In other words, a

heroin addict is getting a needle. The presumption is that you reduce AIDS, which has not necessarily been proven. The presumption is that you reduce AIDS, but you wouldn’t treat the heroin.

That is different than the treatment programs you are talking

about. You are not talking about maintenance. You are talking

about changing someone’s addiction.

And the second thing I wanted to make sure that we were clear

on is that do we have any data, or what percentage of people who

actually get the needle exchange go to treatment? Or in fact, does

giving them the needle perpetuate it, and then they do not see the

need for treatment?

Dr. VOLKOW. Actually, it is interesting, because you were making

the statement in the way that you were saying, which is absolutely

correct, that just providing needles by itself is not helping anyone.

But what research has shown is that needle-exchange programs

in the line of a comprehensive drug-treatment program have been

shown to reduce HIV, and also includes the likelihood that these

individuals will stay for treatment. So needle exchange by itself is

not going to solve a problem. Not at all.

And it also addresses another aspect that is very relevant when

we look at one thing. We sort of say we are looking at treatment.

And the other aspect I view, which is very relevant, is that of prevention. So what is the message that we are sending with respect

to prevention in terms of just exchanging needles?

And that is why, when we bring up that issue, we basically say

what science has taught us is that needle-exchange programs in

line with a comprehensive drug-abuse treatment program have

shown in fact to reduce the cases of HIV when they are combined.

Not by itself.

Mr. CURRIE. You are exactly right. The treatment programs we

are talking about are not about harm reduction. In fact, when we

talk about prevention and recovery, we are not talking about harm

reduction but harm elimination. It’s bottom line the risk factors

you need to eliminate in the prevention scenario. As one attains

and sustains recovery, they begin to manage their illness. They

begin to manage their life. And that goes much beyond a harm-reduction vision.

Mr. SOUDER. I thank you both for your testimony, and we will

probably have some written followups, not only from me but from

other members in the subcommittee.

Thank you for coming.

Mr. SOUDER. If the second panel could come forward. As you

come forward, if you could remain standing so that we could do the

oath. If witnesses would raise their right hands.

[Witnesses sworn.]

Mr. SOUDER. Let the record show that each of the witnesses responded in the affirmative.

Thank you all for being here today. Our first witness is Dr.

Thomas McLellan, director of Treatment Research Institute in

Philadelphia, PA.

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STATEMENTS OF THOMAS MCLELLAN, PH.D., DIRECTOR,

TREATMENT RESEARCH INSTITUTE, PHILADELPHIA, PA;

CHARLES O’KEEFFE, VIRGINIA COMMONWEALTH UNIVERSITY, RICHMOND, VA; KAREN FREEMAN-WILSON, EXECUTIVE

DIRECTOR, NATIONAL DRUG COURT INSTITUTE, ALEXANDRIA, VA; JEROME JAFFE, M.D., PROFESSOR, UNIVERSITY OF

MARYLAND, BALTIMORE, MD; CATHERINE MARTENS, SENIOR VICE PRESIDENT, SECOND GENESIS, SILVER SPRING,

MD; AND HENDREE JONES, PH.D., RESEARCH DIRECTOR,

CENTER FOR ADDICTION AND PREGNANCY, BALTIMORE, MD

Dr. MCLELLAN. Thank you. I was already told that one person

wrote on both sides. I wrote on no sides, so I will just read it here.

I am Tom McLellan. I am a researcher in the substance-abuse

treatment field from the University of Pennsylvania, Philadelphia,

and the Treatment Research Institute there.

I am not an advocate and neither I nor my institute represent

any treatment or Government organization. I offer evidence on the

effects of treatments for alcohol, opiate, cocaine and amphetamine

addictions based on my own work of over 400 reviewed studies and

based on reviews. I’m the editor of the journal Substance Abuse

Treatment, so I see many reviews of other work.

I have five very simple points to make. First, addiction treatment

can be evaluated. It’s not something that you have to wonder

about. The same standards of evidence apply as apply to the evaluation of medications and interventions commonly done in the Food

and Drug Administration. There are over 700 published studies of

contemporary treatments so there is an evidence base.

Point two, effectiveness does not mean cure. We do not have a

reliable cure. Yes, there are many people in the field who have become abstinent and lived productive lives. They are probably not

going to be able to drink or use drugs socially again. So there is

not a cure. On the other hand, evaluation perspective and a determination of effectiveness shouldn’t just mean that the patient feels

better.

The scientific basis for effectiveness means three things, as it’s

commonly evaluated. First is the significant reduction of the substance use. Alcohol, cigarettes, opiates, cocaine, amphetamine—significant reduction.

Second is improvement in personal health and social function.

Basically, a reduction of the society’s responsibility for the individual.

And the third piece of evidence is reduction in public health and

public safety threats. And that is what we mean by effective.

Point three, not all treatments are effective. Some treatment programs are quite competent. Some aren’t, like any other field. Certain treatments do not work. We have talked about them already.

Detoxifications, for example, do not work unless they are followed

by continuing care. Acupuncture does not work unless it is part of

some other broader treatment.

Many contemporary treatment components have not been evaluated. They have simply been adopted well before modern methods

have been brought to bear. And also many evidence-based treatments, treatments that were discussed by Doctors Volkow and

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Curie, are not in practice because of financing and training issues,

and I will discuss that later.

Better treatments have the following characteristics, in general.

I am happy to answer specific questions but in general, longer is

better, in an outpatient setting and one which includes monitoring.

One of the Congressmen asked for one of the components, and

monitoring is an important one.

Better treatments include tailored social and medical services.

Better treatments typically involve family.

Fourth point, addiction treatment is not the same as it used to

be, but the evaluation of addiction treatment is the same as it used

to be. And it does not fit anymore.

Not so long ago, over 60 percent of addiction treatment was delivered in a residential facility someplace. You went someplace to

that famous 28-day treatment, and the question was, how long do

the good effects last? So you did a 6-month, 12-month post treatment evaluation. In general, relapse rates were 50 percent just

about anywhere you went.

Now, addiction treatment isn’t delivered in residential facilities

anymore. Over 90 percent of addiction treatment in this country is

done on the street in outpatient settings. People are ambulatory.

My point there is, it’s too late to wait 6 months, 12 months after

they are out of that kind of care. What you want to know is, are

people attaining abstinence? Are they attaining employment? Are

they being re-arrested? Are they using expensive hospital resources? That evaluation has not caught on yet.

The kinds of studies that have been done have to be able to give

real accountability in the field, if you ask my opinion, now because

that is where treatment is, it’s on the street.

The final thing I have to simply say is that the basic infrastructure of the U.S. treatment system is in very bad condition. Program

closures or takeovers are over 20 percent a year. Program directors

make less money than prison guards and have fewer benefits. The

great majority of programs have no full-time physician, no psychologist, no social worker. That is the majority of treatment programs

in the country. Counselor turnover rates are comparable to the

fast-food industry. The pay is terrible, and there aren’t standards.

Though there are well-studied, excellent medications and therapies available, thanks to the work of the National Institute on Alcoholism and National Institute of Drug Abuse and CSAT, frankly,

most cannot be adopted by the present system. This is a system

that can’t be regulated into effectiveness. It’s going to have to have

financing, incentives, to bring professionals into the field, to retain

them, and it needs the kind of infrastructure that will provide the

kinds of things that are associated with better treatments has to

be available. And that concludes my testimony.

[The prepared statement of Dr. McLellan follows:]

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Mr. SOUDER. Thank you. We will now go to Mr. O’Keeffe from

the Virginia Commonwealth University.

Mr. O’KEEFFE. Thank you, Mr. Chairman, members of the committee. It is a privilege to be here this afternoon.

Others testifying today will address more directly the measurement of the success of treatment effectiveness. I hope to provide

the committee with a perspective on overall treatment policy. Together, these perspectives will, I hope, help the committee in its deliberations about the best strategies to improve drug addiction

treatment.

The main point I wish to make today is that Federal policy is not

optimal for the development and/or deployment of new treatments.

There have been some recent improvements, but much more needs

to be done.

As you know well, Mr. Chairman, because of longstanding strong

Federal regulation, the system for treating opiate dependence has

evolved as one separated, even isolated, from the normal practice

of medicine. This has resulted in a disconnect between the findings

of the research community and the practices of treatment providers.

In 1972, thanks to the work of the country’s first drug czar, Dr.

Jerome Jaffe, proposals related to the appropriate use of methadone as addiction treatment were included in the Nixon administration’s initiative on drug abuse. This initiative established stringent regulations regarding eligibility for treatment, dosage to be

administered, level of counseling, length of treatment and criteria

for take-home dosing.

To prevent abuse and diversion of methadone, the subsequently

promulgated regulation created a closed system that allowed treatment only through specialty clinics. And according to Dr. Jaffe, the

drafters of the regulations did not intend for medication dispensing

to be forever limited to a few large clinics. Although they recognized that access to treatment by individual physicians might be

temporarily limited, they believed that the regulations would be revised as knowledge expanded and as opiate maintenance treatment

became less controversial.

Sadly, this was not the case. Those temporary regulations remained and have been significantly expanded over the subsequent

30 years.

We learned in the 1960’s that treatment could be effective. However, because the general portrayal of patients addicted to opiates

as miscreants, treatment was confined to a small number of specialty clinics generally located in larger metropolitan areas and

controlled by stringent regulations. This depiction of patients generally led communities to resist allowing treatment programs to locate in any but the least desirable areas. Physicians were reluctant

to treat addicted patients because of the public perception of these

patients, the treatment locations and the complexity of the regulations.

Consequently, a non-physician-oriented treatment system began

to develop. Addicted patients became clients of programs that eventually developed a fortress mentality. Because treatment moved

further away from the mainstream practice of medicine and more

and more clients were seen by counselors and advisers instead of

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patients seen by physicians, more and more regulations were needed to assure that appropriate treatment protocols were followed.

Treatment programs became increasingly insular under a maze

of complicated rules, further distancing physicians and the health

care community from the care of these patients.

Meanwhile, the research community lead by NIDA was making

inroads into new treatment methods, pharmaceutical products and

improvement in the treatment of co-occurring diseases. These developments led to new products, new uses for old products and new

approaches to the treatment for this chronic, relapsing brain disease.

It is essential that Federal policy now ensures that these new

emerging developments be transferred to the practice of medicine

as quickly and as responsibly as possible so that more patients will

have access to treatment.

Nearly 6 million Americans affected by this disease remain untreated. This untreated population continues to impose a significant burden on both the criminal justice system and the public

health system. Both NIDA and CSAT have recognized this treatment gap and are working toward closing it.

These efforts are commendable, but the executive branch is constrained by legislative requirements, constrained by mandates and

restraints, constrained by the patchwork of Federal and State regulations, which has grown so complex that very few physicians are

willing to begin treating patients because of the infrastructure required by the rules.

In a sense, over time, we have created a monopolistic system

which has arisen from the complex regulatory environment which

now discourages new treatment providers from entering the field.

We are discouraging treatment with evermore burdensome, monopoly building regulation.

Congress recognized this problem and enacted the Drug Addiction Treatment Act of 2000 which, for the first time in over 80

years, provides an opportunity for qualified physicians to treat addicted patients in their own office or clinic setting. While this legislation was a major step in bringing the treatment of addiction closer to the practice of medicine. And your bill, Mr. Chairman, will

correct some of the oversights of data. We are clearly not at the end

of the road.

There are crucial next steps, not the least of which is the

daunting task of encouraging and enabling 5 million Americans to

seek and receive treatment for their disease.

DATA began the process of de-stigmatization and its treatment,

but it did not end that process. This committee can help ensure

that policies, priorities and funding are all concessive to the effective treatment.

Perhaps, it’s time for a re-examination of existing treatment policies and their consequential regulatory requirements that discourage adequate treatment. NIDA and the institute of medicine have

the responsibility and access to the expertise to provide recommendation for sorely needed policy and regulatory change which

they lack authority and incentive to make.

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The public health as well as this committee would be well served

by seeking their advice on legislation designed to remove existing

impediments to effective treatment.

Thank you, Mr. Chairman.

[The prepared statement of Mr. O’Keeffe follows:]

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Mr. SOUDER. Thank you. Our next witness is the honorable

Karen Freeman-Wilson, executive director of the National Drug

Court Institute in Alexandria.

Thank you for being here.

Ms. FREEMAN-WILSON. Mr. Chairman and members of the subcommittee, I would like to thank you for the opportunity to represent the National Drug Court Institute and address this very important issue.

Dr. McLellan has already talked about the importance of measuring client outcomes during the course of treatment when it is

still possible to alter the treatment plan for the client’s benefit. I

will not duplicate his discussion except to underscore my agreement that traditional approaches of measuring pre-to-post changes

in client functioning have unfairly obscured the true effects of drug

treatment services because they assess outcomes after treatment

has been withdrawn from what is a chronic and relapsing condition.

Although it is the position of our organization that these and

other observations heard here today are applicable to treatment in

all contexts, I will frame my conversation in the context of our findings in the drug court arena.

Drug courts are a unique blend of treatment, case management,

intense supervision and support services along with judicial case

processing. The success or failure of participants in recovery depends heavily on their access to quality effective treatment in drug

court.

There are a number of indicators that can be reviewed to determine whether treatment is effective in drug court. The first is the

rate at which offenders report to treatment pursuant to a court

order and the length of stay and the rate of completion once they

arrive.

Next is the offender’s abstinence from the use of alcohol and

other drugs. Each drug court is required to monitor abstinence

through regular, random and observed drug testing. This means

that most participants are tested at least two to three times a

week.

Another measure of the effectiveness of treatment in the drug

court context is the ability of the offender to comply with aspects

of the drug court program. Is the person actively engaged in community service? Are they actively involved in job search, vocational

training or school? Are they attending self-help meetings? Are they

appearing as ordered for court review hearings and meetings with

probation officers and other court staff? Are they paying their fines

and fees?

Another factor which may assist in the determination of whether

treatment is effective is the status of the offender’s personal relationships during the drug court program. Is there a spouse, significant other, parent or child who regularly accompanies the offender

to court, probation and counseling sessions? How successful is the

participant in improving their living conditions as indicated by living most of the time in their own apartment or house, with their

families, in someone else’s apartment, room or house, or in sober

housing?

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The measures discussed above address our evaluation of treatment while an offender is actively involved in the court process.

Another related measure is the completion of educational or vocational programs and elevation in job status after treatment. One

of the most important factors to the success or failure of drug

courts and treatment is the individual’s decrease in criminal involvement or activity. That is measured generally by recidivism.

While all of the factors discussed above are important, some are

easier to measure than others. It’s relatively simple to maintain

and compile statistics with drug testing. It’s easy to review whether a person reports for treatment or engages in treatment.

In looking at the more challenging measures, you must ask: How

do you gauge the quality of relationships? How do you look at the

number of trips a family member takes to court?

In conclusion, there are a number of considerations that must be

made in an effort to standardize measurements to achieve more effective treatment research. First, it’s important to take any measurement at three key points in time: Before, during and after treatment, whenever possible. There is an inherent challenge involved

in measuring indicators prior to treatment because there will be a

need to rely heavily on self-reporting. I detail the other points and

measures in my testimony.

In concluding, I would recommend that this committee call for

the development and adoption of a core validated data set to be

captured in all federally funded evaluation-and-research studies to

drug abuse treatment.

I would also recommend that this committee put its weight behind the adoption and enforcement of best practice standards for

drug treatment programs with suitable performance benchmarks

that programs must meet in order to establish that they are providing evidence-based interventions with appropriate and documented treatment integrity. National organizations such as

NADCP are ideally suited to review the research to establish performance benchmarks and to promulgate suitable standards for

their respective disciplines.

Thank you.

[The prepared statement of Ms. Freeman-Wilson follows:]

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Mr. SOUDER. I need to correct the record with something because

I was trying to sort it out, and it was in the footnotes of your testimony.

I was very confused when I read this: executive director, Alexandria, VA, because, I am saying, I think she was Attorney General

of Indiana and on the Governor’s drug commission. So first off, you

are one of us, not part of this Washington group here. So I welcome

a fellow Hoosier. I should have caught that earlier in my introduction of you, thank you very much for coming.

Dr. Jaffe is a professor at the University of Maryland in Baltimore. Would you elaborate, did I understand Mr. O’Keeffe to say

that you were the first drug czar?

Dr. JAFFE. I have been called that, Mr. Chairman.

Mr. Chairman, members of the subcommittee, I thank you for inviting me to speak to you on measuring the effectiveness of treatment.

In January, Join Together, a project of Boston University School

of Public Health, released a study called, ‘‘Rewarding Results: Improving the Quality of Treatment for People With Alcohol and Drug

Problems.’’ I had the privilege of chairing the panel that produced

the report. I will offer some highlights of the report here and will

submit the entire report for use by the subcommittee.

First, some preliminary thoughts on evaluation. First, how one

evaluates or measures the effectiveness of treatment programs depends very much on the purpose for undertaking the evaluation.

For example, an employer who wants to know if a program covered

by the company’s insurance plan is effective may be interested in

knowing not only whether or not the problem drug or alcohol use

is stopped but also how soon the employee can return to work.

Another agency may be more interested in knowing if treatment

has resulted in decreased criminal activity.

Depending on resources and goals, one can obtain information directly by finding and interviewing patients or indirectly by analyzing data bases. It’s also possible to look at surrogate measures of

outcome, measures that correlate highly with good outcome, such

as retention in treatment.

Federal agencies have put out a number of guidelines that, if

properly implemented, could improve the overall quality of treatment. The guidelines aimed at improving quality are unlikely in

and of themselves to do the job. They cannot compel high-quality

treatment.

Crucial to high-quality treatment is a well-trained work force as

well as better application of findings that have emerged and will

continue to emerge from research.

But in the real world of treatment where there are about 12,000

programs, two major problems impede the implementation of those

guidelines.

First, many programs are quite small and even many large ones

lack the financial resources to put guidelines into practice.

Second, because the job is stressful and salaries are low, there

is a high turnover of personnel, not only among first-line counselors

and clinicians but also among program supervisors and managers.

With such turnover, much of the investment that programs make

in clinical and management training is lost.

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The Join Together panel concluded that unless there are clear

and continuing incentives to provide quality treatment, quality will

always take second place to program survival or expansion. What

is needed to drive quality improvement is a commitment by those

who pay for treatment to reward good outcome. In other words, reward results.

Again, depending, the results can vary. Merely publicizing results can have the effect of stimulating pride in the better programs and stimulating a sense of urgency in the less effective ones.

You can make the rewards more tangible by paying more to the

better programs or directing more patients to those programs.

Implementing systems that look at outcomes will require additional resources. These shouldn’t be carved from what is now available for treatment. Rewarding results should be seen as a means

to improve outcome. It is not a pathway to getting more treatment

for less money.

The Join Together panel recommends that rewarding results be

defined as a national goal. On the road to reaching that goal, there

are many technical and political obstacles to be overcome. And

many upon different groups will have to be persuaded that it can

be done and should be done.

I thank you for your time and would be happy to answer questions.

[NOTE.—The Join Together report entitled, ‘‘Rewarding Results,

Improving the Quality of Treatment for People with Alcohol and

Drug Problems,’’ may be found in subcommittee files.]

[The prepared statement of Dr. Jaffe follows:]

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Mr. SOUDER. Thank you very much for your testimony.

The next witness is Catherine Martens, senior vice president of

Second Genesis in Silver Spring, MD.

Ms. MARTENS. Thank you, Mr. Chairman, Congressman

Cummings.

As the chairman said, my name is Cathy Martens, and I am the

executive director of Second Genesis and a member of the Board

of Directors of the Therapeutic Communities of America.

As a provider, Second Genesis appreciates the opportunity to provide the committee with our written testimony about measuring

the effectiveness of drug treatment.

Second Genesis is the oldest therapeutic community-based substance provider in the Mid-Atlantic region and Maryland’s largest

provider.

As a successful nonprofit for over 35 years, we continue to serve

the substance-abuse populations in Washington, DC, Virginia, and

Maryland. We have criminal justice programs, programs for women

and their children and a highly respected integrated program for

clients with co-occurring disorders.

Society cannot continue to pay for the individuals who unsuccessfully cycle through various treatment options and criminal justice

systems. In the Outlook and Outcomes 2002 Report from Maryland, an untreated substance abuser on the street costs society an

estimated $43,300 a year. An incarcerated substance abuser costs

$39,600 a year.

In contrast, 8-months of residential treatment at Second Genesis

costs only $17,280, and for the remaining 4 months of the year and

beyond, the recovering taxpayer is a productive member of society

and a taxpayer.

Second Genesis clinical professionals have determined that the

shorter the stay of the client, the more likely that client is to relapse.

Our own data collection demonstrates that 6 months after leaving residential treatment, 70 percent of long-term clients reported

no alcohol or other drug use in the 30 days prior to that survey.

The overall success rate of our program is 63 percent, significantly

higher than that of the Maryland Statewide average of 47 percent

for similar clients.

As a provider, we are largely publicly funded, which requires us

to report to Government contract officers, foundations and other

sources of funding, proof that the dollars that they have invested

with us have produced concrete results. We use the HATS reporting protocol to report regularly and electronically to data collection

systems for our contractors. The majority of this information is in

actual real-time.

We collect information on our clients at admission, halfway

through treatment, at discharge and 90 days post-treatment. However, in order to provide this outcome information, the burden of

reporting has grown enormously. We are also responsible for staff

training and other increasing costs associated with the outcomebased data collection.

Second Genesis has approximately 40 counselors that spend a

minimum of 10 percent of their job completing outcome-related paperwork. This number does not include all of the other paperwork

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that must be completed for each client. It becomes increasingly

burdensome to dedicate staff hours and training to data collection

at the expense of direct client treatment.

We are mandated to maintain this data to prove program effectiveness. Additionally, Second Genesis employs three full-time individuals who manage all aspects of this data collection and its analysis. However, funding to comply with Federal and other contractual mandates has not followed suit.

We collect information on all of the SAMHSA seven domains, yet

it is the analysis of this data that is truly important.

In summary, substance abuse treatment programs should be constructed on and funded on evidence-based methodologies that are

outcome-based and meet appropriate performance standards. According to Therapeutic Communities of America, any outcome

measures should have the following considerations: addicted individuals must be placed in the appropriate level, type and standard

of care to achieve positive and quality results. According to the

NIDA research report, Therapeutic Communities [TC], for individuals with multiple serious problems, research again suggested outcomes were better for those who receive TC treatment for 90 days

or more.

Treatment and any other performance standards must be clientbased and should flow as a function of the client necessitating a coordinated and comprehensive continuum of care for that client. Any

measure or performance standard should recognize that different

treatment methodologies, should reflect the timeframe from which

favorable impact outcomes are likely to occur. This consideration

also includes modifications to treatment, when necessary, in working with special populations.

Any measure should recognize Therapeutic Community residential programs and permit at least 8 to 12 months of continuous

treatment. Outcomes and measures should be no different in application to addicted individuals than any other chronic disease. Realistic goals for specific substance-abuse populations should be established. In the case of substance abuse, unlike any other illness, our

system is often in danger of undertreating the client.

No Federal or State measurement or performance standard

should be mandated without providing necessary direct funding,

technical assistance and capacity building to the service providers.

Thank you for the opportunity to testify before you, and I would

welcome any questions you might have. Thank you.

[The prepared statement of Ms. Martens follows:]

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Mr. SOUDER. Thank you.

Our final witness today is Dr. Hendree Jones.

Dr. JONES. Hendree.

Mr. SOUDER. Hendree Jones, a research director for the Center

for Addiction and Pregnancy in Baltimore, MD.

Dr. JONES. Good afternoon, Mr. Chairman.

And a special hello to Ranking Member Elijah Cummings, who

represents the patients and families in Baltimore City where Johns

Hopkins Bayview Medical Center for Addiction and Pregnancy is

located. And thank you very much for inviting me to testify.

I serve as the director of research for the Center For Addiction

and Pregnancy [CAP]. It is located at Johns Hopkins Bayview Medical Center. And I am also a NIDA-funded researcher on drug

treatment effectiveness. Additionally, my program is a member of

the Maryland Addiction Directors Council and State Association of

Addiction Services, a national organization of State alcohol, drugabuse treatment associations and provider associations whose mission is to ensure the accessibility and accountability of quality drug

and alcohol treatment and prevention services.

I have spent a lot of time thinking about how to expand and improve drug treatment effectiveness, and obviously, we need to close

the tremendous treatment gap. We also need to invest in the best

treatment options, ensuring that our science makes it onto the

streets and makes it into everyday practice.

CAP’s outcomes actually demonstrate that drug and alcohol

treatment can be effective, and I want to share some of our latest

successes with you: 75 percent of the women who are enrolled in

CAP have drug-free deliveries and are drug-free 3 months after

completing our treatment program; 81 percent of our children are

drug-free at delivery; 70 percent of our women maintain custody of

their children; 15 percent of our women actually decrease dependency on welfare; and 95 percent of our women actually remain

HIV-negative while in treatment.

Our average CAP baby is born at a normal time, at a very

healthy birth weight, with normal alertness. Investing in CAP

treatment can actually save $12,000 per infant through a reduction

in the neonatal intensive care unit stays.

CAP successes are actually typical of many treatment programs

across the country that treat women with children. And let me tell

you a little bit how we have been able to achieve those outcomes.

CAP was founded in 1991, and it is an outpatient as well as residential treatment program. And we have a number of ancillary

support services, including the drug abuse treatment that we provide. We provide transportation to and from the program. We have

onsite OB/GYN care and onsite pediatric care and also onsite child

care for women attending the outpatient treatment. And we have

intensive outreach services. So if a client doesn’t show up for treatment, we are out there on the streets looking for the patient to

bring her back in. And it is these ancillary support services that

help us achieve our outcomes.

There are other recommendations I have for improving the quality of treatment services. The ability to conduct studies and actually measure outcomes will improve the quality of treatment. CAP

has been able to conduct these studies because we have been fundVerDate 11-MAY-2000 10:31 Dec 03, 2004 Jkt 000000 PO 00000 Frm 00098 Fmt 6633 Sfmt 6633 D:\DOCS\96744.TXT HGOVREF1 PsN: HGOVREF1
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ed by NIDA. And we have been able to look at specific treatment

interventions, and this information has actually informed our practice and improved it.

Transferring science to service also improves the quality of care.

And what we have learned from studies we need to be able to implement into a first-line, frontline provider service. Without the

technology that was discussed by Dr. Volkow, including the Clinical

Trials Network and SAMHSA’s Addiction Technology Transfer

Centers, the addiction treatment field will be much slower to accept these new technologies.

We also need to be funding new techniques, including emerging

medications as well as medications and behavioral interventions, to

put the best practice into place.

We need to be able to recruit and retain a qualified addiction

treatment work force. The development of course work in medical

and nursing schools is key to encouraging practitioners to recognize

drug dependence or abuse as well as to know where to provide referrals for those patients to treat them.

We also need to not forget our recovering community who has

long been the frontline providers in this treatment.

Finally, it would be good to develop loan forgiveness programs

and repayment programs in order to facilitate people to stay in this

typically low-paying field.

Funding access to the full continuum of care will certainly help

to improve treatment quality. Patients are often not able to go from

one level of care to the next, and CAP patients are certainly not

an exception to this barrier. Funding the full continuum of treatment is very difficult for different jurisdictions given the pressure

on the limited amount of funds that we have, as well as the limitations that exist on current funding mechanisms like Medicaid.

If we were to increase the fiscal year 2005 substance abuse prevention and treatment block grants, Access to Recovery programs,

and target capacity expansion programs, we could help meet the

pressing needs for treatment.

Additionally, better Medicaid coverage would also improve treatment for women with children. We need to be moving toward a system of uniform treatment-outcome measures across funding

streams to help improve treatment quality.

Moving toward this system of uniform performance measures

across Federal funding streams will help benefit providers by reducing the large paperwork demands that are increasing and help

us to be able to more clearly react to the different types of outcomes that are demanded by potentially different providers.

These savings could hopefully help us reinvest in provider training and back into treatment.

When SAMHSA determines the performance outcome measures,

I hope they will consult with the providers as well as the States

because outcome data is first and foremost generated at the provider level.

Thank you very much for holding this hearing today and for

highlighting the importance of drug treatment. My patients and

the Center for Addiction and Pregnancy staff and I applaud you.

And I would be happy to take questions.

[The prepared statement of Dr. Jones follows:]

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Mr. SOUDER. We have three votes. We have approximately 7 minutes left in the first vote.

Are all of you able to stay for a little bit longer? Nobody has a

plane or anything? We are going to go vote.

It will probably be about 20 minutes until we get back unless we

have to hold the vote open for a while.

The subcommittee stands in recess.

[Recess.]

Mr. SOUDER. The subcommittee will come back to order.

I want to thank each of you for your testimony and each of you

for your years of work.

I want to start with two different categories. So let me start. Dr.

Jaffe and I believe Mr. O’Keeffe both talked about how to put some

incentives into the system for behavior. I don’t know whether Dr.

McLellan referred to that, too.

Could you describe a little bit more, you said, I believe it was Mr.

O’Keeffe. Was it you who said regulation alone wouldn’t do it; we

need to have incentives? And Dr. Jaffe referred to incentives as

well.

What exactly do you mean by incentives? Are you saying that

you can’t be eligible for certain programs unless you do this? That

there would be a bonus if you did certain things? Longer stays? Different things?

And if we gave those, would it give incentives for programs to

cherry pick, take the easiest to treat as opposed to the hardest to

treat?

Dr. JAFFE. When you put incentives in for producing results, you

always run the risk that those who are trying to get results will

pick the easiest cases. This is true in medicine in general. It’s probably true of life in general.

And one has to develop the methodology—there is some in place

that is just not perfected yet—of adjusting for how difficult the initial cases are so that you can fairly compare practitioners or programs in terms of what they have achieved. And that is the one

area where carefully comparing programs will need further investment to really make that a fair process.

When you ask about what incentives you can have, the incentives can vary.

They can vary from just posting the scores of programs in the

city. It can appeal to pride. It can appeal to consumers, the people

who are seeking treatment. They can vote with their feet. If you

rank the hospitals in terms of their mortality rates for bypass surgery, you quickly find that people seek treatment at the hospitals

that have the lowest mortality rates.

So you don’t necessarily have to pay more, but clearly the providers, I mean the payers, whether it is the government or insurance

plans or employers could begin to say, we pay more for better outcomes. The net effect of that is that those programs that give bad

outcomes get paid less, and ultimately they are either going to

have to merge with more effective programs or go out of business.

That is what happens to any organization that delivers a less than

adequate product.

The real question there, however, is whether or not at the State

level there will be the political will to stop paying for a particular

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program. Programs often develop their own political support. They

are not without allies and the bureaucrat that tries to say, we are

not going to pay you anymore because you are substantially below

standard, may find he has a very short tenure in the bureaucracy.

I say that having been on both sides of this issue.

Mr. SOUDER. I don’t know if anybody else has a comment, but I

would ask Ms. Freeman-Wilson, could you comment a little bit on

that, coming out of the Gary area where, in the region, there are

success stories and not success stories, but certainly Gary itself to

some degree, East Chicago, have overwhelming challenges.

We are going through the very thing that Dr. Jaffe just talked

about in education. What do you do when a school system is relatively disorganized and how do you get the political will? And

what if the treatment programs were concentrated in that area and

somebody didn’t see how to do that? Yet, fundamentally, there are

basic truths in trying to address the question, because we have

been funding some programs which, we are all kind of familiar

with, are less effective than other programs. But they have a bureaucratic momentum and a size and a number of people who have

been through a comfortability with the insurance or connections.

How do we put this kind of accountability in and yet address the

difficult questions that would be, for example, in northwest Indiana.

Ms. FREEMAN-WILSON. There are two examples in the Gary area

that really speak to Dr. Jaffe’s point. They are the Safe and Drug

Free Schools program and the second is the drug court there, because what happened with both of those programs is that they did

evidence some success. And that success was proven through a very

clear evaluation process, one that was not only given to the participants and those who ran the programs, but those who also funded

the programs both at the Federal level, at the State level and then,

ultimately, the local level. Because the local officials, city and county officials were looked to pick up the funding, particularly for the

drug court program, and they were willing to pick it up because it

showed a reduction in recidivism, it showed more sustained treatment, and it also showed that after a year and after 2 years, that

there was still a sustained reduction in recidivism.

The challenge in both the Safe and Drug Free Schools program

and the drug courts and in other drug courts in the region has been

the consistency of their treatment. I think that the numbers that

were posted in Gary were there because of not necessarily the

treatment, although the treatment was helpful, but also the use of

nonconventional programs and self-help support groups like NA,

like AA and like the presence of the Salvation Army programs.

So when the panelists here talk about the importance of treatment, I think that, and the challenges that you cited in the northwest Indiana region, I think that those are very evident, if you look

at the type of treatment that is important to advance the cause forward.

Mr. SOUDER. Ms. Martens, what is your reaction, as a provider,

to posting results that everybody could see, putting some form of

accountability. How would we do this so that we didn’t have incentives to kind of game the system to some degree?

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Ms. MARTENS. In the State of Maryland, Congressman Souder,

that is already being done. We are talking real-time outcomes. And

actually we just got a RFP yesterday, which mandates providers to

adhere to real-time data collection.

Mr. SOUDER. If I had a cousin who I wanted to send, I could look

at the different treatment centers and have some sort of a common

comparison across?

Ms. MARTENS. Not really, because there is no treatment on demand in Maryland, if you are not in the criminal justice system.

Mr. SOUDER. What if I wanted to pay for it?

Ms. MARTENS. If you wanted to pay for it, yes, you could find

treatment. And I would liken it to the charter school initiatives,

where the efficacy of what you do is judged, as Dr. Jaffe said. You

are not going to choose a school for your child that has the highest

failure rate in the city or the State.

One of the things I was going to mention to you that Maryland

is doing, and I really commend the State for doing this, is that we

have benchmarks to meet to get paid for each client. So you get

paid a little bit at the beginning. And as that client goes through

treatment and successfully completes, and there is a balloon payment in the end for your efficacy with that client. So you are really

being paid for your outcomes with each individual client, which is

a very interesting way for the State to get what they pay for.

Mr. SOUDER. I know Director Walters testified in front of this

committee when we first began to look at how they were going to

tackle the treatment initiative, and he was proposing to do that at

the Federal level.

Dr. McLellan you said that you felt that some of our measurements weren’t adapting for outpatient as opposed to inpatient.

What is your reaction to what they have proposed there?

Dr. MCLELLAN. You’ll get the kind of thing that Dr. Jaffe and

Judge Wilson are talking about if you do post-treatment-only evaluation. If you evaluated first grade schools in the State of Maryland by the number of people who graduated from high school or

college, you’d never figure out what was the best thing to do in first

grade to make that happen.

The kind of model that Judge Wilson is talking about is much

more iterative and proactive. Feedback occurs week to week to

week. And just as in a medical condition blood pressure is a clinical

measure, it is also an outcome. So you don’t have somebody coming

in from the outside taking the blood pressure. They take the blood

pressure measure because it is both an outcome and it is a point

that gives you decisions for the next thing that you do. If the blood

pressure doesn’t go down, you change.

So I think that is what I am talking about. You need the kind

of immediate feedback, especially since 90 percent of your treatment is in an outpatient setting, those individuals, 60 percent of

whom are coming from the criminal justice system, they are not

away someplace in a program, they are in the community. So immediately you want to know, what is the urine test? Are they getting employed or are they getting job training? Are they hooking

up with an AA sponsor? All the things that Judge Wilson talked

about and it is possible to do.

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Mr. SOUDER. That kind of leads to my other big category of questions. One of the more interesting things that happened back when

I was a staffer, this must have been in the late 1980’s. A number

of my conservative Republican friends all of a sudden found themselves in the administration. And one of our principles was, well,

we ought to block-grant things. We, as conservatives, believe we

shouldn’t have so much control and so many regulations.

We heard Ms. Martens say that the paperwork was becoming

burdensome and that they were having to have all these different

people instead of actually being practitioners and so on. And as we

held an oversight hearing, all of a sudden my conservative friends

were having so many of these regulations. Their comeback was,

well, the only variable is accountability which we have been hearing about on this same panel, talking about too many regulations

and we need more measurements and more flexibility to treat the

patients.

Our dollars aren’t increasing as fast as the demands.

But, by the way, we need more information and you are suggesting a very comprehensive evaluation type of approach. And part of

the reason, I remember Becky Norton Dunlop, who was at the Justice Department at that time, said, what we found out was, when

we didn’t require all this type of thing, that most people were honest, but a bunch of people started ripping us off. And our theft and

fraud rate went up so dramatically that it was more expensive

than the paperwork burden. And, furthermore, the public wouldn’t

support this type of effort if when they hear these cases that were

having some of this in, that is, dogging Medicaid or the food

stamps program, where you find some person and they get on 60

Minutes or 20/20 and this person has been ripping off the Federal

Government for this amount of money. So next, we put a whole

bunch of regulations on for everybody in the system.

How would you suggest we do this? Because we want to make

sure our dollars are effective. There isn’t a Member of Congress,

anybody on the street. Everybody I know who is on drugs has been

through multiple treatment programs. And we go through this effectiveness thing and then we put a whole bunch of requirements

on. How would you address this dilemma?

Dr. MCLELLAN. Just to start, I am certainly not the expert here,

there is a big difference between paperwork, which everybody in

this place will tell you is overwhelming. For example, in Philadelphia, it takes 3 to 4 hours worth of paperwork to get somebody into

treatment, and it is paperwork, meaning that it is stuff that you

fill out that you have no use for.

I am not talking about that and I don’t think anybody here is either. I am talking about as a regular part of the treatment process,

the counselors, the people who are working on the team, are measuring whether they are going to work, whether they are still using

drugs, all clinical, just like the blood pressure. The blood pressure

isn’t paperwork in a hypertension clinic, it is critical. You have to

know what is going on so you can make an adjustment.

That is the point that everybody is, that Judge Wilson keeps

making, to use information to make decisions. That is not paperwork, and it shouldn’t be burdensome.

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Mr. SOUDER. Any other comments on that? In other words, if we

could separate it out, these are the absolutely critical things for

medical reasons, for drug treatment and these are things that we

might need for tracking for financial reasons or insurance companies, one last question.

Ms. MARTENS. Dr. McLellan is absolutely right, the day-to-day

paperwork that we do because treatment is holistic. Doctor is absolutely correct. I need to know what your drug test was yesterday,

how was your family visit, are you getting your GED? These are

very important things, and they are always part of treatment.

It is all of these other things that are now layered onto it that

just take so much time that it really takes time away from direct

client treatment.

Mr. SOUDER. I will say, I mean, you have helped clarify that

those are the things that you need there, and then there are other

things we need for waste and fraud reasons which you may refer

to as paperwork. But quite frankly, I believe it was actually in this

committee room when Chris Shays headed the Human Services

Subcommittee in my first term I was vice chair on a Medicaid

fraud case. And the hardest clients to serve are those who have no

insurance, have no immediate family and have some chronic condition and have moved around.

We have a place in Fort Wayne, a health center that has a lot

of these patients. And we were asking the GAO and the Inspector

General, and we had HHS here and asked why they hadn’t terminated this one company that had been found in court of defrauding

the Federal Government of $1 billion. And they were in multiple

regions in the country and our computers hadn’t caught them

under different names.

But the reason that HHS hadn’t terminated them was because

something like 20 percent of these highest risk people who nobody

else would take, no nursing home would take, the State government really couldn’t do it or they had to have a place to put the

people, nobody would take them, so we were having this company

that was bilking because they claimed the reimbursement wasn’t

enough—probably true—to cover the cost of it, so they started

doing that type of thing.

And part of the reason we have the paperwork side for addresses,

information, for tracking is that. But what we need to do is separate: here is the paperwork necessary for that part and what parts

are medically necessary for drug treatment. And that has been

helpful for me for clarification as we kind of tackle that.

I yield to Mr. Cummings.

Mr. CUMMINGS. Thank you very much, Mr. Chairman.

I thank all of you for your testimony. One of the things in listening to the chairman, I see all the money that we spend in government; and I hear the complaints from constituents, well, we spend

money on certain things and then we don’t spend money on other

things.

I really want to have some sympathy with regard to the paperwork. I really, really want to, but it is very difficult. I see taxpayers’ hard-earned dollars being paid to treatment facilities, doing

a great job, by the way, but I also think that with those dollars

comes a certain level of accountability.

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And I know you are talking about two separate things. I heard

you, Mr. Chairman, and I am not sure where the divide actually

comes. But I want to go to you, Dr. McLellan.

One of the things you talked about, and it is a very interesting

viewpoint; I really think that when the public watches this, they

would be almost shocked, although I agree with you, that winning

here is not necessarily getting somebody off of drugs forever. And

I think we still have to educate the public to understand that. Because I think a lot of times the public sees a person on drugs, like

a lady I saw in my neighborhood just the other day, who they once

knew as a bright high school student and now they see them sitting on some steps, dirty, nodding, looking quite, you know, out of

it.

And they say to themselves, you know, OK, I want to do something for that person, but if you told them that reducing the

amount of drugs they use, perhaps getting a job, perhaps coming

up with having good relationships with family and a support system could be part of the measurement of success, I think the general public couldn’t fully understand that and comprehend it, because they want to see that person the way they saw them in high

school when they were cheerleaders.

So I think we do have to educate the public about all the kind

of measurements that you all talked about. And I think that because the public wants to see the dollars spent effectively and efficiently. And so it doesn’t necessarily equal effective and efficient

spending of dollars when they hear those kinds of measurements.

So I am just wondering, I mean, you have heard all of your fellow witnesses up here talk. I mean, are there any measurements

that have been left out, anybody, that you didn’t hear?

In other words, you talk about measuring tools, the things that

you need to measure success. Have you heard of anything that has

been left out that should be considered when measuring success?

Because one of my concerns is—and I know we have a lot of great

treatment providers, but one of my greatest concerns is that young

people—I live in a district that has probably some of the highest

addictions in the country. And I talk to recovering addicts and a

lot of them will tell me they have gone to certain programs that

they found out from going through them. And by the way, it gets

out on the street which programs are, ‘‘real,’’ and which ones are

not. And they tell me that if they go to an unreal program, it can

do more harm than good, but yet our Federal dollars are being

spent.

So I am trying to figure out, you know, how do we make sure?

It may take time to kind of sift away the fair programs and get the

better ones out there so that people can have effective treatment.

And I am just trying to figure out how do we do that. Do you all

have any suggestions?

Dr. MCLELLAN. I can give you an example. I urge you to look at

it. It is precisely the kind of program that Dr. Jaffe is talking

about, and that is the State of Delaware. Now, it is a small State

and it is a very interconnected State, but they basically gave up.

They said, look, we don’t know what to tell you to do, but we know

what we want. And we are going to put criteria into play so that,

I will summarize very quickly, your treatment programs, when you

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open your doors, you will get 80 percent of your contract last year.

However, if you meet the following criteria, you can make as much

as 120 percent of your contract last year.

And I will summarize and tell you that several programs weren’t

able to do it. They closed. New places came and they were able to

do it, and they are functioning now. And what the State is doing

is, they are adding criteria. They started with retention, because it

was the easiest to measure and all the programs agreed with it and

that knocked out several programs. Now they are moving toward

no new arrests. And if they are successful, they have a commitment

from the Justice Department to put additional money into the

treatment side, because it’s worth it, it’s worth it to the Justice Department, but only if they are able to make those—if they can buy

success, in other words.

Mr. CUMMINGS. Anybody else have something?

Now, you all heard the testimony of the other two witnesses earlier and you heard my questions with regard to jobs. And it seems

as if in most States people are placed in a position, particularly if

they get a conviction where they are locked out of so many jobs.

And I am just wondering, when you are trying to help somebody

move forward, you know, there are a lot of barbers in Baltimore.

I don’t know why a barber, why it is such a big deal. I have met

so many barbers who have had drug problems. Apparently, that is

one field that is still open. And the reason you get to know them

is because they talk about it.

Dr. MCLELLAN. They also teach barbering in jail.

Mr. CUMMINGS. And, see, that is good. I am glad you threw that

in.

But if that person came out of prison and there was a law that

said if you have, say, a drug conviction or you had some drug problems or whatever that you can’t be a barber, then that person is

precluded from making an income.

See, one of the problems that happens, and I don’t know why

people don’t think about this, people have fines and child support.

And I believe people ought to pay child support. I mean, there are

a lot of things that go against the person and basically forces them

back into jail or to addiction. In some kind of way, we have to grapple with that.

And Judge Wilson, I mean, in courts, I am sure you see that. A

guy comes in or lady comes in and says, look, I am doing the best

I can, but I can’t get a job. And if I don’t get a job, you are going

to send me back to jail. Or, you know, the reason I went back to

being involved in drugs was so that I could address making sure

I pay my fines, pay my child support, pay whatever I’ve got to pay.

And then, even more so, a job becomes very significant. Am I

right?

Ms. FREEMAN-WILSON. That is it exactly, Congressman

Cummings. And there are two things we look at.

One is, when we talk to people about how they develop their

court programs, we always encourage pre-plea programs because if

you have a pre-plea program and you successfully complete it, then

you are not saddled with the conviction.

But then as we move toward the discussion of reentry nationally,

then we have to look at how the laws in the States affect the abilVerDate 11-MAY-2000 10:31 Dec 03, 2004 Jkt 000000 PO 00000 Frm 00115 Fmt 6633 Sfmt 6633 D:\DOCS\96744.TXT HGOVREF1 PsN: HGOVREF1
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ity of the reentry participants to reenter society and become effective members of society. And so our organization along with a number of organizations, have embarked upon surveys of State laws,

not just to survey those laws, but to look at ways to encourage legislators to begin to move those laws away from being punitive. Because if, in fact, you expect a person to reenter society, become a

tax-paying citizen, how you saddle them with a conviction. Now

don’t get me wrong, there are some folks that need to have convictions on their records; we need that red flag on those records. But

in many instances, it is not appropriate in the case of those individuals who have convictions for possession of drugs, for other property-related crimes, one-time convictions, so that we need to look

at ways to have our laws in the States and to encourage the States

to develop those laws in a way that you don’t saddle the folks the

first time around so that they can come out and get jobs, and pay

support and pay taxes and all of those things that evidence them

as members of society who are productive.

Dr. JONES. I would like to add something on a much more kind

of grass-roots level.

One of the other hats I wear at Johns Hopkins is overseeing an

after-care program for heroin-dependent individuals who have completed a 3-day or 7-day detoxification. It is a 6-month NIDA-funded

after-care program, and we have four goals. And one of the main

goals is getting that person a job.

Now, a lot of our patients have criminal justice involvement. And

what we have found is that there are jobs available—perhaps not

the best job. I mean, a lot of them are in barber shops, doughnut

shops, working construction. But what we found is that these patients are particularly scared about even getting a job.

Some of them have even had a job. And working through that

you know, let us put a resume together. These people never had

a resume, and they are actually sitting down and filling out a questionnaire. We sit there with them and we say, can you come up

with two people who could vouch for you? And sometimes they will

remember, oh, yeah, I did that in the past and that was pretty

good, I have a good contact here.

And then the next step, after they’ve filled out their resume is

practicing interviewing skills, and we do it videotaped so they can

see what they look like, learn how to answer questions.

And then we take them out, and we have what we call job fairs

and we go to places that have hired our patients previously. So

what we are doing is we’re trying to build in small successes and

maximize opportunities of the likelihood for them getting a position. And we do; 39 percent of our patients are actually employed.

And a lot of them have criminal justice involvement.

So it is possible to overcome this, but it takes a tremendous

amount of hand-holding and working through the steps to give

them success.

Ms. FREEMAN-WILSON. Dr. Jones raises an important point and

that is to engage the participation of the business community in

this dialog. We can talk all the time about people needing jobs, but

there are people who give jobs and unless they believe that someone coming out of her program or someone coming out of a drug

court or out of a therapeutic community is a good employment risk,

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and I would argue that they are better because you know, more

likely than not, that those folks are drug free, whereas those who

aren’t being tested, who aren’t in treatment, you don’t have that

guarantee.

But we have to engage the chambers of commerce. We have to

engage State government. We have to engage the other larger employers, be they hospitals, manufacturers, in that conversation

about employing not only the individuals who look good on a resume, but those whose resumes may be a little blemished.

Mr. CUMMINGS. I remember when I first started practicing law,

one of the things I wanted to do was to see exactly how these 12-

step programs worked. And I was just fascinated by the fact that

when I went, just to see how they worked, they had these people

sitting around talking about all their business. You know, it was

interesting.

Dr. MCLELLAN. It is called ‘‘sharing.’’

Mr. CUMMINGS. That sounds a little bit more clinical. And I just

wonder, how important is that to the things, to all your theories

of effective drug treatment? How important is sharing? I am just

curious.

Dr. MCLELLAN. It is not an opinion. There are studies to show

it. It is very effective and it makes so much sense. Environments

change people. So you have been to treatment programs, I can see

that, and you can see the kind of environment that is there and

you can accept that those people, while they’re there, are honest

and are industrious and have the values you want to see.

When they go back out to the environment that produced the

drug abuse to begin with, or in concert with their genetics produced

that, that is very likely to change them back, very likely unless

they are involved on a regular basis. This is what they call ‘‘aftercare.’’

This is the continuing care that Dr. Volkow talked about; everybody here has talked about it. One of the best because it is cheap.

Actually, it is free. It is everywhere, it’s all the time. It is AA, NA,

these 12-step programs. The fact is, only about a quarter of the

people that are referred to them actually will go ahead and really

lock up and then you have a guarantee. Those people do very well.

We need alternatives and we need new kinds of things for people

that don’t want to do that.

Ms. MARTENS. Congressman Cummings, I want to use one of our

programs in your district as an example to you.

In all of your questions, you were asking, it is one thing for us

to get a mom clean and sober. It is another thing, and I know you

can appreciate this in Baltimore, a mom who reads at a third grade

level, does math at a second grade level. She has been getting high

since she was in middle school because her mom did it and her

grandma did it and her dad has been locked up forever. Kid has

so many problems.

We’ve got Hemmett Kennedy Kreger. So we’re working on her

GED while she’s in treatment, case managing her to figure our

what kind of skill set she would like to develop.

As Dr. Jones was saying, it’s the little things. How to go to the

office downtown and get your child’s immunization record, that

sounds easy to us; that can cause mom to think, I am going to get

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high because I can’t do that. These little things that we take for

granted in our life have to be case managed throughout this entire

treatment process. The mayor and I are working now because there

are few places for us to put mom, in a house that does not trigger

her addiction. She remembers the noise on North Avenue, she remembers the smell. She remembers what you look like, and you

may be a trigger for her addiction.

If you don’t treat the client holistically, a mom may not maintain

her recovery, I think that is one of the reasons that therapeutic

communities have been so successful because it involves every part

of the client’s life. Mom’s relationship with her boyfriend may be

a trigger for her addiction, so she can’t go back into that neighborhood or live with her family. And if we don’t look at the whole picture and find jobs, education, housing, and as Dr. McLellan was

saying, the 12-step support system, you can’t leave a Second Genesis program without having a sponsor in the community and already knowing where your meetings are going to be. Where is a

meeting you can take your kids?

These may sound like really simple problems, but they are huge

for a mom that may be in a fourth or fifth generation of the addiction cycle.

Mr. CUMMINGS. That is interesting. In Baltimore, there is an entire community of recovering addicts. They invited me to speak at

something. I thought it was going to be like 30 people. It was like

700. And I realized that and I guess it is like another family.

So going back to what you were saying, Dr. McLellan, I guess it

is a shifting. You shift over to this family where you are doing the

12 steps and you make new relationships and everybody is trying

to, they are trying to get to recovery or trying to be recovered.

On the other hand, if they shift back into that old community,

then again, as you were saying, something pulls them back in. And

it could be one incident, because I remember one time I did a little

tour, and there was a woman in Baltimore who had been off of heroin for 15 years. For 15 years. Had a great job, doing well. Had one

incident that happened in the family, and she was back on. And

it was incredible to me. And she said she stopped going to the 12-

step programs.

So I think that we as a committee have to look at we are talking

about generation after generation after generation. And it is so

costly to try to treat the kids and treat everybody that, at some

point, I think that is why we are so concerned about effective treatment, because like you said, this doesn’t only affect the client, it

affects everybody in their vicinity, which really says a lot.

Thank you, Mr. Chairman, for your patience.

Mr. SOUDER. I want to raise a point and see if anybody has any

comment about this, because one of the most explosive issues we

deal with here, the way we are playing it through, is the faithbased questions. Yet what becomes pretty clear to me is that to expand this program we need political support beyond a more traditional liberal Democratic community. If you don’t have the conservative faith-based community with it, there isn’t enough political

support.

In Indiana, as Judge Wilson knows full well, it gets really nasty

in political campaigns if you take a position that you ought to give

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more flexibility for people who come out of prison and then one of

them gets arrested. Right now, we have a situation where an Indianapolis news media has stated that 10 percent of the people at the

Bureau of Motor Vehicles in Indianapolis are former convicts. Well,

that was before they went to work there. There are other problems

since they have gone to work there. That means, in fact, that

they’ve hired people in that position, but politically, it is going to

be a debatable issue this fall because that is a high number and

it’s lining a lot of Federal jobs.

There are barriers because it is so politically explosive. There is

a big law-and-order type of mentality with it. And unless there is

a way of including in jobs that part of the reason is that we have

had 16 years of Democratic Governors, which I don’t view as great,

in Indiana. But they have been getting As on the score cards on

faith-based because they came to realize, particularly in the minority community, that if they don’t match it with suburban churches

as well, we weren’t going to get the support for the follow-through.

Because an employer may be making, if he is guaranteed there is

drug testing, the type of decision that you referred to, which is, he

knows he has a clean employee.

But there are other risks. For example, a number of my friends

who have hired people have had reoccurring problems because not

everybody is rehabbed all the way. One of our major volunteer programs in Fort Wayne for people coming out of prison went broke

because one of the people relapsed and stole everything they had.

They stole their computers, stole a number of other things. They

were too marginal. And they came back, a number of those people,

not because they viewed it as a business, per se, but because they

are faith motivated and felt they had a motivation.

And unless we can figure out how we are going to make some

coalitioning between the Prison Fellowship and conservative Christian people to back up the kind of the institutional support from

the government, it is going to be very hard to figure out how we

are going to provide this comprehensive follow-through in jobs and

the political support for adequate dollars. Because when we start

to split these things off, it is ironic that we have these political divisions.

And our distinguished judge and attorney general of Indiana

knows what we are talking about, because we have had some very

tough debates in Indiana, and we continue to have them on this

very subject. That makes it really dicey when any politician walks

out there and says, we need to look for housing, we need to provide

for job employment, we need to open up the opportunities. And

then there is something that occurs or there is a backlash or somebody says, what do I have to do, commit a crime to get a job? And

politically, we have to figure out how we’re going to work this kind

of stuff through, because we have put more money into treatment,

but it isn’t at the levels where we need.

And partly this is underneath it, particularly when you look at

the after-care.

Dr. JAFFE. One of the major conclusions of our panel was that

if you want to get broadened public support for the resources that

you need to provide good treatment for those who need it, the public has to believe that treatment is effective.

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Now, it’s not ever going to be perfect. There is always somebody

who is going to relapse even after 15 years. If 99 percent of people

who leave prison don’t do anything, somebody will take a job and

steal from his employer. That is a virtual guarantee.

But if people are convinced that the people who pay for treatment are looking at the programs and making certain that they are

all competent and that the programs that aren’t effective are being

eliminated, or at least they are not being funded with the taxpayers’ dollars, they are going to be more willing to come up with

those resources.

So what we saw was that evaluation and rewarding the effective

programs is a way to build public support as this kind of treatment

competes for resources against other priorities in the public sphere.

There is not enough money for everything that needs to be done,

and treatment needs to compete, we know that. One of the ways

it can compete more effectively is to assure decisionmakers that all

the programs are at least at some minimum standard of competence.

Mr. SOUDER. It is in the job’s follow-through question, too, that

part of the problem here is. If we took the targeted jobs credit and

said that in the targeted jobs credit it should be those who are

highest risk in the society for being unemployed, and I’ll bet if we

look at that, that we would find a fair percentage of those people

have been through a drug treatment program.

So, theoretically, this could be turned on us saying the people

getting the targeted jobs are the people who have committed a

crime when we have high unemployment. What I am trying to get

at is, unless we have a broader base of support that understands

the concept behind this, both from the risk of crime to society, but

also an obligation and an understanding that if these people can

get rehabbed, they are going to be better in their family lives.

But politically we have a problem here, particularly, for example,

we put in the targeted jobs credit that the people who have been

arrested should go to the front of the line because they are the

hardest to employ.

Ms. FREEMAN-WILSON. Congressman Souder, I would say the

way to transcend that goal is to really convince the people who you

referred to of the equal opportunity nature of this problem. It

doesn’t matter whether you are conservative or liberal, it doesn’t

matter where you live, it doesn’t matter what you look like. Congressman Davis talked about it earlier when he said not only were

they having problems in Chicago, but I know because we’ve worked

with the drug courts in King County, IL. There is a heroin epidemic in the suburbs. So if we can get those groups, the church

groups both in the cities and in the suburbs to take that message

to the public—and quite frankly, some already know because it is

happening in their homes—then I think we will have transcended

that political albatross or potential political albatross.

Mr. SOUDER. Often it is, bluntly, put quieter in the suburbs because to go and buy the stuff in the lower-income neighborhoods

and the crime and the related violence that comes from it is in the

lower-income neighborhoods and often the parents in the suburbs

are too busy to be in denial and don’t want to be embarrassed. And

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yet, it is kind of an interesting thing because trying to get that

public is a whole other task we face. Any other closing comments?

Dr. MCLELLAN. I don’t think anybody here is saying fund more

of what we have. Take the opportunity to use measurement and to

take the things that you know you want to buy and link those two

together, and then I think that is going to knock the political albatross off your neck.

Ms. MARTENS. I think, Congressman Souder, when you asked

about the faith-based communities, what we have used effectively

is the potential of collaboration, because there is a great deal of

stigma involved, as Judge Wilson was saying. To begin to get the

faith-based community involved, we do mentoring programs with

them, and we ask them to hold NA and AA meetings in their

churches. They have parties in our women’s and children’s programs, and that begins to invest them in the process that, as Dr.

Jaffe was saying, this is an equal opportunity destroyer. It does not

matter who you are.

Especially with our programs in Baltimore, we are effectively

using the faith-based community to be our partners. They don’t

want to be doing drug treatment. There is really a myth that, you

know, the pastor in your church will be able to heal you. Wouldn’t

it be great if it were that easy?

Mr. SOUDER. Well, I want to make sure that we have in the

record it is an equal opportunity, in other words, in the sense of

people using drugs. But there is no question that the violence is

not equally spread, that the dealing is not equally spread, that the

impact on employment in groups that are already at high risk that

have added to it, that when we are doing a returning offenders program in Allen County, the bulk of them are going into the lowest

income, poorest housing areas where there aren’t jobs and where

the people are moving out of some of the school systems because

drugs are in every school, as evidenced in our highest-income

school in the county that has probably the biggest drug-dealing

problem but there are more students.

They don’t have the shootings in the school. There is, for whatever reasons, probably a higher percentage of parental involvement

in the school, more income, different types of things. And I mean

I can go into an urban school in Fort Wayne and say, how many

have seen a shooting. I will see 75 percent—a shooting other than

hunting for a deer—75 percent will say ‘‘yes.’’ I can go into Homestead or Carroll or other schools that are in the suburbs or rural

school and get none to 10 percent.

There is a difference in the impact of it, even though it is an

equal opportunity destroyer, and most drug users in America are

White, just like everything else. But it has a disproportionate impact because the families may not have the health insurance, may

not have the support group around them, may not have the connection to get a job. So there is disproportionate negative impact,

which is what we at the Federal Government have to be looking

at.

One last question, why, if the programs aren’t effective, hasn’t

the market in health insurance or the people that pay the insurance made some adjustment? In other words, why would they want

to pay two or three times to send somebody through a program if

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a program that lasted just a little bit longer would have had more

success? Why hasn’t the market adjusted?

Ms. MARTENS. The problem is so big, Congressman Souder. I will

use our District of Columbia facility as an example for you. All of

our clients come from CSOSA. They are federally mandated by

CSOSA. CSOSA is putting our clients through a 28-day program.

I have a man right now who is 82 years old and has been shooting

heroin since he was 13 and he is in a 28-day program. I couldn’t

change one of my bad behaviors in 28 days, much less shooting

heroin in my neck since I was 13.

Mr. SOUDER. If this was a private sector, you have private people.

Ms. MARTENS. Very few are private pay.

Mr. SOUDER. Are most people in drug treatment in private pay?

Ms. MARTENS. No. If you had a problem, Congressman, you know

Father Martin’s Ashley in Havre de Grace would probably be a

very effective program.

Mr. SOUDER. I didn’t understand. Did you say 80 percent at this

point is public pay?

Dr. JAFFE. Thirty-eight percent, I think, in 1997. It is in our report. Thirty-eight percent, I think, is private sector and about 62

percent is now public sector with the bulk of that coming from the

Federal Government directly or indirectly.

Ms. MARTENS. Block grant.

Mr. SOUDER. Thank you very much for your testimony today. It

has been very important as we move through drug treatment and

appreciate your cooperation. With that, the subcommittee stands

adjourned.

[Whereupon, at 5:20 p.m., the subcommittee was adjourned.].

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