U.S. GOVERNMENT PRINTING OFFICE

67–551 DTP WASHINGTON : 2001

HHS DRUG TREATMENT SUPPORT: IS SAMHSA

OPTIMIZING RESOURCES?

HEARINGS

BEFORE THE

SUBCOMMITTEE ON CRIMINAL JUSTICE,

DRUG POLICY, AND HUMAN RESOURCES

OF THE

COMMITTEE ON

GOVERNMENT REFORM

HOUSE OF REPRESENTATIVES

ONE HUNDRED SIXTH CONGRESS

SECOND SESSION

FEBRUARY 17 AND MARCH 14, 2000

Serial No. 106–153

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

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: (202) 512–1800 Fax: (202) 512–2250

Mail: Stop SSOP, Washington, DC 20402–0001

(II)

COMMITTEE ON GOVERNMENT REFORM

DAN BURTON, Indiana, Chairman

BENJAMIN A. GILMAN, New York

CONSTANCE A. MORELLA, Maryland

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

JOHN M. MCHUGH, New York

STEPHEN HORN, California

JOHN L. MICA, Florida

THOMAS M. DAVIS, Virginia

DAVID M. MCINTOSH, Indiana

MARK E. SOUDER, Indiana

JOE SCARBOROUGH, Florida

STEVEN C. LATOURETTE, Ohio

MARSHALL ‘‘MARK’’ SANFORD, South

Carolina

BOB BARR, Georgia

DAN MILLER, Florida

ASA HUTCHINSON, Arkansas

LEE TERRY, Nebraska

JUDY BIGGERT, Illinois

GREG WALDEN, Oregon

DOUG OSE, California

PAUL RYAN, Wisconsin

HELEN CHENOWETH-HAGE, Idaho

DAVID VITTER, Louisiana

HENRY A. WAXMAN, California

TOM LANTOS, California

ROBERT E. WISE, JR., West Virginia

MAJOR R. OWENS, New York

EDOLPHUS TOWNS, New York

PAUL E. KANJORSKI, Pennsylvania

PATSY T. MINK, Hawaii

CAROLYN B. MALONEY, New York

ELEANOR HOLMES NORTON, Washington,

DC

CHAKA FATTAH, Pennsylvania

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

DANNY K. DAVIS, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

THOMAS H. ALLEN, Maine

HAROLD E. FORD, JR., Tennessee

JANICE D. SCHAKOWSKY, Illinois

———

BERNARD SANDERS, Vermont

(Independent)

KEVIN BINGER, Staff Director

DANIEL R. MOLL, Deputy Staff Director

DAVID A. KASS, Deputy Counsel and Parliamentarian

LISA SMITH ARAFUNE, Chief Clerk

PHIL SCHILIRO, Minority Staff Director

SUBCOMMITTEE ON CRIMINAL JUSTICE, DRUG POLICY, AND HUMAN RESOURCES

JOHN L. MICA, Florida, Chairman

BOB BARR, Georgia

BENJAMIN A. GILMAN, New York

CHRISTOPHER SHAYS, Connecticut

ILEANA ROS-LEHTINEN, Florida

MARK E. SOUDER, Indiana

STEVEN C. LATOURETTE, Ohio

ASA HUTCHINSON, Arkansas

DOUG OSE, California

DAVID VITTER, Louisiana

PATSY T. MINK, Hawaii

EDOLPHUS TOWNS, New York

ELIJAH E. CUMMINGS, Maryland

DENNIS J. KUCINICH, Ohio

ROD R. BLAGOJEVICH, Illinois

JOHN F. TIERNEY, Massachusetts

JIM TURNER, Texas

JANICE D. SCHAKOWSKY, Illinois

EX OFFICIO

DAN BURTON, Indiana HENRY A. WAXMAN, California

SHARON PINKERTON, Staff Director and Chief Counsel

MASON ALINGER, Professional Staff Member

LISA WANDLER, Clerk

CHERRI BRANSON, Minority Counsel

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C O N T E N T S

Page

Hearing held on:

February 17, 2000 ............................................................................................ 1

March 14, 2000 ................................................................................................. 109

Statement of:

Chavez, Nelba R., Administrator, Substance Abuse and Mental Health

Services Administration, Department of Health and Human Services,

accompanied by Joseph Autry, Deputy Administrator for SAMHSA;

and Dr. Alan I. Leshner, Director, National Institute on Drug Abuse,

Department of Health and Human Services .............................................. 129

Heinrich, Janet, Associate Director, Health Finance and Public Health

Issues, U.S. General Accounting Office; Paul Puccio, executive deputy

commissioner, Alcoholism and Substance Abuse Services, Albany, NY;

John Keppler, clinical director, Commission on Alcohol and Drug

Abuse, Austin, TX; Kenneth Stark, director, Division of Alcohol and

Substance Abuse, Olympia, WA; and Dr. Martin Iguchi, co-director,

Drug Policy Research Center, RAND Corp ................................................. 48

Nance, Jerry, executive director, Teen Challenge International, Florida;

Dr. Charlotte Giuliani, director of substance abuse treatment, Seminole

Community Mental Health Center; and JoAnne Murwin, Seminole

County Resident ............................................................................................ 20

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

Chavez, Nelba R., Administrator, Substance Abuse and Mental Health

Services Administration, Department of Health and Human Services,

prepared statement of ................................................................................... 132

Giuliani, Dr. Charlotte, director of substance abuse treatment, Seminole

Community Mental Health Center, prepared statement of ...................... 34

Heinrich, Janet, Associate Director, Health Finance and Public Health

Issues, U.S. General Accounting Office, prepared statement of ............... 50

Iguchi, Dr. Martin, co-director, Drug Policy Research Center, RAND

Corp., prepared statement of ....................................................................... 87

Keppler, John, clinical director, Commission on Alcohol and Drug Abuse,

Austin, TX, prepared statement of .............................................................. 80

Leshner, Dr. Alan I., Director, National Institute on Drug Abuse, Department of Health and Human Services, prepared statement of ................... 150

Mica, Hon. John L., a Representative in Congress from the State of

Florida, prepared statements of ................................................................... 6, 113

Mink, Hon. Patsy T., a Representative in Congress from the State of

Hawaii:

Followup questions and responses ........................................................... 125

Prepared statements of ........................................................................... 15, 121

Murwin, JoAnne, Seminole County Resident, prepared statement of ......... 37

Nance, Jerry, executive director, Teen Challenge International, Florida,

prepared statement of ................................................................................... 23

Puccio, Paul, executive deputy commissioner, Alcoholism and Substance

Abuse Services, Albany, NY, prepared statement of ................................. 64

Towns, Hon. Edolphus, a Representative in Congress from the State

of New York, prepared statement of ........................................................... 116

(1)

HHS DRUG TREATMENT SUPPORT: IS SAMHSA

OPTIMIZING RESOURCES?

THURSDAY, FEBRUARY 17, 2000

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 10:13 a.m., in room

2154, Rayburn House Office Building, Hon. John L. Mica (chairman of the subcommittee) presiding.

Present: Representatives Mica, Souder, Mink, Cummings, and

Kucinich.

Staff present: Sharon Pinkerton, staff director and chief counsel;

Don Deering, congressional fellow; Mason Alinger and Frank

Edrington, professional staff members; Lisa Wandler, clerk; Cherri

Branson, minority counsel; and Jean Gosa, minority assistant

clerk.

Mr. MICA. Good morning. I would like to call this hearing of the

Subcommittee on Criminal Justice, Drug Policy, and Human Resources to order.

I apologize for the delay. Several other Members are involved in

other committee business.

This morning we are conducting a hearing entitled, ‘‘HHS Drug

Treatment Support: Is SAMHSA Optimizing Resources?’’ I will open first with my opening statement and recognize other

Members, and then we will hear from our witnesses. I think we

have three panels today.

Our subcommittee is conducting this oversight hearing today as

a part of a series of hearings to examine programs and agency operations within the Department of Health and Human Services.

This subcommittee is particularly interested in agencies with critical responsibilities in implementing our national drug control strategy.

The Substance Abuse and Mental Health Services [SAMHSA], as

we refer to the agency, is the Federal agency before us today, and

its support for drug treatment is the focus of our hearing.

National estimates of Americans in need of drug treatment range

from 4.4 to 8.9 million, yet less than 2 million people reportedly receive treatment. This gap of course must be addressed since drug

treatment needs today, unfortunately, are predicted to grow, not diminish.

SAMHSA’s block grant program is a key element to reducing the

gap as States and communities provide direct services and each

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block grant dollar spent on treatment generates $1.50 in additional

State or local treatment spending.

SAMHSA claims to be contributing to the first three goals of our

national strategy, which I will paraphrase. The first goal is educating and enabling youth to reject illegal drugs and tobacco. The second goal is reducing drug-related crime and violence. And the third

goal is reducing the cost of drug abuse.

To achieve these goals, SAMHSA must optimize its resources. It

must also provide the most efficient and effective support possible

for State and community drug treatment efforts. Today, we will investigate whether this is happening and what should be done if, in

fact, it is not.

As we will hear, States and communities are making progress in

their drug treatment efforts but continue to have pressing needs.

Every drug treatment dollar received by those on the front line is

extremely vital.

We will learn that the Federal Government should allocate resources to support more successful treatment programs that will

serve more clients, and that is one of my major concerns is that we

reach out and serve more people, but with more successful programs. We will also learn that SAMHSA has an inordinate administrative cost in overhead, and somehow we must reduce the red

tape and bureaucratic obstacles that hinder service to the States

and also these local communities programs that are so effective. In

doing so, SAMHSA can better achieve the goals of our national

drug control strategy.

Our first panel today represents local treatment efforts on the

front line of the drug epidemic. We will hear testimony from local

treatment providers both public and private indicating that every

treatment dollar makes a difference.

One witness is concerned that Federal funds are not available to

help establish a needed local treatment facility. As a result, clients

must travel significant distances outside their community.

We will also hear from a client how effective drug treatment enabled her to overcome addiction and to reclaim her life. Another

treatment provider represented here today is faith-based. Some of

our most successful programs, in fact, are faith-based. This provider’s counseling and work elements apparently did not match traditional public treatment facility licensing criteria, thus preventing

the program from qualifying for Federal support.

Worse yet, Federal food stamp assistance for its clients has been

cutoff, even though clients would continue to receive food stamps

had they remained on the street abusing drugs. There is something

dramatically wrong with this picture.

Should Federal assistance not reach deserving clients and programs that work even though the program uses religious or faithbased counseling and work as treatment elements?

Our second panel will address the State perspective, where most

drug treatment is actually funded and administered. We will hear

from the General Accounting Office. GAO has provided descriptive

data on what SAMHSA is doing with its resources. This data provides a basis for further questions regarding how agency efficiencies and effectiveness can be improved, a topic we will explore

in this hearing.

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GAO data indicates that about 80 percent of SAMHSA’s substance abuse grant funds flow to the States through block grants

managed by about 11 percent of the agency’s staff. The remaining

89 percent of SAMHSA’s staff is engaged in Washington-based discretionary grants or other agency activities. To me, this represents

some sort of a misallocation of personell and resources based upon

the mistaken belief that Washington knows best. I think our experience has shown us just the opposite.

We have witnesses from several State programs that are successful in breaking the train and chain of drug addiction, restoring

families, and creating productive citizens and saving lives really

needs to be the goal of all of these programs and some of them are

successful, some of them are not.

The States that have some successful programs are New York,

and we visited one of those programs. I do not think the members

that are here today got to go with us but the DTAP program was

extremely successful in Texas and Washington. GAO has commended these States for their successes in a number of drug treatment areas.

We look forward to learning more about what works in these and

other States and hearing about their successes and how we can

pattern them.

We also have a witness who will address the topic of evaluation.

We need to understand how drug treatment works and what, in

fact, works best. Still, we do not need to reinvent the wheel or

spend hundreds of millions, sometimes billions of dollars, on interesting but unnecessary Washington based research at the expense

of precious treatment dollars.

Last week, the SAMHSA administrator, Dr. Chavez, testified on

the effectiveness of current drug treatment programs. She stated,

An evaluation of treatment programs funded by the Center for Substance Abuse

found a 50 percent reduction in drug abuse among their clients in 1 year after treatment. Our services research outcome study produced similar findings 5 years following treatment. We have achieved success that can parallel or exceed the results of

patients receiving treatment for other chronic illnesses like diabetes, hypertension,

and asthma.

Citing a 48 community study that found significant reductions in

drug and alcohol abuse among males, Dr. Chavez concluded, ‘‘We

know what works in prevention and treatment.’’ That is important

for us to also know as a subcommittee in Congress that funds these

programs.

While I agree that we must continue to evaluate drug treatment

programs, I do not agree that the States like New York, Texas, or

Washington must rely on advice and mandates from all from Washington, DC.

These States have fine universities that are quite capable of conducting rigorous research and evaluation. States can easily find talent in Washington, DC, or other locales when needed, but States

remain the true laboratories of democracy where most innovation

does, in fact, occur.

Furthermore, States are quite willing to share data and results

with others and the Internet also is a new mechanism to provide

an efficient way to carry that out.

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Our final panel today will include an official from SAMHSA’s

Center for Substance Abuse Treatment. It is my hope that she and

other SAMHSA officials will provide this subcommittee with the

answers to questions that we have relating to agency activities and

operations.

Among the questions which we need to obtain the answers for

some of the following: Why our States forced to undergo so much

bureaucratic red tape to receive their block grants? I understand

that some States invest more than 400 man-hours just completing

the applications. If the IRS can accept an electronic tax return and

immediately send a refund, other Federal agencies should be just

as efficient.

Why does SAMHSA choose to award such a large percentage of

its moneys through discretionary grants called knowledge development and application [KDA], and targeted capacity expansion

[TCE], grants? Why are these grants not coordinated with the

States, which may be forced to pick up their funding later?

Does SAMHSA really have superior knowledge and are States

clamoring for more Federal guidance? I think not.

The National Governors Association and the National Association

of State and Alcohol and Drug Abuse Directors favor more consolidated block grants, more State flexibility, and less red tape. I remain very concerned with the allocation of SAMHSA’s staff and resources.

While 59 staff are dedicated to all State block grant activities, including mental health, prevention and treatment combined, the Office of SAMHSA Director alone has 73 staff, furthermore, 139 staff

in the agency’s three centers are assigned just to KDA discretionary grants.

I am concerned that SAMHSA’s enormous administrative costs in

the GAO reports in 1999 fiscal year, SAMHSA’s administrative

costs were more than $150 million. Now, if we could just divide

that by 50 States and add $3 million to each State rather than support this huge Washington bureaucracy, how many people could be

treated for that amount?

It is also unclear to me why SAMHSA is spending tens of millions each year for research when the National Institute on Drug

Abuse was established as the primary research agency. Is NIDA

not conducting practical research applicable to treatment evaluation and delivery? If not, why not?

Finally, SAMHSA has a problem for which a statutory cure may

be needed in order to protect State treatment funds. The problem

is that SAMHSA’s enforcement of the Synar provision within the

Substance Abuse Prevention and Treatment block grant. The provision, established in 1992, requires States to reduce smoking. It provides a 40-percent reduction in block grants for State inaction.

In recent years, SAMHSA has moved to impose unreasonable requirements on States, including State-specific annual target rates.

As a consequence, in fiscal year 2000, seven States and the District

of Columbia stood to lose millions of drug prevention and treatment

dollars, but Congress provided them a 1-year conditional reprieve.

I understand that SAMHSA has rescinded its guidance to these

States and still has not issued new guidance. Why the delay? Other

States, in fact, are at risk of losing funds, much needed funds, in

5

the future. Does it make sense to deny desperately needed State

treatment funds because progress regarding youth smoking does

not satisfy SAMHSA? That is a question I think we are also going

to have to ask today. The Nation’s drug czar, the States, and others

think not. This needs to be fixed, and SAMHSA should act now.

[The prepared statement of Hon. John L. Mica follows:]

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Mr. MICA. I wish to thank all of the witnesses who are appearing

before us today. I also wish to thank the ranking member of the

subcommittee whose primary interest has been to ensure that we

have good, adequate, accessible, and effective treatment. I am

pleased to recognize her for an opening statement at this time.

Mrs. Mink.

Mrs. MINK. Thank you very much, Mr. Chairman. I would ask

that my prepared statement be included in the record at this time.

[The prepared statement of Hon. Patsy T. Mink follows:]

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Mr. MICA. Without objection, so ordered.

Mrs. MINK. I would just like to make a few responses at this

point to the chairman’s observations.

I think that we all are very much concerned about how Federal

funds are spent. We are constantly reminding our Federal officials

that they must march to the heavy drumbeat of accountability to

make sure that the statutory guidelines and requirements that

have been laid out by Congress are fully adhered to and that, as

Federal officials, they will be held accountable for this performance.

So given those requirements by statute and by appropriation riders and so forth, the Federal agencies are compelled to adhere to

these requirements and restrictions. So I think we ought not to

criticize the agencies for those actions and steps that they have

taken because of congressional mandates.

I believe very strongly, as the chairman has indicated, that the

primary responsibility for drug prevention and treatment lies in

the local and State communities. I serve on the education committee and we are constantly reminded of those who come to the Congress that the primary responsibility in education is local and supplemented by State funding, and that the Federal responsibility is

very minute. In the case of education, it borders around 7 or 8 percent only of the funding for the total educational requirements

from K–12.

So, similarly, it seems to me that Congress has to abide by the

idea that drug prevention and treatment programs are basically responsibilities of the local and State governments. It is an enormous

responsibility admitted by the fact that Congress has taken steps

to include vast sums of money to supplement the State and local

efforts.

In doing so, I believe it is very critical that the Congress set forth

guidelines on how these funds are to be spent. We cannot simply

be saying that there is a formula based upon population or based

upon some other criteria of need that funds are going to be allocated without some fairly stringent requirements. And yet these

are the requirements that have come under fire.

I think it is important to look at the overhead criticisms that the

chairman has made with regard to the Federal agencies and to

make sure that they are not excessive, and that the bulk of the

moneys are being distributed to the local and State agencies. But

I cannot quarrel with the requirement that the agency places upon

the allocation of these funds by making sure that they are going

for the specific purposes and needs as indicated by the State and

local agencies’s applications.

So I would strongly urge that we not remove the agency’s responsibilities to make sure that the allocations conform to the basic outlines of needs as established by the Congress and established by

themselves. If they set up criteria as the basis for their application

for block grants or other kinds of grants, then they ought to demonstrate that those needs are being met by the Federal funds that

are being allocated.

Treatment is an enormously expensive program but I continue to

feel that that is probably one of our greatest needs and deficits currently in our drug policy program, when we are told that only 50

percent of those that come for treatment are actually able to be

18

serviced, we know that we have not really begun to meet that requirement. Think of the others that are not even coming for treatment requirements and are out there and have not been reached;

80 percent of the addicts have no treatment program. And so rather than diminish the responsibility of the Federal Government in

this area of treatment, I think that Congress has a responsibility

to look at it more critically.

We need to find out what programs are working. That, I think,

is a responsibility of the SAMHSA agency. We have the research

capability at NIH and they need to find research areas that are

better than what are being performed out there in the field today,

but SAMHSA’s responsibility is to tell us what works and what

ways that the Federal Government can intercede to make those

programs that do work more extensively utilized by other State

and local agencies.

Prevention is a whole other part of this enormous triangle. If we

could prevent addiction, then we do not need to be as concerned

about treatment. But if we cannot prevent through all the intervention requirements that we have in our educational system, then we

need to pay attention to treatment.

And so, as a member of the subcommittee, as the chairman has

indicated, I have been very concerned about this treatment deficit

and have tried to do what I could to put my inquiries in this area

because I feel that this Nation deserves better. We cannot relegate

these addicts to a life of despair, hopelessness and total support by

the taxpayers because of their addiction. We need to find ways to

treat them so that they can be restored to active participants in our

society rather than deficits.

The reports that have been issued by GAO indicate that the drain upon our economy and our society is somewhere around $67

billion. I have however seen reports where that figure has been

quadrupled to $200 billion as a drain and cost of productivity and

because of the provision of extra services and other things.

So the cost to this Nation is enormous and the intervention by

the Congress and the Federal Government is essential. We may be

able to perfect it, direct it better, but its intervention is critical,

notwithstanding the fact that I personally believe that this is essentially a State and local responsibility.

Thank you, Mr. Chairman.

Mr. MICA. I thank the gentlewoman.

I recognize the gentleman from Indiana, Mr. Souder. No opening

statement.

I am pleased to recognize the gentleman from Maryland, Mr.

Cummings.

Mr. CUMMINGS. Thank you very much, Mr. Chairman.

I want to thank you and our ranking member for requesting the

GAO report and calling for this hearing.

I want to associate myself with the words of our ranking member, Mrs. Mink. I want to add to that that one of my concerns, in

a city that has the problems that Baltimore has with regard to

drug addiction, is quality of treatment.

One of the things that we have recently talked about with our

new mayor and with a group of former addicts, recovering addicts

now, is that a lot of time, I mean, these people really believe that

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some of the treatment programs are not doing what they claim

they are supposed to be doing. And I hope that some of your comments will go to it. It is one thing to have the treatment slots, it

is another thing to have—for those organizations that provide

treatment to be effective.

I think that if they are not effective or there are no standards,

then I think we are just playing a game on ourselves. Drug addiction, as Mrs. Mink has stated so well, has an effect on so many

parts of our society.

Just the other day, I took my daughter to the emergency room

at one of our local hospitals and I was sitting there for about an

hour and I watched the ambulances come and go and I asked one

of the attendants, I said, you guys are kind of busy. And he just

shared with me that 85 percent of all their ambulance runs in Baltimore city are drug-related. That is astounding. And so, you could

imagine we could probably save a lot of money in Baltimore if we

did not have the kind of problems we have.

But my point is that, you know, I just want to make sure that

whatever money is being spent, that it is being spent effectively

and efficiently, effectively and efficiently.

I note from some documents that we have up here that during

1999 your administrative costs were 6 percent. I mean, I do not

think that is bad at all. But it would be interesting for us to know

what kind of followup there is and, with regard to these dollars

being spent, are we really getting people off of drugs, and if we are

not, then what could we do from this level.

While it is, as Mrs. Mink said, a local kind of situation, if Federal dollars are being spent and there are taxpayers’ dollars, we

want to make sure that they are spent in a way that achieves the

goals that we have set out.

So I look forward to the hearing today and I want to thank all

of our witnesses for being with us.

Mr. MICA. I thank the members of the panel for their opening

statements.

We will now turn to our first panel of witnesses. We have today,

as a little of the chairman’s prerogative, witnesses who are all from

central Florida. I want to say that, in fairness now, on the 27th I

will be in Baltimore with Mr. Cummings, and we are going to do

a hearing in Baltimore, so I will travel there, which is not a big

deal. It is not that far but it is an important hearing.

Mr. Cummings, I hope we can have the mayor and the police

chief there. I was thinking about this this morning. In fact, I want

the mayor and the police chief there, and I want to hear what their

plans are. You have a new mayor, I think, and a new police chief.

I am going to invite them. If they do not respond, I may consider

requiring their attendance. I think it is so important.

Mr. Cummings represents an area that he has, he estimates,

some 60,000 drug addicts. Crime is still high and it is our responsibility to see that the programs work and that the situation in

Baltimore comes under some control. That is surely our responsibility. But I will be there the 27th. I invite Members to be there.

Then I will travel to Honolulu, which I prefer more than Baltimore, on the 20th with Mrs. Mink, and invite the other members

of the panel. I am sorry I have to go and just fly back, because I

20

would love to stay. But we will hear from her constituents her

problems relating to Southeast Asia drug trafficking and treatment

and other things in that community.

Then on March 6th, for the information of this subcommittee, we

will be in Sacramento. Mr. Ose may be joining us. He was with me

earlier in Sacramento. He has requested a field hearing in his community about the problem.

Finally, on the 7th, in San Diego we will deal with the southwest

border and our oversight responsibility, at the request of Member

Mr. Bilbray.

So while the chairman takes a little liberty in inviting these folks

from sunny Florida into the cold cockles of Washington, I am

pleased to welcome them, and we will accommodate the other members accordingly.

On our panel, we have Mr. Jerry Nance, who is the executive director of Teen Challenge International, which is located in central

Florida; we have Dr. Charlotte Giuliani, director of substance

abuse treatment, Seminole Community Mental Health Center; and

Ms. JoAnne Murwin, who is a Seminole County resident from central Florida who is recovering and who has had difficulty, she will

describe, with drug addiction.

I am pleased to welcome all three of you. I appreciate your being

with us this morning.

We are an investigations and oversight subcommittee of Congress. In that regard, we do swear in our witnesses. If you would

please stand.

[Witnesses sworn.]

Mr. MICA. The witnesses answered in the affirmative.

I am pleased to have you join us again today. What we also do

is, if you go over 5 minutes today, she is going to put a little red

light on, and I will ask you to conclude. You can submit lengthy

statements for the record just upon request and I will do that.

Then we will have an opportunity for a few questions from members of the subcommittee.

So, with that, let me introduce and welcome Jerry Nance, executive director of Teen Challenge.

STATEMENTS OF JERRY NANCE, EXECUTIVE DIRECTOR, TEEN

CHALLENGE INTERNATIONAL, FLORIDA; DR. CHARLOTTE

GIULIANI, DIRECTOR OF SUBSTANCE ABUSE TREATMENT,

SEMINOLE COMMUNITY MENTAL HEALTH CENTER; AND JOANNE MURWIN, SEMINOLE COUNTY RESIDENT

Mr. NANCE. I am Jerry Nance. I want to introduce to you one of

the best kept secrets, I believe, in the world; and I believe that is

Teen Challenge.

Teen Challenge was founded by David Wilkerson in Brooklyn,

NY, in 1958. And this year we celebrate 41 years of service, with

140 Teen Challenge centers in the United States and an additional

250-plus centers in more than 67 countries of the world. The majority of these centers operate 1-year faith-based residential programs.

Independent studies have shown that Teen Challenge programs

have consistently documented 87 percent success rates. Let me just

highlight some of the results of a June 1999 research that was

done by Northwestern University study, just a couple of remarks.

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Their research said that one of the most powerful features of

Teen Challenge is the work, training, and the strict discipline. The

research compared Teen Challenge to other drug programs and of

the other group only 41 percent were employed 1 to 2 years after

they completed the program while 90 percent of the Teen Challenge graduates were employed 1 to 2 years later. The Teen Challenge program costs an average of $1,000 a month, in comparison to other programs which cost between $10,000 and

$30,000 a month.

They found that students in the program have an attitude of, ‘‘it’s a privilege to be here’’ and they were very thankful that they

had a chance to participate in the Teen Challenge program.

My responsibilities are that I oversee the Teen Challenge centers

in Florida and now in Georgia. Currently, we operate nine centers

in the State of Florida, three in Georgia, with 350 beds for boys,

girls, men, and women. Our budget last year was $3.6 million, and of that we only re- ceived $15,000 from a block grant in Volusia County to do prevention work. According to the National Teen Challenge headquarters

office in Springfield, MO, of the 140 Teen Challenge centers in

America, less than 10 percent were State licensed. This is because

of the difficulties many times in negotiating contracts and/or relationships between the faith-based program that exists in Teen

Challenge.

Some key issues today that I would like to bring to this hearing’s

attention is, and I am not here today to ask you to fund all faithbased programs, on the contrary, I am here to say that we are

happy to fund what we did as far as our program, but I have three

distinct issues that I believe need to be addressed and need the attention of this committee.

No. 1 is food stamps. At our Sanford, FL, men’s facility, we house

140 men, ages 18 years old and older. Last year our students lost

the ability to file for food stamps. The Food and Drug Administration made a decision to not allow students in programs that were

not State licensed to receive food stamps. This decision cost Teen

Challenge in excess of a $100,000.

This decision not only affected Teen Challenge students, but also

students and other humanitarian organizations, like Salvation Armies and inner-city missions. My question is does this make any

sense? An individual can live in the streets, he can use drugs, he

can rob people and steal and get their food stamps, but if they

come to a faith-based, non-State licensed facility like Teen Challenge, they lose their food stamps. It does not make sense to me.

The second area of concern I believe that needs attention is the

issue of faith-based programs and State licensure. In 1998, Teen

Challenge of Florida attempted to secure State licensure with children and family services at the time that we had lost our food

stamps. But due to the conflict with program requirements, we

withdrew our efforts.

In addition, we reviewed the Department of Juvenile Justice

service provider contracts and the Department of Corrections requirements, and in each case we found key conflicts with the program requirements in relationship to the faith-based issues that we

feel are important to our program.

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Examples: All Teen Challenge’s programs require mandatory

chapel attendance, and that is almost without regard to the main

problem that we have in licensure. Adults in Florida State license

programs were required to have 20 hours of group counseling each

week. The Teen Challenge’s curriculum, although proven successful, was reviewed and found not to be acceptable to the State of

Florida standards. Therefore, to adhere to State licensure, Teen

Challenge would have to restructure the entire program and rewrite or restructure the entire curriculum, and we are not willing

to do that to alter our curriculum or risk jeopardizing the 86 percent success rate for money.

The problem is faith-based programs cannot realistically fit into

the current guidelines used to certify programs. These guidelines

are based on the medical model, which it works for some and others maybe they need the faith-based programs. And the truly faithbased programs like Teen Challenge are based on faith in God as

well as Biblical principles and, thus, we have a model that we believe works.

The current guidelines make no allowances for the differences between the two systems of helping. Though we do have National accreditation standards for Teen Challenge, they differ greatly from

State standards in regards to program. I have a few copies available if anyone is interested in looking at those.

To the best of my knowledge, I do not know of one effort being

made to bring the faith-based residential programs and the State

guidelines together. I would like to suggest a study of how a successful faith-based program can work in cooperation with State

guidelines without violating the separation of church and State.

And I now find that often is the issue.

The third issue I believe needs attention is the medical care for

students in faith-based programs. Individuals who come to Teen

Challenge with addiction problems are usually desperate and destitute. They often do not have family or any other means of support, financial or otherwise, often emergency medical expenses

must be absorbed by Teen Challenge.

The services of Teen Challenge are offered free of charge to

adults who can pay the intake fees. Less than 5 percent of our income comes from adult students with financial contributions.

Currently, 20 percent of our student population are court-ordered. We work closely with the judges and public defenders,

States attorneys, and they refer many, many people to Teen Challenge.

Let me just underscore, in closing, I am not asking for you to

support the program cost of Teen Challenge. But we do need to

evaluate the food stamp issue, the guidelines for licensing of faithbased programs, and the reviewing of medical coverage for residents of Teen Challenge and other faith-based programs.

I would offer my services, as well as the services of the National

Teen Challenge director, to participate on a committee to address

those issues.

Mr. MICA. Thank you for your testimony. We will suspend questions until we have heard from all the witnesses.

[The prepared statement of Mr. Nance follows:]

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Mr. MICA. The next witness is Dr. Charlotte Giuliani. She is director of the Substance Abuse Treatment Center in Seminole Community Mental Health Center.

Welcome. You are recognized.

Dr. GIULIANI. I am director of Substance Abuse Treatment Services in Seminole County.

Seminole County, as you well know, is a county of 330,000 approximately residents. And at this point there is only seven funded

beds in that county.

It is estimated that over 722,000 adults and 247,000 children are

in need of treatment in the State of Florida. Florida’s State-administered adult treatment capacity is only 6,933 beds, and 3,000 of

those beds are available in State-funded programs such as mine

and the balance in the Department of Corrections. The average

waiting period for these beds is in excess of 3 months. At this time

it is estimated that at least 700 adults are on these waiting lists.

So, as you can see, getting help can often be a confusing or frustrating ordeal that appears to create barriers for those wanting

help with their addiction. Many alcoholics or addicts are lost when

treatment is not readily available or accessible.

The use of drugs and alcohol among our children is staggering.

Most children first try alcohol or drugs at the ripe old age of 9. The

increase in the number of children that abuse alcohol or drugs has

tripled since 1992 and a juvenile justice program struggles to deal

with the huge number of adolescents committing crimes.

47 percent of 13-year-olds say that their parents never discuss

the dangers of drug use. This is credited in part to the fact that

a large percent of those parents are abusing drugs themselves. Addiction is a family disease and has to be treated as a family disease.

I realize that because of the daily consequences we as a society

experience, this is not a very popular, nor is it a very tolerated disease. The total economic cost of drug abuse in our Nation is estimated at $246 billion.

That is $965 for every man, woman, and child in the State of

Florida. The cost of substance abuse is incurred by emergency

rooms, hospitals, increased instances of HIV and other substance

abuse related illnesses, rising criminal activity, and a staggering

decline in productivity that affects all businesses.

For every $1 spent on treatment, $7 is saved. So treatment is a

bargain.

Treatment, without a doubt, works. Studies done over the last 20

years indicate that treatment returns people to productive lives,

promotes responsibility, and accountability, reduces criminal behavior and violence.

I want you to hold me accountable for the services I provide and

the way I spend our money. I only ask that you allow me the resources to provide services to the large number of people needing

treatment. The drug issue is about all the things that we value the

most, family, children, businesses, churches, communities, and

treatment, education and prevention.

I could tell you some wonderful success stories, but I am here before you on behalf of the ones whose faces I have looked at that

are no longer with us or no longer alive because of drugs or alcohol.

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This constitutes my own personal war on drugs because too many

have been lost. It will require the partnership of you, our Federal

Government, our State governments and our communities to stop

drug abuse.

I thank you.

[The prepared statement of Dr. Guiliani follows:]

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Mr. MICA. Thank you for your testimony.

I will now recognize JoAnne Murwin, who is a resident of the

Seminole community. Welcome. You are recognized.

Ms. MURWIN. Thank you, Mr. Chairman. Good morning. I am a

little nervous.

Does treatment work? This is a long way from the streets of

Seminole County for me. My name is JoAnne Murwin and I have

a story to tell you.

I am a recovering alcoholic and drug addict who is here before

you today by the grace of God and a good foundation from the

treatment center that I went through. I won’t go into all the war

stories, as all you have to do is turn on the news or pick up a newspaper and my story of abuse is there.

What I would like to say is that, although I think education

plays an important part of recovery, it doesn’t do much for the prevention of this disease. You can educate anyone all you want on the

facts of diabetes, but it will not keep them from getting it.

My mother started the recovery process in our family by going

to Al-Anon. My father is an alcoholic and this is why I inherited

my disease. Addiction is a disease, and the minute I put that first

drug into my body my disease started to progress. My sisters and

I went to Al-Teen for years, and we would discuss what was going

on with my father and in the family. We would swear we were

never going to be like him, and then we would leave the meeting

and smoke pot on the way home.

Well, we were right to some degree. We weren’t like him, we

were worse, because we added the drugs to the alcohol.

I started using drugs when I was 13 in 1972. I went to treatment

when I was 32 in 1992. I used it for 20 years. So believe me when

I tell you that I am an expert on the subject.

By the time I went into treatment, the only worldly possessions

I had were some clothes and pictures I had managed to hang on

to. I was being evicted, had just gotten fired again, had no car, no

money, no self-esteem, and nowhere to go. If you want the youth

today to not start, teach them about self-esteem in school. Don’t

tell them that they are wrong or different. They get enough of that

in their own homes. It does no good to educate children on the dangers of drugs if they live with them at home. It is all they know

and it is in their blood already.

Funny how the disease of addiction, and I quote from the Orlando Sentinel, is still being addressed as ‘‘willful misconduct.’’ Do

you honestly think that I, as a little girl growing up, I said to myself, I think I will use drugs and ruin my life just to be bad? Give

me a break. I used so I wouldn’t have that feeling of not being good

enough, which came from the shame of having an alcoholic father.

I also find it rather interesting that our government insurance,

Champus, does not cover treatment for this disease. Do you know

how most people get into treatment? They have to hit rock bottom

and be threatening to kill themselves to anyone who listens.

I have worked in a number of treatment centers since I got

sober, and we used to tell people to threaten suicide so they could

get help. This is an outrage. All I know is that, without the treatment I received, I would probably be dead right now or in jail, as

my habit was becoming increasingly hard to support and it

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wouldn’t have been much longer before I was on the streets doing

whatever it took to be able to get my next fix.

Today I am proud to say that I am a productive member of society. I own my own business, am a registered voter, have a valid

driver’s license and insurance. These are the kinds of things a drug

addict never even thinks about. I play softball 2 nights a week. I

take care of my 91-year-old grandmother, who is unable to care for

herself. I am a member of the American Business Woman’s Association. And I continue to sponsor and help other addicts seeking

recovery.

You cannot start just by educating the children. You have to stop

this vicious cycle by treating everyone in the family so that it does

not continue to be passed down to future generations.

Working together on this, we might be able to really help a lot

of future alcoholics and addicts. I beg you to continue your support

and do all that you can to help us, that never knew what hit us.

Does treatment work? I have stayed clean through my grandfather’s death, the hurt of a broken heart, and the savage rape by

a stranger who broke into my house one night wearing a stocking

mask on his head. I then had to endure the re-victimization of the

system, and I continue to struggle with this issue today.

Did I want to have a drink to calm my nerves that night or dull

the pain from the beating I took? You bet I did. But I didn’t do it,

and I owe it all to the treatment center that taught me how not

to use drugs and my God.

Thank you for listening and helping people like me who went to

treatment using one of your funded beds.

[The prepared statement of Ms. Murwin follows:]

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Mr. MICA. I thank all of our witnesses. And we will start questioning.

I am going to yield first to Mr. Souder. Mr. Souder, you are recognized.

Mr. SOUDER. I thank the chairman. I have a plane to catch and

I appreciate your generosity.

First let me say, Ms. Murwin, I heard years ago from a State

Senator friend of Richard Worman in Indiana that many legislators

either turn to God or booze with our problems. They are nothing

compared to your problems. And I really uphold you and praise you

for being able to struggle and confront many of the worst things

that could possibly hit an individual, as coming from a child to the

rape and everything else, and being willing to stand as an example

for others and hold your commitment to God and your commitment

to staying clean. And I think you will continue to be as successful

as you are. And I thank you for your willingness to speak up.

Congressman Ramstad has a bill to try to make sure that in insurance we can get drug and alcohol treatment covered, and we

will continue to try to do that. It is a slow process because it is very

expensive and health insurance costs have been going through the

roof. And some of the programs, quite frankly, have been fairly

marginal in their returns and there is a big difference in types of

programs. But we are doing the best we can. I thank you.

I wanted to pursue with Mr. Nance a couple of questions, because for the last few days I have been immersed with this whole

charitable choice question because we have been dealing with over

in the Education Committee Even Start, and I have read either the

summaries or every court case dealing with faith-based organizations right now, and particularly as it relates to a number of these

things.

First, I want to ask you a technical question. Were you receiving

the food stamps or were individuals in your program?

Mr. NANCE. The individuals in the programs.

Mr. SOUDER. And then they would turn them over to you?

Mr. NANCE. And then they would turn them over to us.

Mr. SOUDER. Is the Federal requirement that it has to be State

licensed, or is this a State decision?

Mr. NANCE. We understood it from the State agency that the

Food and Drug Administration had set down these laws and the

States were mandated to follow them, as I recall.

Mr. SOUDER. We will attempt to get this clarified, and I also

would raise this with Governor Bush, because it may be a State application that relates to that.

Mr. NANCE. I have raised it with Governor Bush.

Mr. SOUDER. What was his answer?

Mr. NANCE. Through Jim McDonough with the drug czar, he said

he turned it over to a staff person and we have not been able to

resolve it.

Mr. SOUDER. Also, you had in your testimony that you would like

to see a study of faith-based programs and how they can work in

cooperation with State guidelines without violating separation of

church and State.

This is a quagmire. And let me suggest a couple of basic principles. First off, be very wary. I am familiar with the cross and a

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switchblade and it has impacted many people’s lives with success

of Teen Challenge and the Victory Life Temples in Texas with

Freddie Garcia and Juan Rivera and others. But you need to be

very careful about getting the Government’s hands on any program

that is successful because it is amazing how they can make them

less successful. We may be tolerant of faith-based organizations as

long as the faith does not get too much. We are a little nervous

about that.

As I understand the court decisions, which are evolving every

day and which are not clear, is that you cannot, while receiving

any direct Federal funds, ever require mandatory chapel time as a

condition for entering a program, and that is not likely to change,

which is right at the heart of many of these programs. It is unlikely because proselytization clearly cuts multiple directions. As

somebody who represents and I am a baptist, we usually lose in

any type of State religion. And we are not too hot on it, either, and

you need to be careful about funding it.

At the same time, we have made progress on staffing requirements, because there is nothing that says that religious people cannot administer programs that help people if you are not teaching

religion with government funds. So there can be separation of programs, but if you had somebody come in that did not participate

in that, now, that is different. In other words, you probably will not

be eligible for any program that is a direct grant program as long

as that is a key component, and I believe probably the most critical

component of your program.

Mr. NANCE. It is.

Mr. SOUDER. But vouchers for food stamps do not make sense because vouchers are viewed differently as direct grants. Vouchers

should be the individual’s decision where they go.

You posed the ridiculous question which one possible solution

would be, put a bunch of men in cars in an empty lot and then they

could get the food stamps and come over to your program. It does

not even make any sense.

Mr. NANCE. Well, that’s what we said to them: What if we

brought the 140 men and put them on your parking lot and they

went one at a time into your office and filled it out? They said,

well, if they put your address down, they are not going to get them.

Mr. SOUDER. We should be able to look at this question. It looks

like an overzealous person coming after Salvation Army and rescue

missions, your program and others. Because, quite frankly, we give

vouchers for multiple programs that are faith-based, and even education, which is the most controversial. For IDEA, we do it for

buses and materials for religious-based schools.

When it is something that an individual makes a decision, there

is a different standard than when it is a grant coming from alcohol

and mental health and antidrug funds.

I had one other question, and that is, and I just wanted to clarify

this. You get 20 percent of court ordered—could you explain again.

When you say, ‘‘medical care,’’ you are not getting any dollars for

the court ordered students, on the other hand, that is because you

view this as a mission?

Mr. NANCE. Absolutely. We accept, and based on our approval of

that person coming into the program, we will do an interview with

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them. Before they come into the program, the courts or the public

defender or prosecuting attorney will call us and ask us to do an

interview with this person, and then we’ll work with them, and the

judge sentences them to Teen Challenge for a year.

Mr. SOUDER. You would have to have, and I gave you some of

the guidelines with that, is that if you were in those court structures programs, able to delineate certain things, like bus services

or things where there is not proselytization with government funds,

you might be able to recoup some costs. But as long as they are

going to the substance of the program that ultimately is dependent

on individuals committing their lives to Christ or changing through

some court commitment, we are not likely to ever clear that, for

reasons to protect Teen Challenge as well as the government.

I thank you for testifying today and also thank you for your work

in central Florida. I wish I could hear the next panels. I went

through your written testimony. And will continue to work on the

treatment.

Mr. MICA. Thank you, Mr. Souder.

I am pleased to recognize the ranking member of our subcommittee, Mrs. Mink, at this time.

Mrs. MINK. Thank you very much, Mr. Chairman.

I would like to join my colleague, Mr. Souder, in expressing our

profound respect for your mission, Jo-Anne Murwin, for your uplifting testimony and for your recitation of your enormous personal

struggle, which you have translated to a social dimension, and by

doing so, emphasize the importance of our treatment and prevention programs.

So we cannot lose sight of that essential ingredient, in whatever

we do regarding drug policy, it is important to look at the worldwide production and interdiction by law enforcement programs. But

our primary goal must be helping and finding a way to rescue all

the people in our society who are troubled by drug abuse and drug

addiction. So I commend you for the steps that you have taken,

your determination and you are certainly an example and role

model for the program and for all the people that we are trying to

get help, you are certainly a shining example. So I want to commend you personally for what you have done.

Mrs. MINK. Dr. Giuliani, I am interested in the State funded programs that you mentioned in Florida, that the State has only 6,933

beds?

Dr. GIULIANI. Yes.

Mrs. MINK. Is that with only State funds?

Dr. GIULIANI. That is Federal and State funded.

Mrs. MINK. What is the estimated total need for the State of

Florida?

Dr. GIULIANI. I would estimate there is probably a need for about

12,000 beds.

Mrs. MINK. 12,000 beds, even though you say there are 722,000

adults that are in need of treatment in Florida?

Dr. GIULIANI. Not all of these people are seeking treatment at

the same time. As you can see, there are only 700 on the waiting

list right now. That means that those people are the only ones desirous of help and seeking treatment at the time.

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Mrs. MINK. To what extent is residential treatment necessary for

treatment of addiction? Can you have an outpatient kind of program that is going to work as well?

Dr. GIULIANI. I won’t say that outpatient does not work, because

it does work in some instances. The people I personally see, and

the clients I have, normally have lost everything. So you are looking at—they have nowhere else to be. It is difficult to come into an

outpatient session for 2 hours a day and then go back to the community or stand on the corner where everybody is using and selling

drugs.

So being an inpatient, it brings them out of that environment

and makes them feel safe and protected. It also gives them a

chance not to have the contact, to be able to change themselves and

see that there are other people and other ways to change.

Mrs. MINK. What is the total cost of the Florida treatment program? How much is the State spending?

Dr. GIULIANI. I can’t answer that right now. I can tell you how

much I get from—— Mrs. MINK. I am sure that the chairman can provide those figures.

Mr. Nance, I am concerned also, as Mr. Souder indicated, about

how within the constitutional requirements of the separation of

church and State we can provide such basic things as food and

health care while not transgressing the requirements of the law to

keep religion and State separate. So I am curious about the fact

that 20 percent of your cases are court ordered. If they are court

ordered, then there is a compulsory conjunction of a State service

with your agency.

How do they justify that then if they are not going to justify your

licensing?

Mr. NANCE. I think basically they are looking for beds to place

people that have addiction problems; and the court system, I think

80 percent of the inmates in the State of Florida are drug-related

inmates. Because of that, they don’t have beds and they are looking

for programs that will help people; and when a public defender or

a prosecuting attorney offers this as an option to a judge, it gives

a judge an opportunity to do something. They know that they are

not going to pay us for our services, but it is basically, as Mr.

Souder mentioned, that is our mission to help people.

We interview the student and let them know that it is a faithbased program, and if they are in agreement with what we are

doing and how they will be treated in the program, we will accept

them, based on that. And whether they choose Christ or not, they

are still accepted in the Teen Challenge. That is part of the program. We are not going to cut the chapel out.

Because of that, every time we look at a relationship with the

Department of Corrections, there is always the required chapel

that we will not compromise because we feel that the faith in God

is an absolute, key part. We accept them and that is a good place

to put some of the individuals coming before the judges that are

seeking help.

Mrs. MINK. Has there been any inquiry with respect to the constitutional compliance of the courts ordering residential care in

your youth challenge?

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Mr. NANCE. We have not done any.

Mrs. MINK. There has not been any constitutional question?

Mr. NANCE. Not to my knowledge.

Mrs. MINK. The State doesn’t pay you at all for housing these

youth offenders so that there is no expenditure of State funds?

Mr. NANCE. That is correct.

Mrs. MINK. So you can’t use the court order as a basis for qualifying for food stamps and anything else?

Mr. NANCE. Not so far, because we are not State licensed. In our

adult programs, we are licensed.

Mrs. MINK. How does the court get away with commissioning the

courts to an unlicensed facility?

Mr. NANCE. Our juvenile programs are licensed under the Florida Christian Child Care Agency. I don’t know how they figure that

all out.

Mrs. MINK. Thank you very much.

Mr. MICA. Mr. Cummings.

Mr. CUMMINGS. Thank you very much, Mr. Chairman.

Ms. Murwin, I would like to congratulate you on your accomplishments. As I was listening to you, I couldn’t help but think

about the neighborhood that I live in where there are so many people who have not been able to overcome the challenges that you

have, and they are in so much pain that they don’t even know that

they are in pain. And I want to thank you for your example, because I think your example is one that will say to other people that

they can do it too. So I really do appreciate what you have done.

I appreciate the fact that you have come here and divulged information that all of us would consider personal, but through your example, I think you will touch and continue to touch other people.

I guess, as I was listening to our witnesses today, I am just curious, Mrs. Mink asked the question about whether in-house treatment was more effective. What do you all see as working? What

works? I am convinced as I said a little earlier that there are folks

when they see the almighty dollar, and our Federal dollars, when

they see that dollar they will come up with facilities to do a job.

And that is not to take away from those organizations that I know

are doing a good job, but when it does when they are not doing

what they are supposed to do, it causes Congress to say, why are

we spending this money?

I am one who is really protreatment, but I also know that is

what I have heard over and over again ever since I have been here,

are we wasting our dollars? Are we really affecting anybody or are

we affecting the people that we think that we are?

What do you all see from your experiences that works? I know

it is not going to work for everybody and I understand that. But

to get maximum effectiveness, I guess that is what I am trying to

get to.

Mr. NANCE. I can only speak for Teen Challenge, but I know that

a crack addict who is addicted to crack cocaine is not going to make

it in an outpatient program. It is not going to happen. If you find

one, it will be a very rare person that can stay off crack cocaine;

or someone that is mainlining heroin, they are going to have a very

difficult time.

Mr. CUMMINGS. Why is that?

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Mr. NANCE. It is the nature of the drug. It consumes every emotion. Every thought of the day is consumed with that addiction.

They wake up in the morning asking the question, where am I

going to get the money for the crack? They know where they are

going to get it; the question is, what am I going to steal today?

How am I going to get that money? That is what they are thinking;

they are not thinking about, how can I get treatment? It is because

the nature of crack cocaine does that to their person.

Long-term treatment is the success of Teen Challenge. Of course,

we believe in the faith-based component of the program, but also

it is the time. We are a 1-year residential program for adult men

and women and even longer for some of the juveniles. Because of

the length of stay—and when you say you are going to get a crack

addict off of drugs in 18 to 28 days, I am going to tell you, good

luck. Even though there are some very good 28 day programs, most

crack addicts need longer care than 28 days to get free from drugs.

I think there are individuals that can get help in outpatient

kinds of programs. We have some of those, but by and large, if they

are in a community where there are drugs available, they find it

very, very difficult not to use.

Mr. CUMMINGS. What is done once they are in treatment to get

them where you are trying to get them to?

Mr. NANCE. I can only speak for Teen Challenge.

It is discipline. It is healing their relationships with themselves

and with their families because they have got a lot of burned

bridges. We work with them to heal that. Then we try to help them

accept themselves, that they are not losers and forever damned to

addiction. We teach them job skills and job training so when they

graduate Teen Challenge they will have a career that won’t pay

minimum wage, and can have a career in computers or whatever,

that they can make a living beyond.

Because it is just like the prostitute in the street, you tell her that I will put you on minimum wage and they make $300 in a

week, they can make that in a night or an hour. It is real hard to

survive on $300 a week in America.

We have to meet that need while they are in treatment of giving

them life skills that they can make, and that is why the values

training, the biblical training of honesty and trust and not manipulating, those are the principles; and a lot of the State programs

teach the same principles of dealing with your anger and the issues

of life, you have kids growing up—we have a kid at 7 years, his

father put a rubber strap on him and stuck the first shot of heroin

in his arm and laughed at him as he fell around the room. We have

other guys with cigarette burns on their skin. These kids are angry

and they are mad as heck at the world. They want drugs to just

deal with the pain.

Mr. CUMMINGS. Mr. Nance, what kind of area do the young people that you work with come from? Is it a rural area?

Mr. NANCE. It is everything. It is costs—there are inner city kids

and country boys. There are kids and young adults coming from all

walks of life. We have people flying in Learjets, dropping their kids

off, and people sleeping behind trash cans. Take your pick.

Mr. CUMMINGS. How long have you been doing this?

Mr. NANCE. Eighteen years.

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Mr. CUMMINGS. We get all of these reports from the drug czar

from everybody. We get report after report telling us teen usage is

down. Teen usage is up; we get a whole lot of data.

In your 18 years, can you kind of tell us—and this will be my

last question—what you have seen? The differences in who you see,

what kind of people you see, was there one time, for example, just

about the only people you saw were African Americans or Hispanics, and now do you see a change? Has it been constant? Was

there a point in time when you saw things sort of explode? Can you

answer that for us?

Mr. NANCE. Yes, there are a lot of questions there. There are all

different races that come. Fifty percent of our student population

are black, 40 percent are white and the other 10 percent are Hispanic in Florida and Georgia. Across the Nation, that range will

differ.

There have been changes. We are seeing more and more heroin

addicts coming to Teen Challenge for help, but the last 10 years

it was crack cocaine, 90 percent of the students coming to Teen

Challenge for help; and these would be predominantly 18 years old

and above, were coming because of crack cocaine.

We had an executive with Winn Dixie Corp. that came to Teen

Challenge for help. He had gone through several short-term programs and had gotten fired and kicked out because of drugs, because of short-term programs. But now we are seeing more and

more heroin.

We don’t see as many addicted—the juveniles didn’t used to be

addicted, but we are seeing more and more juveniles addicted coming to us than we used to see. The ones that started playing around

at 9, 10, 11 years. They tend to do that during the experimentation

stage, and by the time they are 17 and 18, they are addicted. We

are seeing 14- and 15-year-old kids addicted to drugs. They don’t

care about anything in the world but getting drugs. They will stab

you, sell their body, whatever they need to get drugs. And the

youth are more violent today than ever before.

Mr. CUMMINGS. Thank you, Mr. Chairman.

Mr. MICA. Dr. Giuliani, do you receive State or Federal assistance?

Dr. GIULIANI. Yes.

Mr. MICA. Both?

Dr. GIULIANI. We have Federal block grants, and then we receive

Department of Children and Families funding.

Mr. MICA. Have you ever gotten a discretionary grant?

Dr. GIULIANI. No.

Mr. MICA. Let me ask you a question. How much do your expenditures in your program total?

Dr. GIULIANI. About $255,000.

Mr. MICA. For the year?

Dr. GIULIANI. Yes.

Mr. MICA. How much is your program, Mr. Nance?

Mr. NANCE. For 12 facilities and 350 beds it is $3.6 million.

Mr. MICA. Ms. Murwin, did you go through both public and private treatment programs, or just public?

Ms. MURWIN. Public.

Mr. MICA. How many?

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Ms. MURWIN. Just one.

Mr. MICA. Was that one successful the first time around or did

you ever have repetitive experiences?

Ms. MURWIN. No, it was successful the first time, but I did end

up staying there for 6 months. It was supposed to be a 30-day

treatment, and after 30 days I knew that I was not ready to go out

into the world so I stayed there 5 more months.

Mr. MICA. Did you have to wait for treatment?

Ms. MURWIN. Yes. I had to go home and wait, and I continued

to use drugs. The only reason that I ever ended up in treatment

was because my sister was already clean. She had gone through a

couple of treatment centers herself, and she grabbed a hold of me

and kept me. She, like, baby-sat me until I got into treatment.

Mr. MICA. So long-term treatment, once you got it, was successful?

Ms. MURWIN. Yes, sir.

Mr. MICA. Are you familiar with others who participated in these

programs?

Ms. MURWIN. Yes, sir.

Mr. MICA. And similar success?

Ms. MURWIN. Yes, sir.

Mr. MICA. Thank you.

One of the frustrations we have is we have almost doubled the

amount of money in treatment in the last 7 years, and I think, in

the last 5 years, have had substantial increases, I think somewhere

in the neighborhood of 26 percent trying to get the money to the

programs.

Your $255,000 and your program—in my opening statement I

showed the way the dollars are spent in Washington. What do you

think of 73 people in the administrators office of the national program, what do you think about 11 percent of the staff being used

to administer 80 percent of the funds in the program, and then 89

percent of the staff—now, this is not peanuts; this is $155 million

in administrative costs.

$155 million in administrative costs going to Washington. I was

absolutely stunned at the cottage industry that is built up around

the Beltway. That is just the administrative costs. If we adjust the

amount of money in some of these evaluation programs which, in

my estimation, may be duplicative of NIDA’s efforts and some

other efforts, you have $64 million or 64 percent of the contracts

specifically identified for technical assistance and evaluation for

the grants. We are up to a quarter of a billion dollars in overhead.

What do you think?

Dr. GIULIANI. Sir, it is way too much. I know that when——

Mr. MICA. Doesn’t that warm the cockles of your heart to go back

and know that your Congress is increasing the money, and we have

created an incredible bureaucracy? These people are feeding off

of—I could name the firms here in contracts to help even prepare

the forms to give to the bureaucrats to review.

Dr. GIULIANI. For every dollar I receive, and speaking to Mr.

Nance, if I spend 1 hour with a client, I am spending 45 minutes

doing paperwork on that client.

Mr. MICA. I’m sorry, would you repeat that for the record?

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Dr. GIULIANI. For every 1 hour I spend with a client, I am spending 45 minutes on paperwork for outcome measures, reporting to

the State, reporting to the District and reporting to the Federal

Government. And it is not uniform.

Mr. MICA. What is absolutely incredible to me for the benefit of

the ranking member, who is with me, and the record, I attended

the drug summit we held at the State level and asked the department, Florida Department of Children and Family Services, to

list—to give me a list of the programs; and there are 22 State grant

programs awarded to Florida, 19 received by organizations that already either receive block grants or State funds for providing substance abuse services.

So we are spending all of that money and all of that administration to do basically the same thing over again. It is absolutely

mind-boggling.

I am going to put the subcommittee and the House on notice that

when their appropriation comes up, I will do everything, including

stopping the proceedings of the House, by calling for successive motions to adjourn until we take the money from this overhead and

put it into these treatment programs.

So everybody is on warning here. We are going to find a way to

get that money out of these bureaucracies and these blood-sucking

Beltway bandits into the programs.

I thank you for coming. You won’t get anything out of this, Mr.

Nance, because you don’t even participate, nor do you get the opportunity to fill out those forms. That is a blessing. But we will see

what we can do to try to make your programs eligible for some of

the requests that you have made that sound reasonable.

I appreciate your coming here and helping us do a better job to

serve those who need service and particularly thank you, Ms.

Murwin, for your testimony today.

Mr. NANCE. Thank you.

Ms. MURWIN. Thank you.

Mr. MICA. We will excuse this panel.

I would like to call the second panel.

Ms. Janet Heinrich, U.S. Health Finance and Public Health

issues with the GAO; Mr. Paul Puccio, executive deputy commissioner of Alcoholism and Substance Abuse Services, Albany, NY;

Dr. John Keppler, clinical director of the Commission on Alcohol

and Drug Abuse, Austin, TX; Dr. Kenneth Stark, director of the Division of Alcohol and Substance Abuse of Olympia, WA; and Dr.

Martin Iguchi, co-director, Drug Policy Research Center, RAND

Corp.

Mrs. Mink, I am going to excuse the third panel today, Dr.

Camille Barry, and ask them to come back; and if necessary, I am

going to also subpoena the Director of the office, Mrs. Chavez, who

is the administrator and who we invited today and is not coming

today. So I am excusing at this point—with your permission, we

will have her back, and Camille Barry, to respond to both of us and

also have a full opportunity to respond to what has been brought

up here today.

So this will be our final panel.

Mrs. MINK. I agree with that, Mr. Chairman.

Mr. MICA. Thank you.

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At this time, as I mentioned to the previous panel, if you didn’t

hear me, this is an investigations and oversight panel. I would like

you to all rise, please, and be sworn.

[Witnesses sworn.]

Mr. MICA. As I informed the previous panel, if you have lengthy

statements or documents you would like entered into the record,

upon request, we will grant that accommodation. I think we have

everybody seated now.

I would like to start with the General Accounting Office, Ms.

Janet Heinrich. You are Associate Director of Health Finance and

Public Health Issues. Welcome, and you are recognized.

STATEMENTS OF JANET HEINRICH, ASSOCIATE DIRECTOR,

HEALTH FINANCE AND PUBLIC HEALTH ISSUES, U.S. GENERAL ACCOUNTING OFFICE; PAUL PUCCIO, EXECUTIVE DEPUTY COMMISSIONER, ALCOHOLISM AND SUBSTANCE ABUSE

SERVICES, ALBANY, NY; JOHN KEPPLER, CLINICAL DIRECTOR, COMMISSION ON ALCOHOL AND DRUG ABUSE, AUSTIN,

TX; KENNETH STARK, DIRECTOR, DIVISION OF ALCOHOL

AND SUBSTANCE ABUSE, OLYMPIA, WA; AND DR. MARTIN

IGUCHI, CO-DIRECTOR, DRUG POLICY RESEARCH CENTER,

RAND CORP.

Ms. HEINRICH. Thank you, Mr. Chairman and members of the

subcommittee. I am pleased to have the opportunity to testify on

the Substance Abuse and Mental Health Services Administration’s

efforts to support an effective drug abuse treatment system.

We are releasing the report to you that you requested on

SAMHSA’s funding for drug abuse treatment-related activities and

efforts to determine whether funds provided to States support effective drug abuse treatment programs. I will summarize the key

findings of our report in which we described the activities supported by SAMHSA for drug abuse treatment, both the block grant

and the knowledge development and application grant programs,

SAMHSA and State mechanisms for monitoring fund use, and

SAMHSA and State efforts to determine the effectiveness of drug

abuse treatment supported with block grant funds.

The Federal Government has made a considerable investment in

drug abuse treatment-related activities, about $581 million in fiscal

year 1996 which is the latest year of complete block grant data. Of

these funds, more than 80 percent was spent by all States for treatment services funded through the block grant program.

To better understand the types of services States provide, we

surveyed 16 States that received at least $25 million for their fiscal

year 1996 block grant. The States we surveyed support a range of

services, primarily in outpatient settings. Methadone treatment expenditures ranged from 2 percent to 50 percent, in part demonstrating the flexibility States have in determining the services

supported by block grant funds. States also use State funds, other

Federal funds, such as Medicaid, and county funds to support drug

abuse treatment services.

Block grant set-aside dollars, about $25 million were used for

technical assistance contracts requested by the States and program

evaluation efforts. Examples of technical assistance include redesigning treatment policies and procedures, establishing cost-effecVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00052 Fmt 6633 Sfmt 6633 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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tive treatment models, and training seminars. SAMHSA spent the

remaining funds, approximately $78 million, for KDA grants to determine the effectiveness of selected treatment practices, expand

the availability of treatment services for specific locations and populations, and promote the adoption of best practices in treatment

techniques. To help improve the overall quality of substance abuse

treatment and facilitate the adoption of current knowledge about

effective interventions, SAMHSA has developed treatment protocols

by bringing together clinicians, researchers and policymakers. This

effort is coordinated with the National Institute on Drug Abuse.

SAMHSA monitors grantee use of funds through onsite reviews,

and reviews of independent financial audit reports and grant applications. These mechanisms are used to monitor grantees’ compliance with program requirements, identify grantees’ technical assistance needs, and provide grantees guidance for improving program operations. The current accountability system for the block

grant is mostly based on a review of State expenditures designed

to determine whether States comply with statutory requirements.

SAMHSA does not track States’ responses to deficiencies to determine if they are resolved, nor does SAMHSA focus on the outcomes or effectiveness of States’ drug abuse treatment programs.

Several State and SAMHSA efforts are under way to determine

the effectiveness of drug abuse treatment programs, using client

outcome measures such as substance use, employment, and in

criminal activity. Nine of the States we surveyed conducted such

assessments, but the outcomes measured, the populations assessed,

methodologies used and availability of results vary from State to

State, making an overall program evaluation impossible.

SAMHSA is funding a pilot effort with 19 States to develop and

report on uniform core client outcomes. SAMHSA has also asked

all States to voluntarily report client outcome data in the year 2000

SAPT block grant application. This effort will not yield consistent

data because some States are not currently collecting the outcome

data requested.

SAMHSA has supported two national studies that suggest some

drug abuse treatment can be effective in improving outcomes, such

as decreasing substance use and criminal activity.

In conclusion, there are efforts under way to determine program

effectiveness. While SAMHSA monitors State expenditures to determine whether block grant funds are used in accordance with

statutory requirements, monitoring is not designed to determine

the effect State drug abuse programs are having on client outcomes. A few States have systems in place from which lessons

could be learned about measuring the effectiveness of treatment,

using client outcomes. All of these efforts should help to determine

what additional actions are needed to obtain uniform State reporting on the results of drug abuse treatment.

Mr. Chairman, this concludes my statement and I will be happy

to answer any questions that you or other Members may have.

Mr. MICA. Thank you. We will withhold questions until we have

heard from all of our witnesses.

[The prepared statement of Ms. Heinrich follows:]

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Mr. MICA. I recognize Mr. Paul Puccio, executive deputy commissioner, Alcoholism and Substance Abuse Services from Albany, NY.

Mr. PUCCIO. Thank you, Mr. Chairman. It is a pleasure to be

here. I am going to speak the highlights of my written testimony

and sort of summarize the basic points we want to make.

First, I want to set a context. The New York State system is a large and comprehensive delivery system. It is approximately $1.3

billion on an annual basis to pay for prevention and treatment

services. That is the publicly funded system. The block grant approximates about $100 million of that amount. There are about

125,000 people on any given day in the treatment system; about

250,000 people are treated annually. It is a very large and comprehensive system.

But I want to point out two very important factors. One is that

the gatekeepers for admission to the system are very diverse and

multiple in a State like New York. We have judges from drug

courts to the traffic courts to family court; DAs, you mentioned the

DTAP program, on the social welfare side, employment side, all of

them have authority to mandate people into treatment. Approximately 40 to 50 percent of all the people in the treatment system

are there because of some form of mandate.

Also, the system does not exist in isolation of other human service systems. Successful alcohol and drug treatment services don’t

arise only out of the treatment system; they arise out of a complementary set of services associated with the provision of health

care, mental health services, housing services, child welfare services, and it goes on. Systems operate in some sort of synergistic

fashion in order to make a difference for the lives of people enrolled.

The other thing to understand is that all of these systems that

send people to us, all of the gatekeepers are demanding expectations of the system. They all are looking for points of accountability

and for good outcomes of treatment. That is an important understanding because it relates directly to the reporting requirements

that fall to the system. Everyone is accountable to multiple gatekeepers and there are multiple systems of accountability that are

cumbersome and difficult for our providers, and for States and

county governments, as we deal with these demands for accountability.

I would also point out that one of the things that happens in a

State like New York is that we, as the single State agency, play

a very significant role as systems managers. We are not only managing our own system of services, which is very complex and extensive, but we are also doing it in relation to other service delivery

systems; and that is an important understanding about what we do

at the State government level.

This system did not get built without a long-term partnership

with the Federal Government. Federal agencies working with State

agencies, working with county governments and providers helped

build the system over a long period of time. The block grant sustains a portion of that system, and KDA local funding was used to

incrementally improve the system with an infusion of technology,

as well as to provide additional services which complemented and

added to the richness of the service delivery system.

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It is also important to know that technical assistance that is provided by SAMHSA is a valuable commodity to the States. We in

New York use technical assistance to provide managed care training to our providers as they begin to enter the world of managed

care. They needed to get up to speed, and that was an important

element in terms of using those resources to train those providers.

The system is very accountable. We have shared with the committee copies of our evaluation studies. We are doing very well in

terms of demonstrating the effectiveness of our service delivery system. That effectiveness is enhanced by the multiple points of accountability. Everyone wants the same things in terms of outcome,

and we are beginning to see significant improvement.

We are beginning to allocate our resources in the State of New

York based upon provider performance. Not only must you do well,

but you must be increasing standards and do so in a cost-effective,

cost-efficient manner. We are pleased with that.

I would say to you that we have a concern with regard to the future of the system, in particular our relationship with the Federal

Government. We have a very rich and diverse system. It is unique

to New York; no two States are the same in terms of the service

delivery system. It is important when moneys flow into the State

of New York, there is a dialog and discourse with the State agency

about how things will fit; if they don’t fit well, there is the potential that there will be ineffective use of those resources. It is important that money flow through the State in a way that allows us to

assure its integration into the system.

We also are very concerned about data reporting, and this is a

major issue for us. As I mentioned, the multiple systems of accountability, we see a lot of that and we cannot have multiple systems lying on top of multiple systems.

We in New York have built a significant information system that

supports accountability in our State. As we look to the future for

new reporting requirements that come from the Federal level, it

has to be integrated carefully with what we do, and we need that

to occur so there is not an inappropriate disinvestment in the already expensive information systems that we have in place.

The bottom line is that we see the need, as we look to the future,

for increased flexibility in the use of the block grant in terms of

being able to accommodate the emerging needs and the changing

needs. We need systems of accountability that integrate Federal,

State and local and provider concerns and are not competitive and

result in dislocation and disruption; we also need a continuing

partnership with the Federal Government that basically produces

an effective local service delivery system such as we believe that

we have in the State of New York.

Thank you.

Mr. MICA. Thank you for your testimony.

[The prepared statement of Mr. Puccio follows:]

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Mr. MICA. Dr. John Keppler, clinical director, Commission on Alcohol and Drug Abuse from Austin, TX.

Welcome, and you are recognized, sir.

Dr. KEPPLER. Mr. Chairman and members of the committee, I

thank you for allowing me to be here. At the outset, I am submitting this packet of information from Texas for the record.

Mr. MICA. Without objection, that information will be made part

of the record.

Dr. KEPPLER. I will summarize some of my thoughts from my little prepared talk today.

I spent 15 years in the direct delivery of service both in private

practice at the faculty of a medical school and rehabilitation medicine and being a medical director and direct service provider to individuals with this problem, both in detoxification and active treatment, both inpatient and outpatient in the public and private sector. And so in my last 21⁄2 years of going into different kind of public service, it has been an interesting perspective to see the struggles which the country faces.

Texas, as does the rest of the country, faces an immense struggle

with what I prefer to call an epidemic of substance abuse. The

availability of the substance throughout our society as an agent

that causes many people to fall ill, like any other illness that we

face. Against the overwhelming need and demand for these services

are rising health care costs and costs shifting from private to public

sector, where the public-sector dollar for substance abuse literally

becomes one of the few places you can obtain what one would refer

to as adequate substance abuse treatment services.

Again, the dollars being so precious, the quality of outcome and

the quality those services provided is very important. The substantial portion of total available publicly funded substance abuse services outside criminal justice comes from the substance abuse prevention and treatment block grant in our State.

We have worked closely with SAMHSA over the years on several

policy matters, including the difficult issues surrounding services to

those with both mental health and substance abuse problems; and

Texas is about to implement the children’s health insurance program, and is proud of the excellent benefits for substance abuse

prevention and treatment that it contains. It is perhaps one of the

largest benefits in the country for our children.

We are grateful for SAMHSA’s clear leadership on that and very

grateful for the collaboration between SAMHSA and NIDA, for the

excellent technical assistance we have received; and we appreciate

their publications. That has helped and trained a lot of folks in the

public sector. They are very readable and extremely helpful.

We served about 40,000 people with the substance abuse prevention and substance abuse block grant, and as you heard from the

doctor who was here before, you can quintuple that number who

actually need and want services. There is more than just need, but

as we define want, you can quintuple that number to around

250,000.

We have some concerns. We are concerned about the KDA

projects. They are well intentioned, but SAMHSA’s involvement is

time limited. When SAMHSA is out, it is up to the State to continue the program, a program that may not fit into our service

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plan. In Texas, SAMHSA has helped us develop a strong data collection system, and that system coupled with our knowledge and

need surveys puts our State in the unique position to make the

best and most efficient use of funding currently being awarded

through Federal KDA grants.

We are excited, though, about the 19 States participating in the

treatment outcome and performance pilot studies, and we believe

this project has a great potential to develop standardized methods

to measure the effectiveness of our programs, particularly in the

area of looking at outcomes from the aspects of case mix adjustment, which I believe we need to do in our field very strongly. We

have collected outcome data, performance outcome data since 1985

and get outcome data on 70 percent of our clients, which I have included in this packet. We know it works in Texas. We also know

where the problems are.

With the support of SAMHSA, we utilize a great deal of epidemiological data to help us monitor the drug trends in our State. I

believe our emerging epidemiologic studies are very important.

I would like to say how much we appreciate SAMHSA’s national

leadership. Certainly that leadership has helped Texas strengthen

and develop our data collection tools. Now we would like to use

these tools to be able to make all of the relevant funding decisions

in the State.

Giving the States control over the money currently set aside for

KDA will preserve the best parts of this program. The money will

meet the needs of the most vulnerable populations and develop innovative services. That is what we are already doing at the State

level. We need the added flexibility to ensure that the money devoted to these projects are pursuant to our State delivery plan.

This change would help us better meet the unique needs of Texans

struggling with addiction, and that is a mission that I share with

the Federal.

Thank you for an opportunity to testify today. On a personal and

professional level, I have struggled with this issue in the private

and public sectors. I relate extremely strongly to the previous panel

members, who are out there on the front lines, and respect their

work. Thank you.

Mr. MICA. Thank you.

[The prepared statement of Dr. Keppler follows:]

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Mr. MICA. Now I recognize Kenneth Stark, director, Division of

Alcohol and Substance Abuse from Olympia, WA.

Mr. STARK. Thank you. I will try to be as brief as possible. I

would like to take a few minutes to respond to some of the questions that came up during the previous panel. When I speak about

those issues, I will touch on them relative to Washington State because, as has already been stated by Paul from New York, each

State is somewhat different. There are different needs and resources and different systems that have been built, although they

all try to focus on serving the best practice possible, given the demands for those resources.

Let me first mention that our division is the single State agency

responsible for managing block grant resources. In the State of

Washington, we get about $30 million a year for the block grant,

out of a total of $110 million per year budget for prevention, treatment and related support services. So you can see that the block

grant is a part of our budget but not by any way, shape or form

the largest part. We have a fairly substantial State investment in

services.

One of the things I heard earlier is that treatment is expensive,

and part of the context of that is, compared to what? When you

look at alcohol, drug problems, and particularly when you get to

issues of chronic addictions, we know at least in Washington State,

and I am sure that these numbers are not that different nationally

that more than 50 percent of all emergency room visits that are related to trauma are alcohol- or drug-related. We know that a good

82 percent of the kids locked up in our State juvenile correctional

facilities have a substance abuse disorder. Seventy percent of the

people in jails and prisons have a major problem.

We know that when we provide treatment, those numbers are

substantially impacted. People get better. So the question is: Is alcohol/drug treatment expensive? Well, in the context of spending

nothing else, maybe it is, but in the context of spending money on

the consequences of not funding alcohol/drug treatment, alcohol/

drug treatment is cheap.

In the State of Washington, in the public sector, the average cost

of alcohol-drug treatment per client is about $2,500. That includes

our so-called failures and our so-called successes; it is not that expensive. We know from a lot of data collection and a lot of research

that we have done—and this is not just self-reported data, but this

is verifying data from other records, including criminal records,

vital statistics, birth records, medical records—that when you provide alcohol/drug treatment compared to a population that needed

that treatment that is comparable and didn’t get it, there are significant cost savings. Even after accounting for the cost of the alcohol and drug treatment, it more than pays for itself. And in Washington we have been fortunate to have major support from the Governor and major support from our State legislature and some of the

other program areas that have seen our data and know that when

you fund alcohol/drug treatment, you are funding health promotion/

crime prevention. It is a key issue.

Treatment standards were mentioned earlier. It is important to

have treatment standards. I can’t tell you a thing about programs

that are out there in the State of Washington that are not certified

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and accredited by us because we don’t monitor and regulate them,

and so we don’t research them; so I can’t tell you about those. I

can only tell you about the ones that we fund, we regulate and we

accredit.

Faith-based services, we do fund faith-based services, but there

is that issue, and it is a Federal one, about you cannot force somebody to go to chapel or go to church. So we have got faith-based

organizations who are accredited by us and are funded by us, but

the faith-based part of the program for the clients that we fund has

to be optional.

Six percent SAMHSA administration, is that good or bad? I

couldn’t tell you by looking at that chart. I can tell you that the

administration in our division is 6 percent, and I don’t see that as

expensive, assuming that you know what the other services are

that get funded with that. In our division, 6 percent covers budgeting, contracting, contract monitoring, evaluation, training, technical assistance.

So is 6 percent expensive? In our division, no. As a general number, I would say no. In this case, on that chart, I can’t tell you; I

would have to look at all of the details.

What are some of the issues? SAMHSA positive stuff. I am moving faster now. Clearly technical assistance is helpful. Clearly the

studies on evaluation are helpful. The State needs assessment

grants that SAMHSA has funded are very helpful. What is problematic, the block grant is not a block grant, it is ‘‘blockegorical.’’ It has so many set-asides and requirements it is incredibly cumbersome to manage.

Then the second bullet in my written testimony talks about the

block grant application. You, Mr. Chairman, have talked about 400

hours to fill it out. Part of the reason is because the block grant

itself, the congressional requirements are so categorical. SAMHSA

has to require us to report on a number of different things, so they

can get some relief by that.

There is also a big push that I would like to make relative to a

comprehensive research strategy and outcome-performance-based

strategy. We lack one. There are a lot of activities going on, but we

lack a comprehensive strategy within SAMHSA, as well as across

the Federal agencies working in partnership with the States, to

truly look at how we can best measure outcomes utilizing resources

available. One of the problems is the institute funding for research,

although it does a lot of good research it has very little relationship

to the SAMHSA block-grant-funded programs. Why is that? The

red light is on. I will close and answer questions later.

Mr. MICA. You can finish. We give a little bit of breathing time.

Mr. STARK. On the KDAs, good news and bad news. They have

funded a number of good programs. The challenge with the KDAs

is that there needs to be a stronger relationship between SAMHSA

and the States relative to developing the priorities for funding with

the KDAs, as well as the reporting protocols, and how it fits into

a comprehensive strategy. So we think we could use some increased partnering there.

I already talked about the NIDA stuff. There needs to be a closer

link between the Federal institutes research and the block-grantfunded prevention and treatment programs.

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The national household survey, while it is a great tool for a national macro picture of the alcohol-drug use patterns and the problems, even with the new proposed State sort of monitoring processes, it will not be useful for States. Again, the number of people

that will be included from the individual States are so small to

render them useless for counties to be able to look at individual

county-level needs. So there is a problem there.

And the national household survey is not what I would consider

low cost. It is a fairly expensive study, and it seems to me maybe

we could look at how that could be made more efficient, and some

money could continue in the SAMHSA budget to fund State needs

assessment projects where you can get lower-level, county-level

needs which at the local level you need.

And then finally, my last point in the written testimony, how do

we get more State representation in policy development relative to

SAMHSA’s activities? One of the ways to do that is on committees,

including the current SAMHSA advisory committees, and having

been on one of those committees, I can tell you, although they do

good work and I appreciated being on it, there is minimal participation from States on those advisory committees. But there is significant grantee participation on those committees, and I think

there needs to be more balance, since States are the predominant

receiver of SAMHSA funding.

With that, I will close.

Mr. MICA. Thank you.

Now I would like to recognize Dr. Martin Iguchi, co-director of

the Drug Policy Research Center of the RAND Corp.

You are recognized, sir.

Dr. IGUCHI. Thank you, Mr. Chairman, and thank you for this

opportunity to testify. I ask that my written statement be entered

into the record.

Mr. MICA. Without objection, so ordered.

Dr. IGUCHI. As a member of CSAT’s National Advisory Council,

as a NIDA treatment researcher, as a psychologist and former drug

treatment program administrator, and as co-director of the Drug

Policy Research Center at RAND, I have spent considerable time

thinking about SAMHSA’s role as it relates to the provision of drug

treatment in America.

I am going to focus on one question: Is SAMHSA helping local

and State communities to make the best use of their scarce drug

and alcohol treatment resources? My discussion on this question involves three areas of SAMHSA activity in support of the community decisionmaking: one, helping communities to identify treatment costs, treatment utilization, and treatment outcomes; two, are

they helping communities to determine where treatment is most

needed; and three, are they helping communities to identify best

treatment practices? SAMHSA plays a vital role in these areas,

and as I will discuss, they continue to face many challenges.

In the first area, communities need information to assess what

treatment resources are in place, the cost of those resources and

how those resources are performing. This is a very complicated

process, as a single individual may utilize services from a variety

of systems. For example, a single person may be enrolled in drug

treatment, they may be getting treatment for depression at a comVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00088 Fmt 6633 Sfmt 6633 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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munity mental health center, they may be on Medicaid, and they

could be involved with a criminal justice diversion program. Each

system contacted by that individual keeps its own records in its

own separate data base. In order to understand the coordinated

cost of services utilized by a given individual requires a single data

base integrating information from multiple systems.

Recently in partnership with the States of Oklahoma, Washington and Delaware, SAMHSA developed a data base system capable

of merging cost and utilization information from Medicaid, mental

health and substance abuse systems. This integrated data base system represents an important step forward in that it overcomes significant technical obstacles and recognizes the multitude of agencies and resources that must be coordinated to evaluate service delivery.

Although it would be ideal for all health delivery programs to

monitor outcomes as a matter of routine, doing so can be an expensive and complicated proposition. This is particularly true for substance abuse treatment because followup is complicated by a distinct lack of resources in existing agencies to collect this information, by the illegal nature of the problem, by the low socioeconomic

status of many in treatment, and by the multiple life dimensions

positively influenced by treatment that need to be measured to

fully reflect the effect of treatment.

For example, treatment may reduce substance use, it may diminish criminal activity, it may diminish violent behavior, it may improve mental health, it may increase the likelihood of employment,

or it may prevent the birth of a drug-exposed child.

Recognizing the complications and expense of ongoing outcomes

monitoring in community settings, SAMHSA has commissioned a

working group specifically to address this issue, and they have entered into numerous partnerships with States to develop performance measures for a variety of treatment interventions. Quite appropriately, these groups have focused, to date, on a number of

drug treatment process measures that may be used by communities

as predictors of outcome. These intermediate measures might include, for example, the amount of substance use reduction, treatment retention, treatment engagement, patient satisfaction, or

quality-of-life improvement.

While significant progress has been made in the development of

tools for assessing cost and performance, much work remains to be

done in integrating cost and effectiveness measures. While this is

not an issue for SAMHSA alone, the lack of consensus among

economists regarding the best means for conducting economic evaluations of drug treatment programs means that the comparisons

across different evaluations are compromised by a lack of reporting

standards. This leads to decisionmaking guided by cost considerations alone—without adequate attention to effectiveness.

On my second point of helping communities to determine where

treatment is most needed, in 1998, the U.S. GAO reported serious

deficiencies in States’ abilities to develop estimates of treatment

need. This problem continues. States still do not have capacity for

assessing treatment need. SAMHSA’s recent expansion of the National Household Survey on Drug Abuse to allow for State-level

analyses represents a potential improvement in the availability of

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epidemiological data for communities. However, in order for this information to be useful to States, several problems must also be addressed.

First, SAMHSA needs to place considerably more emphasis on

releasing the data as quickly as possible to State analysts in a form

that allows for analysis of regional need.

Second, States require more technical assistance to develop systems for monitoring treatment need. SAMHSA needs to provide

leadership in the development of analytic models that will allow

States to make use of their own data. At this point, there is very

little capacity.

On the third point of helping communities to identify best treatment practices, SAMHSA has done an excellent job in the promotion of evidence-based practices. The addiction technology transfer centers and the treatment improvement protocols all play an

important role in the dissemination of ‘‘best practices’’ guidelines.

Another mechanism for promoting treatment quality is through

accreditation. In the treatment of chronic opiate abusers,

SAMHSA’s new role in accrediting methadone treatment providers,

formerly an FDA function, represents a tremendous move forward

for the field and holds significant promise for the promotion of evidence-based practice.

In addition to dissemination, SAMHSA appears to recognize that

many community treatment programs already provide excellent

care. SAMHSA has several projects that document and evaluate

these model programs. SAMHSA also has a number of treatment

projects that take empirically validated treatments and apply them

in multiple community settings. These studies are important as

they help to identify barriers to implementation, they demonstrate

the real-world utility of interventions known only to researchers,

they provide important information regarding cost cultural relevance, and they serve as models for policymakers and other treatment providers to consider.

In summary, SAMHSA has clearly played a vital role in helping

communities to make good decisions about their allocation of scarce

treatment resources. However, and as might be surmised from my

brief review, SAMHSA has several challenges ahead. In particular,

SAMHSA has a great deal more work to do in helping communities

to identify treatment gaps. In order for the expanded National

Household Survey on Drug Abuse to be useful, a system must be

put into place that will get the data to States in a form that they

can use.

Further, there is a tremendous need to upgrade the analytic capability of States and to provide them with technical assistance to

make use of the data. This challenge must be met if communities

are to make optimal use of their resources, and if we are to have

full participation as a Nation in achieving the goals established in

healthy people 2010.

Thank you.

[The prepared statement of Dr. Iguchi follows:]

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Mr. MICA. I thank each of the witnesses for their testimony. Unfortunately, some of the other Members are not here. They canceled

the floor proceedings, and there are other hearings, so we don’t

have the normal participation of all of the Members.

For that reason, also, I have concurred with the minority in asking the final witness, Dr. Camille Barry, and also the administrator, Dr. Chavez, to appear at a later date so that will be a continuation of this hearing. We suggested also to staff that we may

ask Dr. Leshner, the head of NIDA, to also participate in that,

since we may need to look at the cooperative effort of NIDA and

SAMHSA.

With those comments, let me, if I may, ask some questions.

First, for GAO. I notice on the GAO report table, for the 27 of the 29 contracts, over $1 million are awarded to Washington, DC

area contractors.

Does this practice raise an issue of limiting business and range

of knowledge to a particular area? Did you all look at that at all?

Ms. HEINRICH. We did not evaluate the contracting practices at

your request. We simply obtained from SAMHSA the listing of the

contracts that they do support. And as you state, I think almost 99

percent of them are in the Washington, DC area.

Mr. MICA. How might GAO ascertain the level of satisfaction of

the States with SAMHSA’s involvement and contributions to their

efforts?

Ms. HEINRICH. Well, we certainly could go out to the States and

ask those types of questions. And certainly you have some wonderful representatives here that will be able to give you information

on that, as well, I am sure.

Mr. MICA. Could a comparison be made of States’ support for increased block grant assistance versus discretionary funding?

Ms. HEINRICH. Yes, a comparison could be done.

Mr. MICA. Now, I looked through the report, Mrs. Mink did too,

and we may want to re-craft additional requests for GAO’s study.

It provides us some preliminary information, but I think not in the

depth or scope that we would like to obtain. But I appreciate your

cooperation with this subcommittee.

I heard, New York and Texas and Washington, a little bit about

your programs. Now, if you could recall for us on the committee the

dollars that come from block grant and Federal sources versus

State.

Mr. Puccio of New York.

Mr. PUCCIO. Our total system is about $1.3 billion. Half of that

is Medicaid. About $100 million is the block grant and it is about

$270 million in general fund tax dollars.

Mr. MICA. $100 million is block grant?

Mr. PUCCIO. Right. And about $700 million is Medicaid program.

Mr. MICA. And the balance is State?

Mr. PUCCIO. State, local tax levy, and miscellaneous receipts

from public assistance funds and a variety of mixed revenues.

Mr. MICA. How about you, Dr. Keppler?

Mr. KEPPLER. I prefer—I can get you the information on Medicaid because that is administered by the Health and Human Services Commission, which is our umbrella agency. So our agency does

not control the Medicaid substance abuse dollars, nor the dollars

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our legislature dedicates for the in-prison treatment, our criminal

justice system.

It is $122 million of the Federal substance abuse block grant,

and I believe $27.5 general revenue for the programs we fund, publicly community-based projects outside Medicaid.

Mr. MICA. Mr. Stark, for Washington?

Mr. STARK. In Washington State, it is $110 million total budget.

$30 million of that is Federal block grant funding. A little over $50

million are several sources of State funding, and the remainder is

a blend of Medicaid and direct Federal grants.

Mr. MICA. In looking at the regulations that pour out and the

constraints that are put on these programs, it appears that many

of the programs are driven by Federal regulation requirements. Is

that correct, Mr. Puccio?

Mr. PUCCIO. It is more driven in New York by our regulatory

structure. Every treatment program is licensed and regulated and

monitored by us. Whether it is faith-based or not, if they provide

treatment in the State of New York, they are going to be subject

to one of our licensing requirements.

Mr. MICA. How does that overlap with Federal regulations? Are

State regulations pretty much a mirror of Federal?

Mr. PUCCIO. State regulations pretty much govern the service delivery side of things. Where the problem arises is that the setasides and the other requirements that are inherent in the block

grant basically put in place requirements and restrictions in terms

of how it is that we use money. Any money that goes into the treatment system has to follow our regulations, but some of it has to

be targeted at HIV, at people who are IV drug users, pregnant

women. It goes on and on like that.

With all the different set-aside requirements, depending upon

the locality, they may or may not have demand or service requirements that fit that mix; and it’s the mismatch of the requirements

against the local need that sometimes causes the problem.

Mr. MICA. So all of you three agree we need, first of all, more

flexibility in the block grant program? All right.

What about in discretionary grants? How do they work? Mr.

Keppler, how does that work for you in Texas?

Mr. KEPPLER. Well, as I tried to explain, I think it’s somewhat

problematic for us. In fact, we are oftentimes loathe to apply because it even limits our flexibility more. If we decide to go after

something that has been decided upon that seems to fit what we

might need, at some point in time it may go away and then we

have to figure out how to shift things to pick that up and then

catch the next one. So our desire to go after a significant sum of

money which we would just prefer it go through the formula of the

block grant and be distributed for us to plan, it is very hard to pick

it up.

Mr. MICA. Now, in your States, I asked Florida to provide me

with a list of all the programs that receive grants and then see how

many they were already funding. Would the pattern be similar that

most of the discretionary grant money goes to programs that you

already are supporting?

Mr. PUCCIO. Absolutely. That is absolutely correct.

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Sometimes what happens is that the KDA may actually add an

element of service that is missing from the service delivery system,

especially in certain geographic areas. So we may have a need for

specialized women’s beds that serve women and their children in

a particular area, and a KDA might fit that particular requirement, and then it does complement with what takes place in that

geographic area, even though we may already have substance funding with that provider. It fills a gap.

Mr. MICA. So in New York, in most instances, there is already

going to be a program that is supported by the State?

Mr. PUCCIO. Yes.

Mr. MICA. Texas?

Mr. KEPPLER. Again, I want to emphasize, some of the clinical

ideas have been extremely helpful, they have been extremely helpful ideas, ideas about how to put processes in.

Mr. MICA. If we had the cash, I think you could probably come

up with some pretty good programs.

Mr. KEPPLER. I wouldn’t argue with that.

Mr. MICA. Now, Mr. Stark, are most of the discretionary programs funded by the Federal Government that receive money in

your State already funded also by the State?

Mr. STARK. I would say probably around 60 to 70 percent. And

sometimes within that 60 to 70 percent, what you end up going

through the KDA is helping us expand capacity.

One of the problems that results, though, is that expanded capacity is generally reimbursed at a rate higher than we usually pay;

and then the other difficulty is, within the 30 percent that are not

tied to our system, without there being a connection when the Federal money runs out, they come to us and want to continue and,

of course, they are not part of the existing system.

Mr. MICA. So they may not be a part at the beginning, but you

get them in the end?

Mr. STARK. Well, in the end the pressure, once the Federal

money goes away.

Mr. MICA. Once it starts, someone is going to have to pick up the

slack or the program. Not that these programs are not all worthwhile, but the astounding figure to me is the bureaucracy that is

required, $155 million in overhead, the pure number of administrators to administer a smaller program.

Now, I guess, Dr. Keppler, you gave quite an encouraging statement to fund these programs, and without these programs what a

disaster we would have. That is not really the question before us.

I have some pretty conservative members on the panel, and I have

some pretty liberal members on the panel. I think to a man and

woman on the panel, they will spend whatever is necessary no matter how conservative. Now, the liberals, it is easier for them to do

just philosophically. But that is not the question here. The question

is, the money that we are spending, is it being spent as efficiently

as possible?

I also could spend the rest of the afternoon talking about the bureaucracy to support the bureaucracy that we have created. I

mean, I would imagine that many of the things that your folks in

New York or Austin or Olympia, I would imagine we have forced

you to employ administrators and evaluators. Maybe they are not

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spending 45 minutes filling out forms for an hour of treatment, as

you heard, but I know that there is duplication in this.

Then the other thing, too, I think everyone would agree we need

some evaluation or measures of performance. We have got to have

some accountability. About how many levels of this?

Then, the thing that is astounding to us, too, is the lack of possible coordination between NIDA and SAMHSA in, say, research is

important, some of the other things that are going on. So I think

that maybe as a result of this hearing we might bring NIDA into

the mix and see if anything can be consolidated.

Again, the intent of the hearing is to see how we can get the

money to the programs that are most successful, retain some accountability, provide the maximum amount of flexibility. And it

sounds like most of the programs you are overseeing on a day-today basis, New York sounds like they have a pretty awesome control on these programs. And then there are probably areas, and

maybe you could summarize these for me, there are some areas

that only the Federal Government can provide assistance, and resources where it cannot be done effectively by the States or the

local programs?

Mr. Puccio, I will put you on the spot. Dr. Keppler is second. Mr.

Stark, tell me what would be the best things we could do at the

Federal level that would fill a gap and provide assistance, things

that should be done at our level?

Mr. PUCCIO. Two things, one of which is to focus on research and

target it at the needs that are arising in the States. Good basic research is fine, but it also has to fit the needs that are arising out

of the populations that are using drugs and out of the needs of the

treatment providers.

Mr. MICA. How is that filtered to SAMHSA or NIDA?

Mr. PUCCIO. I think they have a variety of mechanisms, advisory

committees and so forth, to surface that.

Mr. MICA. One of the criticisms that I think Mr. Stark made is

that we do not have a balanced representation. Would you agree

with that?

Mr. PUCCIO. I think that’s fair. I’ll also give you an example of

sort of what I’ll call an inventive approach to things. NIDA has

been working to develop clinical trial networks which deal with the

fusion of technology arising out of their research.

There is an effort to look at research practice collaboratives,

which we have used in the State of New York to build a relationship between our treatment providers and the State agency. We

had discussions internally about how to fit these two things together in order to expedite the process of technology transfer and

the rapid deployment of new technology that we hope will be there

on the pharmacological side into the treatment system, and that

has always been a concern of ours. And we think that by building

partnerships that allow research to move State systems into the

provider community in a much more rapid fashion is something

that could be done.

It is not easy. Each agency at the Federal level and sometimes

at the State level has its own interest and jurisdiction. But if we

could figure out ways, like we are attempting to in New York, to

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build those linkages to go rapidly deploy technology, we may be

able to make some significant gains.

Mr. KEPPLER. I would be loathe to say that the universities and

the brain research and things and practical clinical research in

Texas wasn’t the equal of any other States or any other domain.

I would be loathe to say that.

At the same time, some of the directed work on developing best

practices, and I sometimes wish they would be a little more forthcoming in what they think they might be, but I think it is deeply

tied to the outcome study.

I hopefully have some faith in TOPS too in that, even though it

sounds like bureaucratic jargon, that mixed case adjustment work

they are trying to do where they find out where under each kind

of addict which treatment works for them. Well, all addicts are not

the same. Alcoholics are different within those subgroups, which

goes to your question, sir, before regarding how do we know what

works.

Well, we’ve got to know what works for different subtypes of

those people. Then you can say what works. I think that needs to

go on and it needs to be organized.

That being said, our State agency itself was mandated by our

legislature, develop best practices within Texas and we’re working

on that. And the brain research and biochemical and biological research at NIDA is invaluable, I think, in medications; and I salute

that highly. This is a unique specialty that they are doing there.

Mr. MICA. Mr. Stark, did you want to comment?

Mr. STARK. Sure. You know, I’m sitting here thinking about what

I was going to say and I realize that there is only one way to say

what you’re thinking, and that’s say it and not try to tone anything

down or cover anything up.

Mr. MICA. I do that all the time. It gets me in trouble.

Mr. STARK. Yeah, it does me too.

When I really look at the whole issue of does treatment work,

which has come up today at the table, and you look at the block

grant and we’ve been criticized in some of our publicly funded

treatment programs about a mixed bag of program that may work

or those that don’t work, the question comes to my mind of, why

is it that we do not know, every one of us, definitively that these

programs work? Why don’t we know that?

We’ve been funding block grant programs for quite a while.

We’ve been funding research for a long time. Why don’t we know

the answer, and why isn’t it consistent from one person to the

other? And it gets back to what I said earlier, that there has been

a disconnect between the research money and the publicly funded

block grant programs.

And I don’t mean that as a negative slam on any of the agencies,

it is simply a matter of there’s been a disconnect. The research

money has gone predominantly over history to university researchers. Although most of it goes to biomedical, and I agree that we

really need to look at that, some of it has gone to services research

and applied research, but much of that services research and applied research has been funded toward theoretical models, always

looking for that magic bullet, looking for some new thing.

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Well, why are we looking for a new thing if we haven’t answered

the question about whether what we’re doing right now works or

doesn’t work? Why would I want to run off and find something new

if I believe what I’m doing now works?

So we need to do some research on what’s being funded today

and verify does it work or does it not work. If it does not work,

then, by all means, change it. If it works, then expand it.

Mr. MICA. Mr. Iguchi, did you want to say something?

Mr. IGUCHI. Yes, I would very much like to say something.

I think there are such a multitude of agencies and a multitude

of levels of government involved here that all are requiring information and answers and, in fact, requests for information and answers have multiplied remarkably with many recent changes of

government asking for much more accountability with real numbers.

We have the general over at ONDCP now putting together a

wonderful plan with performance measures, the PME plan, and

you have all these different plans and goals and different guidelines being put together and being mandated by very, very many

people; and, so, everybody is trying to respond at once with their

best possible answer. But, with all these different voices, all that

you’re hearing right now from every level is chaos.

And I think the role of the Federal Government is to help cut

through that and help find some simpler answers and simpler ways

of doing things. But to do that you have to bring all these different

voices together, and you actually have to sift through a lot of that

chaos. I think that to a great extent, from what I can see,

SAMHSA’s efforts of trying to put together evaluation instruments

and to model things that are being done well and in the States that

are doing them well and bring them to the attention of other

States, that that actually has been an effective way for disseminating information. And they are getting a lot better at it.

So I think that from where I sit as an evaluator, I actually have

been very pleased that there have been States, like the State of

Texas, that are doing this really very well, but they have no way

of getting out and telling other States how they are doing it.

Most of the different treatment programs that I’ve come to know

as being excellent treatment programs in the community I knew

nothing about until they were brought to my attention by different

technology transfer mechanisms at SAMHSA.

And so for researchers and others to find out about what is going

on right in the field and try to figure out what they are doing, for

all these different pieces of information to come together, I think

there is a role for the Federal Government, and I think it’s actually

that it is actually taking place at SAMHSA right now.

Mr. MICA. Are you on the advisory committee at SAMHSA?

Mr. IGUCHI. Yes, I am.

Mr. MICA. You’re an evaluator?

Mr. IGUCHI. I am an evaluator, yes.

Mr. MICA. Well, there is no question there is chaos. And Congress has helped create the chaos, and it has magnified.

Mr. Puccio, did you say we have multiple systems on multiple

systems and we have multiple evaluation systems, we are creating

more and we are creating a huge bureaucracy?

99

I mean, they are well-meaning folks and they are mandated either by law or regulation, but what I am hoping to achieve this

year is to figure out some way to bring order to the chaos so that

we simplify the system.

I am going to ask one last question, and then see if Mr.

Cummings wanted to ask questions.

If we went to, like, a 90–10, 90 percent of all this money went

to block grants, and we included flexibility, a little bit of accountability, now we have got to have a little bit of accountability in

there, but flexibility, and then, granted, there are some things that

we said that the Federal Government could do best, research, there

are other areas, providing data and things that would be beneficial

to all, could you support that?

Mr. Puccio.

Mr. PUCCIO. Generally, yes.

Mr. MICA. Mr. Keppler.

Mr. KEPPLER. Generally, yes.

Mr. MICA. Mr. Stark.

Mr. STARK. [Witness nods head in the affirmative.]

Mr. MICA. I do not want to ask you. You are an evaluator. Well,

what do you think? Go ahead.

Mr. IGUCHI. I require, I guess——

Mr. MICA. My goal is to put you out of business, you understand.

Mr. IGUCHI. And that would be impossible to do, as you know,

because better numbers just means we get better analysis.

Mr. MICA. Not all of you, just we want enough and at the right

level.

Mr. IGUCHI. And in fact, I think that many States are doing very

good treatment. But the issue isn’t so much are they doing good

treatment. Can they do it better is the issue, and more effectively.

Mr. MICA. Well, we are studying the hell out of this. Again, Mr.

Stark, how many times and over and over and year after year in

study. We do not want to put money in programs that do not work.

We want to fund those that are most successful. But at some point,

how many times do you reinvent the wheel?

Mr. IGUCHI. I think that there are emerging problems that one

of the things about the drug abuse problem is that it is constantly

evolving, and that there are always new challenges that we have

to face. And actually, as far as science being brought to the world

of drug abuse treatment, it is a fairly new phenomenon. So that

there is a long way to go yet before we can say we’re there and we

are providing the most effective service. We can do this a lot better.

And so, there is a huge role here for continued research and for a

better evaluation.

Mr. MICA. I think everyone agreed that there are some things

that have to be done at that overall level, and even at subsequent

levels.

Mr. IGUCHI. But they are very different. I mean, each of these

States has a position that, yes, they can spend their money most

effectively and they do know what’s best. The problem is that there

are a lot of issues that come up that cross a lot of different borders

that they are not able to solve by themselves and that there is a

role for Federal leadership in. There are also a lot of very small

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subpopulations whose voices are not heard even in their own

States.

Mr. MICA. Most people have said that most of what they get that

is helpful is from NIDA.

Mr. IGUCHI. I’m not sure that that’s what you heard.

Mr. MICA. Well, a little bit. They said they got some things, but

they also said there is duplication.

Mr. IGUCHI. I think one of the things that SAMHSA has done

very well in terms of improving treatment and bringing good treatment to the attention of other States is going out in the community

and highlighting the problems.

Mr. MICA. I think we want to do that and that should be one of

that 10 percent responsibilities.

Mr. Cummings.

Mr. CUMMINGS. Thank you very much, Mr. Chairman. I had to

run to another meeting, but I am sorry that you dismissed the

SAMHSA people because that is why I am here. I wanted to hear

from them.

Mr. MICA. I did that at the request of Mrs. Mink.

Mr. CUMMINGS. Mr. Chairman, that doesn’t matter to me.

Mr. MICA. We wanted to give them full opportunity. She cannot

be here, so we will have them back and we will have a full panel.

We also do not have the administrator today, which we requested.

So we are going to request the administrator, the individual that

was assigned today in a full hearing, and possibly Dr. Leschner, if

the minority would agree.

Mr. CUMMINGS. I understand, and I thank you for clarifying that.

I just wanted to make sure.

You know, I guess from where I come from, you know, when you

have accusations flying, I would like to be able to have the person

who is being accused to be able to defend themselves. Because in

my neighborhood I have seen so many people accused of things and

were not able to defend themselves. So I just wanted to make sure

that we are clear on that and that we will have that opportunity.

And I want to thank you, Mr. Chairman, for that. I understand,

and I appreciate it.

One of the things I think that concerns me as I listen to this discussion is that, you know, if you were to go to my neighborhood

and if you were to talk to the people on the corners and you were

to talk to them about drug treatment, what they would say is that

there are a lot of people making a lot of money, but we are not getting much better. A lot of people making a lot of money, a lot of

people being experts on this, experts on that.

We can send people to the moon, we could send a ship to Mars,

we can do all kinds of things; and you cannot convince me that we

cannot figure out what works and what does not work and cannot

get that information out. It is incredible to me.

And I have got to tell you that I do not think that it takes—and

I do not know that much about it—but I do not think it takes a

rocket scientist to figure this thing out, in other words, what works

for certain populations dealing with certain drugs.

And again, I think that what happens, and I think the thing that

worries me, Mr. Chairman, is that, if we have situations where the

tools that we have are not properly evaluating, and even if they are

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and if that information is not getting out, then what happens, and

I am telling you I have seen it over and over again in this Congress, what happens is people, say, let us not spend the money on

it, let us not do it because it is not working. And I think that is

so unfair to some people like the lady who sat up here, Ms.

Murwin, the lady who sat up here a few moments ago and talked

about her overcoming.

So I want to ask a few questions so we can kind of get through

this a little bit so I can be clear. Some you all apparently feel that

treatment works. Is that true? Treatment works.

There was a recent study and I cannot even remember, I think

60 Minutes did it, I know it was in the Washington Post, where

they talked about how the research is done a lot of times on

projects like this and the research apparently is oftentimes put on

a shelf and never used. And even things that work a lot of times

may not be refunded, they may not get their proper due, or things

that do not work do not get put to the side because nobody uses

them.

Again, it goes back to what the guys in my neighborhood are saying, people are getting rich off of us, but are those dollars really

getting to the people that they need to get to?

Let me tell you, the biggest problem with all of this is that if

there is not integrity within the system, then what is going to happen is that we are not going to stand still, but we are going to go

backward because you are going to have all these people saying, I

have got treatment, I have got treatment, I have got treatment and

the addicts are going to get sicker and sicker; and then we are

going to move from generation to generation to generation, as I see

in my neighborhood of addicts.

And so, to the GAO people, did your report issue recommendations on how SAMHSA could improve oversight in monitoring the

block grants?

Ms. HEINRICH. No, sir, we did not have any recommendations.

What we did was describe the programs as they currently exist in

terms of the block grant and the KDA grant programs. And we also

were asked to determine how SAMHSA and the States were actually monitoring their programs from a perspective of accountability.

And the systems that we have currently in place really do seem to

focus more on assuring that the States are complying with the statutory requirements. We were also asked to describe SAMHSA and

the States’ efforts to determine the effectiveness of drug abuse

treatment supported with block grant funds. And what we found

there is that there are activities going on at SAMHSA level, and

there have been at least two large SAMHSA-funded national studies and then several States have really exemplary programs in

terms of evaluating program effectiveness, patient outcomes. And

three of the States that are doing the most are here today.

Clearly, there are many other States that are not doing nearly

as much in terms of determining program effectiveness.

Mr. CUMMINGS. How do you determine, since you just gave those

wonderful compliments to these States, what is the standard for

saying that my program works and works well? I mean, is it like,

we treated 10 people and, after 5 years, 6 of them are still off of

drugs? I mean, how do you measure that?

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Mr. CUMMINGS. How does somebody go around saying what you

just said, they have got the greatest programs in the country?

I need to know that. And the reason I need to know it is because,

if you have got something that is working, and assuming that you

have a reasonable kind of measuring tool, then what you said, Mr.

Stark, is what we ought to be doing, using the best practices of

things that work.

Let me just give you a little example that upsets me. In my

school system in Baltimore, they go around asking everybody all

over the world, how can we educate poor kids, when we have got

schools with kids from the very kinds of neighborhoods that these

kids come from there are not doing well, who are doing well.

It seems to me, and maybe I am missing something, that somebody would say, well, if we have got school X 2 miles away in the

same kind of neighborhood, children with the same kinds of backgrounds in the same city, that we might just want to make a phone

call over to school X and say, now, X, we are having problems over

here with Y; what are you doing that we are not doing?

And yet, still we are spending thousands and thousands of dollars exporting experts from everywhere, and going back to what

you said, Mr. Stark, maybe, maybe we have the answer of what

works. Maybe we have the measuring tools of what works.

And so, I want to know how do you measure, to say, how does

somebody come to the conclusion that was just stated, that you all

are some of the best programs, and how do you measure yourselves? Or do you measure yourselves?

Mr. STARK. In the State of Washington, we very much do measure ourselves. Just to give you an example, although we do some

of the rigorous scientific studies that would be funded by NIDA,

working with researchers from the University of Washington and

Washington State University and some private researchers, although we do some of those very expensive studies that actually do

track the client population and interview them pre and post and

have comparison groups. That data, although good and whatnot, is

still self-report data and clients are simply answering, are they still

using drugs? Are they getting in trouble with the law? Are they

participating in work? Are they using health care services at the

rate that they used to be or not? Are they living now in a shelter

versus a house versus whatever?

Although those questions get asked, we continue to get challenged even by our State legislature, even on those rigorous scientific studies, yeah, but that’s self reports. What’s the real impact?

Did it really cost us, the people of the State of Washington, less

money for those individuals that you treated compared to those

that needed treatment that were similar and didn’t get it?

So, about 10 years ago, we began to look at tracking and integrating multiple data bases. We said, what are the consequences

of addictions? And you’ve already described a number of those.

There is crime and there is health problems and there is violence

and there is poverty and there is a whole lot of consequences related to true addictions.

So if those, in fact, are the consequences, we ought to be able to

measure those. And if alcohol and drug treatment has an impact

in improving in those areas, we ought to be able to measure that.

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So we began taking clients who received assessments but no

treatment and then those that received different types of treatments, residential treatment followed by outpatient, or residential

treatment only, or outpatient only, and then compared treatment

completers to treatment non-completers, then looked at subpopulations, pregnant women versus kids versus chronic SSI, supplemental security income clients, and we began to look at those outcomes. Prior to them coming into treatment, what did they cost the

State of Washington? Post treatment, what did they cost the State

of Washington. In some of the studies, we only looked at 6 months

post treatment. Some we went as far as 5 years out.

And in virtually every case, every study we did showed significant positive outcomes with the aggregate. Now, that isn’t to say

that some of those clients didn’t fail. Some of them did. But

through the aggregate, taking the failures and the successes together, those treatment programs had major reductions in real

health care expenditures, real reductions in crime and jail and prison time, real improvements in employment and earnings, and I

could go on and on.

So we measure it a variety of different ways. We do use

SAMHSA funding, and we very much appreciate it. SAMHSA has

done a good job working with us in helping us build this infrastructure. And we also use NIDA, National Institute of Drug Abuse, dollars by partnering with researchers and going after that money to

do this research.

Part of the question is, if you are going to evaluate and evaluate

effectively, there is no free outcome; it costs money to collect data,

analyze data, and put out reports.

The other question, Chairman Mica, was about why do so many

of these things end up on the shelf? Well, part of it is that there

is lot of the expensive research that has been done, and in some

cases it answered questions that nobody else was interested in

quite frankly. In some cases, it answered questions everybody else

might be interested in, but it was written academically, not from

a policy perspective. And when it got done, they met their need for

publish or perish, if you are in higher-ed you know what that is

all about, and then it got shelved.

We need to have a national strategic plan and some coordinating

committee that comes together and looks at maximizing those research results and look at how do we move from research to policy

and to practice. And there are some activities going on now, but

they need to be coordinated.

Mr. PUCCIO. If I can, I am going to draw a distinction between

outcome measure and impact measure and give you an example of

those two things.

A drug court judge is going to be interested in whether or not

a treatment program is effective in terms of reducing criminal behavior. So we actually do measure whether or not our programs

produce reductions in criminal behavior along with gains in employment and a variety of other measures.

We then take those measures and we deploy them in rank order

and compare one program to another. So you may have in a community three or four or five providers that are providing similar

kinds of services. The question then arises that are the outcomes

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of provider A better than B and then, if so, why; and then how do

we work that through?

One of the things we have done is use the peer review requirement that is under the block grant and use that to have providers

work with providers on sharing their technologies to make sure

they are, in fact, improving. That is very different than looking at

what I will call impact.

I am a school board member and I know what it is like to live

in a community where you struggle with trying to understand what

is happening in terms of the overall impact of drug prevention and

treatment services in your community.

In the State of New York, we have begun to take, and I know

Ken has done this in Washington, take surrogate data, we have

looked at PINS petitions, we look at drug arrests, we look at emergency room visits, we look at a whole variety of different indices

that get at this impact measure, aggregate it at the county level,

and then rank order counties to be able to compare and contrast

those counties that are suffering more or less from the consequence

of outcome drugs and then begin to talk about prevention strategies on the level that make a difference in terms of achieving better

outcomes and match that up on a State-wide basis.

The problem you run into is that, at the subcounty level, the collection of that data is extraordinarily difficult. So with my school

district, with 1,000 kids in it, the collection of PINS information at

the county-wide information, which is children that are in protective service under probation, this is a very difficult thing to go have

available. We have it at the county level but we don’t have it broken down into smaller jurisdictions.

We are trying in New York City, for example, to break it down

into the zip code level. But even then, that is a very large aggregation of a community.

It is a very difficult thing. It is time consuming. It is expensive.

But I think we are all working hard at building the data systems

that allow us to say yes, it works, and then to compare and contrast providers so that we can begin to get at the components of

what are the treatment differences that make for better outcomes

beyond what we have right now.

Mr. CUMMINGS. If you had a situation where you took your criteria, your measuring tool, and discovered that drug treatment center A, had according to your measuring tool a 10-percent success

rate; and B, had a 75-percent success rate; and C, had a 70-percent

success rate, what happens to the guy with the 10 percent?

Do you follow what I am saying? I mean, does somebody say,

look, you are not even close? And let us assume that you have got

some complaints going along with it. I mean, does that person get

kicked out or are you all trying to help them, too? Because the

thing that I am worried about is that if we do not begin to look

at those kinds of things, all of you are going to be out of a job. I

am serious, not because of me, but because the Congress will say,

wait a minute, it is not working.

And you all provided some wonderful testimony today that really

I am sure helps Mr. Mica, and I know he feels a lot better than

he has in a long time because you all have said some very positive

things about treatment. But I can tell you that if that word gets

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around and everybody begins to feel up here that treatment is not

working and folks are operating on a 10 percent level with a few

70 and 65 percents, you have got a problem, because there are

some people who have the opinion that once on drugs, never off.

Do you understand the question? Is there a mechanism in your

States to kick somebody to say, look, you are not doing it. It is not

getting done. We are spending a lot of money on you. We are wasting taxpayers’ dollars. We have had people that have come into

your program, they thought they were being treated, they weren’t

being treated, they came out of the program, they are still on

drugs, and they are worse off than they were before, because now

they go around saying, see, treatment does not work. Why should

I be bothered?

Mr. KEPPLER. I agree with that. And I certainly will say this,

yes, we do monitor them. We go out and look at them. We have

a compliance visitor if they are not doing it. That kind of outlier

would very likely be defunded, with one proviso, sir. Unless that

program was 10 percent, if I went there and I saw they were taking care of the sickest, most chronic people that had been treated

before on multiple occasions, and as a choice at the State level we

said we still have to have some commitments, we aren’t ready to

let them die yet, as opposed to another program that were firsttime, younger people, who perhaps were just substance abusers

and not yet fully dependent for a year, for 10 years, for 15 years,

I’d look at that a little differently. In other words, what kind of

cases are they treating?

That being said, if they are treating the same kind in each one,

look the same, no difference in their history, I would certainly go

after the 10 percenter. They would be done. They would have to

move on.

One more thing, and this will leave me Dr. Clark and Dr.

Leschner, who I both deeply respect, this is a complex

neurobiological disorder. I’m sure you have heard that. We don’t

fall under necessarily the criticism we have for some other terminal

brain diseases which have taken years and years to cure and treat.

We are just coming into the place of learning new ways to treat

stroke, new advances in Parkinson’s disease, new advances in

multi-infarct dimension, new advances in schizophrenia, all these

types of complex neurobiological disorders of which substance dependence disorders are just one, so we are on that same playing

field.

Mr. CUMMINGS. Is it State law that will allow you to kick them

out?

Mr. KEPPLER. It would be our State auditors, probably akin to

who would look at what we are doing in our legislature that makes

us do this performance-based contracting with progressive sanctions.

Mr. CUMMINGS. Do you think most States have those kinds of

mechanisms? I mean, do you?

Mr. STARK. Washington State does.

Now, there are two levels in Washington State. There is both the

issue of contracts. There is also the issue of accreditation. We accredit both publicly funded as well as private-pay treatment programs through our division in the State of Washington. So, with

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the 10 percent issue, if it were the first time we had done an evaluation of that program and discovered only 10 percent, we would

probably start with some training, technical assistance. But if it

was clear that there was only 10 percent success and they were

satisfied with 10 percent success and it wasn’t changing, then if it

was a contracting agency, we would be looking at getting rid of the

contract. And if the program continued and it was quality of care

issues, we would be looking at the issue of accreditation.

But I want to point out another thing that is different. There are

times, many times, when somebody who needs maybe a year of

treatment starting off in maybe short-term residential treatment

followed by continuing outpatient treatment, they need that multilevel care, high intensity, then low intensity. And they get into the

high intensity program and when they finish that level, they can’t

get into the next level because it’s full, there are no open slots.

Mr. CUMMINGS. Like after-care.

Mr. STARK. It is continuing care. It can be fairly intensive outpatient. So the question becomes one of, can you punish treatment

program, No. 1, because the rest of the treatment that that individual needed wasn’t available? So that’s another issue you have to

consider in this when you are comparing one treatment program to

another. It is not only the issue of case mix adjustment and are

you, in fact, comparing the same client across different systems,

but it is what else did that individual need and did they or did they

not get it?

It then becomes incumbent upon every level of treatment program to be working very, very diligently to identify the additional

needs of the client they are serving beyond just the alcohol drug

treatment need, whether that that be housing, food, shelter. I

mean, you know as well as I do, we put people in prison and we

let them out of prison and they have major drug and alcohol problems and family problems and poverty problems, and we let them

out on the street and they walk out on the street with no job and

no place to stay and we wonder why they got in trouble again.

Now, I don’t know what you think about that, but clearly we’re

doing the wrong thing if we know that we are all going to strive

to find a place to sleep and eat to get our basic needs, and if they

are not met through some mechanism, we have a job, we have

training to get a job, we have a place to stay that is a safe place,

then we will figure out a way to get that, whether that’s through

medicating ourselves with drugs to forget about our problems or

committing crimes to get the money to pay for the basic needs.

Mr. CUMMINGS. Before I came to Congress a few years ago, a

group of men in my community volunteered to do an after-care program for people coming out of the boot camp system. And one of

the reasons why I have asked the chairman to make sure that

when they come to Baltimore that we bring the New York program

up, the one that the State’s attorney up in New York started, and

I am hoping we will be able to do that, Mr. Chairman, is because,

one of the things that we noticed for recidivism, and I think in

dealing with their drug problems, if we could get somebody a job,

a job, and get them sort of reoriented toward their family, as opposed to the corner, toward their kids and get into sort of a selfhelp kind of discussion kind of thing, what we discovered is that

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those guys who we could keep off the corner, get jobs, and get more

oriented toward their family were more apt to really pursue treatment and were more apt to do well. And this was basically—I

mean, it just worked.

Apparently there is a New York program which is basically an

alternative to a prison program that works, I guess, you’re familiar

with. And one of the things, we had testimony from the folk up in

New York, I was sitting there and I kept hearing the success rates

and I said there has got to be more than just getting them into

treatment. And finally, at the end of the testimony, the guy says,

jobs, jobs, jobs, jobs.

And I said, that is it. I mean, not that that is the total cure, but

when you think about it, one of you all said people get up in the

morning, and what they are doing is they are going out and looking

for their fix. They are basically going out trying to figure out how

to kill themselves, to be frank with you, because that is what it is,

is a slow death.

So if you could find things to occupy their time, give them a

sense of value, give them a sense of whatever. But it is a complicated process. I understand that. If anyone wants to comment on

that, you may. But I want to thank you all for your testimony. And

would you all agree that there should be measuring tools?

Mr. KEPPLER. Yes.

Mr. IGUCHI. Yes.

Mr. PUCCIO. Yes.

Mr. STARK. Absolutely.

Mr. MICA. I thank the gentleman from Maryland. I want to associate myself with his remarks that we do need to find some way

to better coordinate all of the efforts and the things that are required to make these programs successful, mental health, job training, social services, health care.

I did visit the DTAP program, and that is a totally integrated

program. It is expensive, but the alternative is far more expensive.

And many of these people, their lives are a total disaster, not only

their lives, the lives of their families.

I could go on, Mr. Cummings, and tell you about some of the people I met. One guy spent half of his life in jail. He was 38 and in

and out. The social cost. Another one, his wife had died of a heroin

overdose. He was a heroin addict.

But we have got to figure out a way to make this all come together. We have got to figure out a way to try to eliminate some

of the bureaucracy we have created. We want these programs evaluated, but we do not want paralyses by analysis. And we have got

to figure out a way to make this whole thing function.

As I said, I do not know if you heard me, there are some conservative members and some liberal members, but I think they all

want to see that everyone who needs treatment has treatment and

that it is effective and that we hold the programs properly accountable.

The good news is that we will have a continuation of this hearing. In fact, I will leave the record open. And I would also like a

copy of all of this hearing transcribed, if possible, on an expedited

basis so that the administrator can see the comments from this

hearing and then respond to them.

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I want the administrator here, not only the deputy that was supposed to be here. And we can also invite Dr. Leschner to see if

there are some things we can do more effectively in a cooperative

effort.

So, with those comments, I do want to thank each and every one

of our witnesses today, thank GAO for their report. And also, for

the record, I think we need to ask some additional questions of

GAO and, hopefully, get some more answers so we can do our job

more effectively in an oversight capacity.

There being no further business to come before the subcommittee

at this time, again, I thank our witnesses, they are excused, and

this hearing is adjourned.

[Whereupon, at 1:04 p.m., the subcommittee was adjourned.]

(109)

HHS DRUG TREATMENT SUPPORT: IS SAMHSA

OPTIMIZING RESOURCES?

TUESDAY, MARCH 14, 2000

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 10:15 a.m., in room

2154, Rayburn House Office Building, Hon. John L. Mica (chairman of the subcommittee) presiding.

Present: Representatives Mica, Mink, Cummings, and Tierney.

Staff present: Sharon Pinkerton, staff director, chief counsel;

Steve Dillingham, special counsel; Don Deering and Frank

Edrington, professional staff members; Lisa Wandler, clerk; Cherri

Branson, minority counsel; and Jean Gosa, minority assistant

clerk.

Mr. MICA. Good morning. I’d like to call this hearing of the Subcommittee on Criminal Justice, Drug Policy, and Human Resources

to order. I apologize for being late.

Mrs. Mink, as you know, we have many folks from our districts

in town, and while I love people with the various agencies in Washington, I have a certain appreciation of the people back home.

Mrs. MINK. Apology is noted and accepted.

Mr. MICA. Thank you. For that, we’ll begin our hearing today.

This hearing is actually a continuation of the February 17 hearing,

and the hearing is entitled, ‘‘HHS Drug Treatment Support: Is

SAMHSA Optimizing Resources?’’ I will have a brief opening statement, and then yield to our ranking member, Mrs. Mink, for her statement. Then we’ll hear from

our witnesses.

Today, our subcommittee is resuming its oversight hearing on

programs and operations of the substance abuse and mental health

services administration, also referred to as SAMHSA, which is located within the Department of Health and Human Services.

We began this hearing on February 17, but both the majority

and minority agreed to adjourn the hearing and continue at a later

date, so we could obtain a more detailed response to some of the

issues that were raised, and also to hear directly from the administrator of SAMHSA, Dr. Nelba Chavez. Since we’ll discuss the topic

of agency-sponsored research on drug abuse and treatment, we also

decided to invite the Director of the National Institute of Drug

Abuse, also known as NIDA, Dr. Alan Leshner. NIDA funds drug

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abuse research, and it’s important that we have him for this discussion while we also have the administrator of SAMHSA.

A startling statistic that we discussed in our last hearing was

that the national estimates of Americans in need of drug treatment

range from 4.4 to 8.9 million people, yet less than 2 million people

reportedly receive treatment services. We’re most concerned about

this gap in treatment services and how to address it. In that regard, I noted that SAMHSA’s block grants are key to reducing the

treatment gaps, as each grant block dollar spent on treatment generates $1.5 in additional State and local treatment spending. We

heard from State and local providers the successful drug treatment

programs are now in place, and every drug treatment dollar is so

vital to our efforts.

I was concerned to learn that participants in a successful faithbased treatment program lost their eligibility for food stamps. We

must do everything possible to prevent such absurd results and

also to fund more successful drug treatment programs that, in fact,

serve more clients. We learned that SAMHSA has huge administrative and contractual operational costs, and that oftentimes the

agency also imposes unnecessary burdens and red tape on States

and providers.

We also heard from the General Accounting Office [GAO], which

reported on what SAMHSA is doing with its resources. This data

raises questions regarding agency efficiencies and effectiveness.

The data indicates that 80 percent of SAMHSA’s substance abuse

grant funds flow to the States through block grants, and they are

managed by 11 percent of that agency’s staff. The remaining 89

percent of SAMHSA’s staff are engaged in something else, and

those activities include research and technical assistance, which

seem to be inordinately based in Washington, DC.

To me, this raises a red flag and many questions. Do we have

reason to believe that only Washington area consultants know

what works best for our States? Driving in from the airport yesterday, I was looking at some of the massive buildings and so-called

Beltway bandit operations that have grown up around the Capital.

It seems nice to have those high-paying activities in the shadow of

our Nation’s Capital. But are they providing the treatment and

funds to those programs and individuals out there beyond the Beltway?

I’m aware that fine public and private universities train drug

treatment professionals and researchers. I believe they are quite

capable of assisting programs in that regard. Witnesses have testified from various States with programs that are successful in

breaking the chains of drug addiction, restoring families, rebuilding

job skills, and saving lives. The States included Florida, New York,

Texas, and Washington. GAO commended these States for their

successes in a number of drug treatment areas. Today, we have as

a witness the Administrator of SAMHSA, which I said, Dr. Nelba

Chavez. Dr. Chavez has testified that CSAT-funded treatment programs are working resulting in a 50 percent reduction in drug

abuse among their clients 1 year after treatment. She further concluded and stated, ‘‘we know what works in prevention and treatment.’’

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Despite the success and others that she will mention, I think

that Dr. Chavez will agree with me that we cannot be complacent

in our efforts or satisfied with a status quo. Significant challenges

lie ahead, and our future successes depend on how efficiently and

how effectively we allocate our resources to accomplish shared

goals in preventing and treating drug abuse.

Let me outline some of the issues that I hope we’ll address at

this hearing today. If we can’t cover them today, we can followup

with another hearing after today. With regard to SAMHSA’s operation, my concerns include: agency administrative costs, organizational staffing, contracting practices, how our research and evaluation dollars are expended, and are we getting good results, discretionary spending practices, grant application, the whole process,

and processing award efficiencies.

With administrative costs of over $150 million annually, we must

ask what is being accomplished and at what price. Again, if you go

back and look at 89 percent of the expenditures and grants being

administered by 11 percent and the other 11 percent of the funds

consuming a tremendous administrative overhead costs, something

is wrong. What concerns me also is that many of the projects that

we and GAO reviewed and are already funded by either State government or other Federal block grant programs for which we’re incurring this huge administrative overhead.

Something is wrong. I just learned from SAMHSA that GAO

staffing figures do not include dozens of contract employees who

augment SAMHSA’s staff. SAMHSA now employs almost 600 people. I’m concerned about reported staff reductions and turnover in

the agency’s three centers, and whether this contributes to low

staff morale.

Also, I’d like to ask the staff to conduct a review and investigation of how many of the former staff are now some of these contract

officials. I found, while investigating other agencies, that some of

the former employment of the agency personnel turns into cottage

industry on a contract basis.

We also need to examine what value SAMHSA has received from

its hundreds of millions of dollars in research and evaluations. I’m

a strong supporter of research and studies, particularly scientific

studies that will lead us to do a better job and more effective, and

I don’t think we could ever spend enough to make certain that

we’ve explored every research avenue, but we also must see that

if we are duplicating activities, that we eliminate that duplication,

and most cost effectively, expend these hard earned taxpayer dollars on effective research.

I think the administrator will share some highlights with us

today. I have with me a copy of the ‘‘Handbook for Evaluating Drug

and Alcohol Prevention Programs, Staff/Team Evaluation of Prevention Programs.’’ It’s called STEPP, I think is its acronym, published in 1987 by SAMHSA’s predecessor agency ADAMHA. It

looks like it would be very helpful to evaluate activities. I’m told

that it was distributed and sold through the Government Printing

Office for many years. Is this evaluation guide no longer useful? If

not, why not? Should similar handy guidance be prepared and

made available to treatment professionals? Is this an illustration of

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my concern that the agency may unnecessarily be reinventing the

wheel?

Let me mention another area that I’m most interested in that remains a drug treatment priority. That area is the nonviolent offenders who are eligible, motivated, and in need of treatment. It’s

my understanding that SAMHSA’s discretionary grant programs

provide some limited support for treating offenders who are not incarcerated. I’m very aware of the need for offering treatment to deserving nonviolent offenders who have a need and desire to break

the chains of addiction, and who also hope to obtain productive employment and engage in law-abiding behavior.

In this regard, I have a copy of the report of the National Task

Force on Correctional Substance Abuse Strategies entitled, ‘‘Intervening With Substance Abuse Offenders: A Framework for Action,’’ published in 1991 by the Department of Justice. This national task

force with participants from ONDCP, the Office of National Drug

Control Policy, Justice, HHS, including ADAMHA, State treatment

and correctional agencies, probation and parole organizations, and

experts from institutions, such as Yale, outline promising correctional treatment strategies. This is back in 1991.

This project and its publication received extensive praise from treatment professionals, yet it only cost $100,000 to complete. Are

we getting that return on our investment today? Has anyone paid

any attention to this report? I ask SAMHSA to convincingly answer

the question and to ask its expensive contractor ‘‘Where’s the beef?’’ Finally, we also need answers to the question of how well

SAMHSA coordinates with NIDA. NIDA, as we know, is the primary agency with a responsibility for conducting drug abuse research, and we use NIDA in research in assisting States and local

programs. Is NIDA research relevant and does it demonstrate its

value to the States? If not, why not? How is SAMHSA documenting

and expanding this contribution? I’ve raised a number of questions,

a number of questions were raised in the hearing that we conducted previous to today’s meeting, and I hope that we can hear

from Dr. Chavez and Dr. Leshner on these and other issues today

as we explore ways to improve our delivery of an effective and efficient drug prevention and treatment program and policy for our

whole Nation.

[The prepared statement of Hon. John L. Mica follows:]

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Mr. MICA. With those opening comments and remarks, I’m

pleased to yield now to the gentlelady from Hawaii, our ranking

member, Mrs. Mink.

Mrs. MINK. Thank you, Mr. Chairman. First, I’d like to ask

unanimous consent that a statement by our colleague, the Honorable Ed Towns of New York, be submitted for the record.

Mr. MICA. Without objection, so ordered.

[The prepared statement of Hon. Edolphus Towns follows:]

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Mrs. MINK. Mr. Chairman, it is of course the responsibility of

this oversight committee as a subcommittee of the Government Reform Committee to pay attention to the ways in which the various

agencies and departments of government function and whether

they carry out the mission of their responsibilities as delineated by

Congress. We have to be, I think, absolutely sure, in whatever criticisms we level against an agency, that we compare their functions

and activities with what this Congress has charged them to do. The

criticisms of their conduct would not be fair in my estimation. It

did not take into contact the myriad of riders and charges and

other kinds of mandates that they have been given either by authorizing legislation or through appropriation riders.

Having said that, I think it’s also important to understand that

in this particular agency of SAMHSA, our charge is drug treatment, but SAMHSA has responsibilities in mental health, so although its budget is $2.5 billion, about $400 million of that amount

is spent in the mental health area, of which we are not making any

specific inquiries today.

In addition, there is another area known as knowledge develop- ment and application, which is allocated $329 million, both of

which are under considerable scrutiny by the Congress through its

appropriation process.

The area that you have called attention to in this particular continuation hearing is the block grants and the outside contracts that

have been awarded to ascertain whether the moneys are being well

spent and doing research and a variety of other things. The block

grants constitute $1.6 billion of the agency’s funding, and as I understand it, these funds are distributed to the various State agencies based upon formula, based upon criteria elaborated by the

Congress. And that the SAMHSA agency is the Administrator pursuant to those instructions laid down by the Congress.

The GAO report indicates that the administrative cost, which

this agency has reported roughly at 6 percent, does not constitute

an excessive administrative overhead. You have raised the question

that perhaps the true cost of the manpower is the number of individuals that are assigned to specific tasks within the agency. In

that context, you have raised the question as to whether the true

criticism should be with the allocation of personnel, and you have

outlined that perhaps 11 percent of the personnel is spent on the

administration of the block grants.

So we have much to hear from the agency, and I appreciate the

presence of Dr. Nelba Chavez at these hearings. I’m confident that

she will adequately explain the various issues that you have raised,

and I look forward to Dr. Chavez’s testimony. Thank you.

[The prepared statement of Hon. Patsy T. Mink follows:]

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Mr. MICA. I thank the gentlelady. Now I’m pleased—— Mrs. MINK. Just one more comment. Following the hearing we

had on February 17, I sent to GAO a series of questions which

arose from the testimony that we received, and I would like to have

the responses and my questions inserted in the record at this point.

Mr. MICA. Without objection, the responses from GAO will be

made part of the record.

Mrs. MINK. Thank you.

[The information referred to follows:]

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Mr. MICA. Thank you. I would like to now recognize the gentleman from Massachusetts, Mr. Tierney, for the purpose of an

opening statement.

Mr. TIERNEY. Thank you, Mr. Chairman. I’ll just associate my remarks with those of the ranking member, and I look forward to the

testimony of the witnesses and thank them for being here today.

Thank you.

Mr. MICA. Thank you so much, Mr. Tierney. Welcome back, Dr.

Leshner. I think you know the procedures. This is an investigations

and oversight subcommittee of Congress. We do swear in our witnesses. If the witnesses will please stand and be sworn. I’m sorry,

I don’t know this gentleman’s name. Could you identify yourself for

the record and let’s get a name plate.

Mr. WHITE. I’m Timothy White from the General Counsel’s Office

from the Department of Health and Human Services.

[Witnesses sworn.]

Mr. MICA. The witnesses have answered in the affirmative.

I would like to welcome the witnesses this morning. I understand

we just have two opening statements. First, Dr. Nelba R. Chavez,

and she is the Administrator of the Substance Abuse and Mental

Health Services Administration with the Department of Health and

Human Services. The second witness will be Dr. Alan I. Leshner,

and he is the Director of NIDA, the National Institute on Drug

Abuse, also under the Department of Health and Human Services.

We’ll recognize first Dr. Chavez. We won’t run the clock on her

since we only have two Members.

STATEMENTS OF NELBA R. CHAVEZ, ADMINISTRATOR, SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH AND HUMAN SERVICES,

ACCOMPANIED BY JOSEPH AUTRY, DEPUTY ADMINISTRATOR FOR SAMHSA; AND DR. ALAN I. LESHNER, DIRECTOR, NATIONAL INSTITUTE ON DRUG ABUSE, DEPARTMENT

OF HEALTH AND HUMAN SERVICES

Dr. CHAVEZ. Thank you very much, Mr. Chairman, good morning

to you and members of the subcommittee. I do want to thank you

for the opportunity to testify and provide the subcommittee with

information on the operation and effectiveness of SAMHSA’s programs. Before I proceed, however, I would like to enter our written

testimony for the record.

Mr. MICA. Without objection, the entire statement of the witness

will be made part of the record.

Dr. CHAVEZ. Thank you, Mr. Chairman. Also testifying with me

today is Dr. Joseph Autry, who is our Deputy Administrator for

SAMHSA. I want to thank you for the meeting and also it is indeed

a pleasure and honor to be here with Dr. Alan Leshner.

There are some people that I would very quickly like to just recognize for the wonderful work that they do throughout the United

States for individuals and families and children who are in need

of substance abuse services. First, I’d like to recognize General Arthur Dean from the Community Antidrug Coalitions of America;

Sue Thau from the Community Antidrug Coalitions of America;

Tom McDaniels from the Legal Action Center; Dr. Linda WolfJones from the Therapeutic Communities of America; Jennifer Pike

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from the National League of Cities; and Mr. Jack Gustafson from

the National Association of State alcohol and Drug Abuse Directors. Also Crystal Swann, who is with the U.S. Conference of Mayors; and finally, Dr. Westley Clark, who is SAMHSA’s Director for

the Center for Substance Abuse Treatment. He is in the audience

as well.

Thank you, Mr. Chairman. It is an exciting time for the fields

of substance abuse and mental health. We have established

SAMHSA over the past 7 years as a critical component of our Federal health and human service system. We have improved prevention and treatment services across the country and, at the same

time, streamlined our management. For example, we reduced the

number of administrative offices from 20 to 7 through consolidation. We were able to reassign 44 FTEs and transferred to the centers for program support. Never before has the potential been so

great and pride in our efforts so strong. The data attest to the fact

that our strategy is reaping dividends. Recent studies show that

drug use among teens is no longer on the rise. It may, in fact, be

declining and without exception, our treatment programs, across

the board, are helping people triumph over addiction and are leading to recovery. We have accomplished a lot for a small and lean

organization. Most of our budget is distributed by formula set by

Congress that limits flexibility to target funds based on need. However, with the tools and the limited discretionary resources available, we are clearly and capably carrying out our mission with success.

Despite the Nation’s recent success in preventing and treating

substance abuse, we are far from declaring victory. Unfortunately,

the stigma of substance abuse and mental disorders persists. Lack

of health insurance parity combined with limited government resources prevent people in need from receiving treatment services,

and we still have much to do to improve service system performance and quality because of past emphasis.

Much of the work done to date is focused on male hard-core addicts. The demographics of substance abuse are changing. We often

think of substance abuse as the province of adolescent and early

childhood, of boys and not girls. Well, the girls have caught up with

the boys and as the youth of the 1960’s grow older, the number of

older persons who abuse illicit drugs and alcohol may increase simply because the rates of substance abuse for this age group are

higher than they were for previous generations.

Our systems are not prepared for an aging group of drug abusers, and at the same time, treatment for teenagers, male or female,

is far from its potential. Our predictions, combined with the potential cost to society, argue strongly for an approach to prevention

and treatment that balances the need to fund services with the

need to improve the services available and to ensure services are

targeted and relevant to the populations in need.

To help address the needs, we are working to give States increased flexibility with their block grants. As you may know,

SAMHSA has a reauthorization proposal on the table. The Senate

has already acted and approved the measure. I hope the House will

act soon.

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SAMHSA’s role is clear. The findings from KDA grants offer

service providers and purchasers of prevention and treatment services including Federal, State, and local government, access to improved, more efficient, and more effective prevention and treatment

models. Targeted capacity expansion offers a way to target prevention and treatment services to the areas of greatest need. Block

grants provide a way to help support States and maintain their

prevention and treatment delivery systems. And data collection and

evaluation provides accountability for the Federal resources entrusted to SAMHSA. This four-part strategy is the balanced approach that we need to continue if we are to make progress.

Again, Mr. Chairman, and members of the subcommittee, thank

you for the opportunity to appear today. I’ll be pleased to answer

any questions you may have. Thank you.

Mr. MICA. Thank you for your testimony and remarks.

[The prepared statement of Dr. Chavez follows:]

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Mr. MICA. Rather than start with questions, we’ll first hear from

Dr. Alan Leshner, Director of NIDA. Thank you and you’re recognized, sir.

Dr. LESHNER. Thank you very much, Mr. Chairman, and members of the subcommittee. I’m very pleased to be here today to tell

you about NIDA’s diverse research portfolio and how research findings are being used to better understand and prevent and treat

drug abuse and addiction. I provided a detailed analysis in my

written testimony, but I’d like to make just a few points if I may

here.

NIDA is one of the scientific institutes of the National Institutes

of Health, the world’s leading biomedical research institution.

NIDA supports over 85 percent of the world’s research on the

health aspects of drug abuse and addiction. Our comprehensive

portfolio addresses the most fundamental and essential questions

ranging all the way from the causes of drug abuse and addiction

to its prevention and treatment. We also work hard to ensure the

rapid and effective dissemination of our research findings into practice.

Because of our dominant world role in science, NIDA is ever

mindful that even our most basic research findings must be useful

beyond just to the scientific community. For example, the fact that

scientists can now use the most advanced brain imaging techniques

to see the profound effects that drugs can have on the brains of

awake, behaving, experiencing individuals may not immediately

appear to be relevant, but I point out that it’s precisely these kinds

of abilities that are rapidly providing us with new insights into

how to prevent and treat addiction. They are also helping us determine the factors that make individuals more or less vulnerable or

susceptible to becoming drug addicts.

NIDA supported science is also significantly advancing drug

abuse treatment in very direct ways. For example, NIDA researchers have developed a wide array of behavioral treatments and

interventions, including cognitive behavioral, relapse prevention

and new family therapies. They also developed the patch, gum, and

spray for nicotine addiction and LAAM and methadone for heroin

addiction. NIDA is also working to develop medications to treat cocaine addiction and to develop both behavioral and biological treatments for methamphetamine and other emerging drug problems.

NIDA is working very closely with our sibling agency, SAMHSA, to

bring buprenorphine, yet another effective treatment for heroin addiction to the clinical toolbox of physicians and others.

Moreover, NIDA research has shown not only that drug addiction

treatment is effective, but also that it reduces the spread of HIV,

reduces drug use by up to 60 percent, and diminishes the public

health and safety consequences of addiction, including the increasing criminal behavior.

Research clearly shows that treating drug users while they are

under criminal justice control dramatically reduces both their later

drug use and their later recidivism to criminality by 50 to 70 percent. It is this combined set of scientific findings that is serving as

the basis for the new trend that’s gaining momentum throughout

this country of blending criminal justice and public health approaches.

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NIDA is also taking a proactive role to be sure that the science

is used to improve the quality of drug addiction treatment throughout the United States. As is the case for other chronic disorders,

effective treatments for addiction do exist. However, as is also the

case for other disorders, we can do better. Moreover, few of the new

treatments are being applied on a wide-scale basis in real-life treatment settings. In response, NIDA has expanded on a model pioneered by other NIH institutes, the National Cancer Institute, the

National Heart, Lung, and Blood Institute, the National Institute

of Allergy and Infectious Diseases, and we have established the National Drug Abuse Treatment Clinical Trials Network. We call it

the CTN for short. The CTN will provide a much-needed, national

research and dissemination infrastructure to both test new pharmacological and behavioral treatments and to systematically research how to correctly incorporate these interventions into real life

settings.

We’ve already established the first six nodes and have brought

42 community treatment providers into this infrastructure. We’ll

bring another six nodes including another 40 treatment providers

into the network this year.

Our ultimate goal is to include as many universities and community treatment providers in the network as possible and, of course,

to be truly effective, the network must blanket the entire country.

The National Drug Abuse Treatment Clinical Trials Network

epitomizes NIDA’s role as a supporter and conveyor of reliable

science-based information. However, to truly optimize its dissemination of new findings to frontline providers, we work closely with

colleagues and many other Federal agencies, particularly

SAMHSA. A prime example is SAMHSA’s addiction technology

transfer centers, which are working closely with the nodes of our

Clinical Trial Network to help ensure that rigorously tested and effective treatment programs are disseminated to communities across

the country.

To conclude my introductory remarks, because addiction is such

a complex and pervasive health issue, we must include in our overall strategies a comprehensive public health approach, one that includes extensive research, education, prevention, and treatment.

We’re very pleased about the tremendous progress in drug addiction research and how these scientific advances are offering us the

tools and practical solutions to reduce the devastating problems

caused by drug abuse and addiction for all Americans.

Thank you very much. I’ll be pleased to answer questions.

[The prepared statement of Dr. Leshner follows:]

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Mr. MICA. Thank you. Let me start with a few questions, if I

may, for Dr. Chavez. One of the concerns that was raised as a result of the GAO report that we requested was the distribution of

personnel. You testified in your opening statement about some

changes reducing the administrative offices. Did you say 20 to 7?

Dr. CHAVEZ. Yes, sir.

Mr. MICA. And moving FTEs to centers. I wasn’t quite sure what

that was. Could you elaborate on the movement of those personnel?

Dr. CHAVEZ. In 1996, the House Appropriation Committee requested that we review our organization, and one of the things that

they were looking at was the duplication. For example, we had

many duplicative services in all three centers at SAMHSA. Their

recommendation was that we centralize many of these administrative services. In addition, they also recommended that we look at

some areas that needed to be strengthened.

Mr. MICA. Where did these 44 people come from and where did

they go? 44 FTEs, are they just slots?

Dr. CHAVEZ. These were FTEs and these were slots.

Mr. MICA. Eventually, people moved from one point to another

point. Where did they go?

Dr. CHAVEZ. They went to the three centers, to the Center for

Mental Health Services, to the Center for Substance Abuse Treatment, and the Center for Substance Abuse Prevention.

Mr. MICA. So we have the same number of people. They’ve just

been moved to other responsibilities?

Dr. CHAVEZ. That is right. Some of those individuals—some of

those positions were vacant, so those positions were also transferred to the centers.

Mr. MICA. One of the other things that caught my eye was the

number of personnel in the administrator’s office, which GAO reported at least 73, and I think you said there were 7. Can you account for this discrepancy? Where are the other folks working?

Dr. CHAVEZ. The reason that the Office of the Administrator appears to be large is that numerous essential operational and coordinating functions are grouped with the Office of the Administrator,

the umbrella organization. For example, in my immediate office,

there are seven individuals, a total of seven that are directly in

that office, including Dr. Joseph Autry, who is the Deputy Administrator. There are five others that are detailed. One is detailed to

the Department of Health and Human Services. Another person is

detailed to HCFA. And the other to the Executive Secretary. In my

office, I have a Deputy, an Assistant, and a Secretary. Dr. Autry

has a Secretary and an Assistant. So in the immediate office there

are seven individuals. Those other individuals which are listed are

in various offices and provide agency-wide roles. For example, contract and review, which was one of the groups that the House Appropriation Committee recommended be centralized. They are responsible for managing legally required reviews for the centers. We

also have program coordination and policy activities and offices

that are responsible for coordinating many of these activities. Some

of these offices are in statute. For example, we have an office for

AIDS. We have an office for women. We have an office for alcohol.

We also have legislative services as well as Equal Employment Opportunity, Civil Rights, and Executive Secretary functions.

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Mr. MICA. There are 73 people total assigned to your staff, and

then you have each of the different activities. Mental health has

113, substance abuse prevention 118, and Center for Substance

Abuse Treatment 115. So most of what you have in these other activities would be a duplicate at your full administrative office. For

example, you have 12 in communications, public communications.

In mental health for that entire agency there are 13 substance

abuse, and communications has 22. And 26—I’m sorry, 7 in substance abuse treatment. So you have duplicates in the Administrator’s Office of which we have those activities, and each of the individual activities, one being just for citing—the numbers would be

as I cited with public communications; is that correct?

Dr. CHAVEZ. Let me—— Mr. MICA. Those numbers are correct. I’m just looking at one

function, which is communications or PR, and you have 12 in your

office.

Mr. AUTRY. Mr. Chairman, may I respond to that, please. If you

look at the fact that SAMHSA is an operating division within the

Department of Health and Human Services, that means that we

have functions that we have to carry out, including clearance of

testimony, clearance of reports, doing special reports to the Congress, reports to the Secretary, et cetera. Those are functions that

are carried out within the Office of the Administrator. The functions that are carried out in the centers are primarily those related

to synthesizing knowledge information, disseminating that to the

field around specific issues like substance abuse treatment, substance abuse prevention, mental health services, so there is not duplication in that area. Also, Dr. Chavez noted, we did centralize a

number of the functions so that all of the peer review mechanisms

are now centralized in OA. That did result in a savings of FTEs.

Grants management contracts management, and a number of offices that run administrative services were also centralized in the

OA as well as legislation and policy staff. So those are not duplicated in the Centers.

Mr. MICA. One of the major concerns, if they put the chart back

up, on the block grant, the SAMHSA funding and staff allocations

was—I’m sure you’ve seen it—State block grants, which accounts

for 80 percent of the funds, which you give, that would be non-mental health or just in substance abuse prevention treatment? Can

you put that chart up?

Again, what has raised some questions about the expenditure

funds is—and 6 percent may be a good figure for overall for admin- istering $3 billion at whatever total amount of funds you’re administering, but with the bulk of the money, 80 percent of the money

is given out in State block grants, 11 percent of the personnel are

used. To give out the discretionary grants or other activities, 89

percent of the administrative funds are used to distribute to 20

percent, which has brought many to believe that we should block

grant just about everything. Then we had people at the last hearing noting that there is overlap. They couldn’t answer questions

about research and scientific activity. I know some of your responsibility is evaluation, and that’s an important activity, and also

mandated by Congress. But there were questions as to why that

hasn’t been researched, being given to NIDA which has that reVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00165 Fmt 6601 Sfmt 6601 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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sponsibility, to bring down the cost of administration and put more

of this money out into the treatment programs.

So we have some serious questions about the amount of money

that is being expended for a very small portion of the budget. Did

you want to respond?

Dr. CHAVEZ. Yes, sir. Thank you. Let me talk a little bit about

the administrative costs and the excessive overhead that seems to

be seen. SAMHSA’s overhead costs are not excessive—— Mr. MICA. We’ve all agreed on that generally. But 11 percent of

the personnel, according to the GAO, we didn’t study it. We have

no prejudice in this. All we’re trying to do is look at the facts. They

say 11 percent of your personnel are used to distribute 80 percent

of the fund. The 89 percent are in the expenditure of 20 percent

of the funds, and some of those activities are indeed NIDA, who

has the lion’s share of activity, I would imagine.

Dr. CHAVEZ. You are correct. NIDA is the premier research institute.

Mr. MICA. Should we turn the rest of that over to NIDA, the activities you now have in R&D?

Dr. CHAVEZ. Yes, I would like to answer the block grant question

if that’s OK with you.

The question that has been raised is that perhaps we’re either

shortchanging the block grants staffing, whether it’s appropriate

and reasonable. The block grants differ from all of our SAMHSA

programs in that the States decide on which project will be funded

and then they manage these directly.

What we have done at SAMHSA is to ensure that the staffing

for the block grants is in proportion to what we believe is critical— in relation to the work that needs to be done. Now, the staff members who are assigned direct responsibilities are also supported by

other staff members to carry out the necessary functions. For example, we do a lot of technical assistance which is, by the way, requested by the States. We do site visits and we do audits. Joe, I

don’t know if you want to add anything else to that.

Mr. AUTRY. Mr. Chairman, if I may add a couple of comments.

One of the things about block grants is that they are, by definition,

moneys that go through the States with very little strings attached

to them, if you will. And so there is not the degree of review of application, nor the degree of oversight in terms of what specific activities that they are funding that is necessary in a discretionary

grant program. As Dr. Chavez indicated, the review of the applications regarding TA, making sure we do appropriate audit procedures are the main function of the block grant staff. It’s not as

labor intensive as our discretionary grant program. Most of our discretionary grant programs are what we call cooperative agreements, which means there’s a significant Federal oversight role in

developing both individual project and cross-project, or cross-program evaluation, to determine how effective and efficient those activities are as they are delivered in the real world.

Dr. Chavez is quite correct that our program is quite different

from Dr. Leshner’s, and as he noted, his institute does, in point of

fact, conduct research. They do clinical trials work, they look at behavioral therapies, medications interventions, et cetera. Once you

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tioner, many times what you develop in the laboratory or very controlled setting differs significantly on what really works in the real

world. And we’re very pleased to have an ongoing dialog with Dr.

Leshner to continue to get his input as we try to improve the effectiveness and efficiency out in the real world.

The acknowledge development activities that we support are in

service of the block grant and in service of targeted capacity expansion trying to find more effective ways to intervene, better ways of

doing assessments, and more efficient ways of using what we know

and constantly trying to improve our knowledge, including feeding

interventions back to NIDA that need additional research. So it is

more labor intensive than the discretionary grant program.

Mr. MICA. Well, first of all, Dr. Chavez, I never or anyone from

this panel, accused you of shortchanging in the administration and

overhead for the block grant program. It appears to be fairly cost

effective to administer in the scheme of things. That’s not the problem. The problem is on the other side of the equation. I could be

a better advocate for your department than both of you are because

there are many things that Congress has mandated. Part of your

costs are the evaluation system, which we require to be set up, and

accountability. And that’s an important mandate. From the testimony we heard from folks, that sounds like we went a little bit

overboard, and we need to go back and grant a little bit more flexibility.

There was one witness who said she spends 4 hours preparing

forms. Almost 1 day a week preparing forms and reporting and 4

days for treatment. That’s how bad it’s gotten in the reporting

area. We’re here straightening out many of the things and States

overreact. The other thing we heard was also duplication. When

you’re down at the lower end of the pecking order, the States have

requirements and Feds have requirements, and this poor little person who is trying to treat folks at the end of the feeding chain, and

sometimes smaller operations, are burdened with overhead and

spending time on completing forms rather than treating people.

The other thing that we are concerned about technical assistance, and we do need to provide that. Sometimes, only the larger

body can provide that. In this case, hopefully, the Federal Government and agency can adequately provide technical assistance on a

broader base. You didn’t say, I think, publications. We had testimony that noted some of what you do, as far as even publications

and bringing information together and disseminating, is extremely

valuable.

Our problem is we also heard testimony and have evidence that

show many of the discretionary grants are given to treatment programs that already are getting State money or indirect Federal

money through State money, so they are going through sometimes

three levels of evaluation or scrutiny or reporting. And it seems

like we’ve created a very expensive overhead for some of these

KDA activities. So we are wondering why we can’t shift more

money to get out to the treatment programs and less money for administering discretionary programs.

I’m sure there are some unique programs that only the bureaucrats and only the people in Washington can decide that are valuable for national interest, but when you spend $129 million, and

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if my plan works, to spend only $29 million and give $2 million additional dollars to States for those activities—she doesn’t like that.

OK. We’ll redo the figures. In any event, we’re trying to find a way

to have less administrative overhead yet more money into the programs, eliminate these extra requirements. And the final thing is

if there’s overlap with Dr. Leshner, if we could shift to NIDA with

some interagency agreement. For them to conduct this, then the

problem we have is even when we get into some of these testing

areas. I don’t want to take all the time.

I want to yield, and then we can come back. We get into some

of these testing areas, and I find that there are further delays in

testing and evaluations. I just read out a report that now we may

be looking at 2003 before the earliest standard for new drug tests,

and technologies-acceptable standards can be implemented. So we

have research. We have testing. We have evaluation. We have different important functions in trying to sort out how we can make

them all fine-tuned and efficiently delivered.

Dr. Leshner, finally, could you see us combining and working in

some interagency agreement and shifting all of the research activities to your agency?

Dr. LESHNER. Actually, sir, I don’t think we have literal overlap

in what our two agencies do. We conduct research and applied research and SAMHSA, and we overlap, at most, just a hair at the

edges of what we do and in an attempt to provide a somewhat

seamless transition.

Mr. MICA. They may not overlap, but I just say there are administrative costs. Is there any efficiency of you doing the whole enchilada and having some type of cooperative agreement?

Dr. LESHNER. Not that I’m aware of, sir.

Mr. MICA. Maybe we can ask GAO to look at that question, specifically. Sometimes, it’s hard for agencies to come up with consolidation recommendations and dichotomy of scales.

Mrs. Mink.

Mrs. MINK. Thank you, Mr. Chairman.

Dr. Leshner, your primary research mission, as I understand it,

is to analyze how drugs impact on behavior, on human development, and create a wide variety of mental and physical disorders.

Is that basically the type of research that you do in NIDA?

Dr. LESHNER. That’s a portion of the research that we support

because we represent 85 percent of the world’s research. Our research portfolio ranges, actually, all the way from the very most

molecular levels of analysis of understanding how drugs of abuse

function and produce addiction through prevention research, treatment research, and research on the organization and financing of

services for substance abuse. And so we say we do everything from

the molecule to managed care, or everything from the most molecular level all the way out to understanding social systems and how

those social systems affect and respond to the drug abuse and addiction problem.

Mrs. MINK. The primary function of SAMHSA is to distribute

block grant moneys for treatment of drug addicted individuals, and

that’s how they distribute their block grants. Is it at all feasible to

consider a suggestion that NIDA then determine whether the treatment programs that are funded by the Federal Government are

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working and to what extent they could be improved, or to what extent they could be translated in other venues?

Dr. LESHNER. We do, in fact, study the treatment system, both

public and private and its effectiveness, and again have determined

it to be highly effective. However, we don’t have any authority over

individual programs or the way in which States administer the

treatment programs.

Mrs. MINK. I don’t mean to suggest you would have any authority but to study whether they are effective or not.

Dr. LESHNER. We do, in fact, not tied to any particular funding

stream, but, of course, we do analyze the nature of this treatment

system in this country and the way in which it’s functioning.

Mrs. MINK. Is that why they distribute it then to the various

State agencies?

Dr. LESHNER. I believe it is. Just as one example, we recently

produced the first science-based guide to drug addiction treatment,

which has now gone out to over 250,000 communities in this country, and we’ve had over 55,000 copies downloaded from our

Website. Every State is using this guide as a part of its own activities, and it’s a compilation of research and what we’ve learned from

research, so I do believe that the information is, in fact, available

to the States. The States are participating actively in our Clinical

Trial Network. In fact, the State director from Oregon is a member

of the CTN oversight board. So that there is a close relationship

between us.

Mrs. MINK. So the work that you’ve just described as part of

NIDA and the work that is now assigned and taken over by

SAMHSA, you say there’s only a fine line of duplication of effort?

Dr. LESHNER. My own view is that there is virtually no duplication. There is, however, an attempt to have a seamless connection

between what we do and what SAMHSA does. An example of that

I mentioned in my testimony is the Association of the Addiction

Technology Transfer Centers that SAMHSA supports with our clinical trial network. Another example would be, just last week I was

in Oregon meeting with our northwest node, and present in the

room were the people from the Center for Substance Abuse Treatments Practice Research Consortium, so we do, in fact, try to mesh

activities as much as we can in order to have that translation. My

own view is we have virtually no overlap.

Mrs. MINK. I know that it’s not particularly appropriate for one

agency to criticize or make comment about another agency’s function, but since we are here today to try to understand SAMHSA,

and if there are any possible ways in which their application of the

law can be improved, would you be able to comment, with respect

to this one area that the chairman has criticized with the KDA, if

there is any room for improvement as to how the funds should be

allocated there or commissioned out by contracts and so forth. Is

there anything that you could clarify for us?

Dr. LESHNER. I don’t know enough about the administration of

it to make any comments like that. I can say that the KDAs, with

which I’m most familiar, use science and use the science base that

we’ve provided as a foundation for what they do, but I really am

not qualified to comment on the administrative ends of it.

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Mrs. MINK. Are you able to comment on whether SAMHSA has

need for the delineation of this program for research and for evaluation and for dissemination of information?

Dr. LESHNER. I find SAMHSA’s programs extremely useful in

terms of helping to get dissemination and translation into actual

practice of what we do. I apologize for going on, but just give you

one example, NIDA research produced something called the matrix

model as a treatment approach for methamphetamine addiction.

The subject must be well known to you and SAMHSA’s Center for

Substance Abuse Treatment has now done a multisite KDA demonstration of that program in a variety of places around the country, and I believe that again is an example of the relationship that

can exist.

Mrs. MINK. Thank you. Your responses to my question, I think,

are very illuminating. While we could probably get the same response from SAMHSA, Mr. Chairman, sometimes it’s much more

compelling if you have another agency corroborating what I believe

the primary witness, Dr. Chavez, has already testified to. Frankly,

Mr. Chairman, administrative costs are always a disturbing factor

when you think of the tremendous need out there for additional

funds and only 50 percent of the people that should get treatment

do. I think it’s relevant to say that the Federal Government does

not have the entire responsibility for drug abuse treatment. We

share only a limited participation in this area. The main function

ought to be State and local governments, but in looking at my own

situation in my State, I find that the Federal Government is supporting more than 50 percent of what we are spending in my State,

and I think that’s willfully lacking in terms of our own State performance.

So while I would like to see many more dollars going out there

to my State for treatment, I do think that the burdens that have

been placed upon this agency for evaluation and research and dissemination of information and so forth require this 50-person allocation for administration of these block grants. But I think it’s worthy to look at it and to study it, but I see really no basis for criticism of the agency’s use of these 50 bodies.

There’s one column in this column which is mental health, which

is not part of our inquiry, so we’re only taking the three, and there

are 50 bodies that go across the line block grant. But I don’t think

that’s only for analyzing who gets the grants. It’s to make sure that

the use of the funds as appropriate and in accordance with the law,

and I think that you and the majority members in particular are

always honing in to make sure that the funds are properly spent,

yet you don’t want one-size-fits-all, and you don’t want the Feds

dictating how the funds are going to be used.

So you’re kind of in a tough spot, Mr. Chairman, in trying to

meet all of these criteria. But I think in this instance, I personally

am satisfied that the agency is doing well, and while I would like

to have more money and greater freedom in my district for how the

funds are to be used, I don’t see any particular discrepancy in the

administrative costs allocation insofar as the testimony that’s been

presented so far. Thank you, Mr. Chairman.

Mr. MICA. Thank you. I’ll respond in my questions when I get

time after Mr. Tierney.

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Mr. TIERNEY. Thank you. Dr. Leshner, let me go a little bit

astray here on this. You said about 95 percent of your work was

drug abuse and treatment research. How much of that is allocated

to alcohol abuse?

Dr. LESHNER. Another NIH Institute, the National Institute on

Alcohol Abuse and Alcoholism [NIAAA], has primary responsibility

for alcohol research, because if you have a grant from NIDA, you

may also be studying alcohol in the course of it, since most drug

addicts are, in fact, polydrug users, we estimate, and this is an estimate that we support, about $40 million a year, that includes alcohol.

Mr. TIERNEY. Most of it goes under another NIH——

Dr. LESHNER. NIAAA.

Mr. TIERNEY. You also indicated NIDA was instrumental in coming up with a patch, gum and spray for nicotine treatment, that

your research actually resulted in the development of those.

Dr. LESHNER. Yes.

Mr. TIERNEY. NIDA is not the one advertising or selling those.

I am curious to know how they got in the hands of private manufacturers and what the deal was underlying that?

Dr. LESHNER. We have our own research laboratories in the hospital on the grounds of the Johns Hopkins Bayview campus in Baltimore, and one of our researchers, Jack Henningfield, did the pioneering work on the addicting qualities of nicotine and on techniques for administering nicotine-like substances through other vehicles, which goes into the public domain, where private companies

are, of course, free to pick up the technology.

Mr. TIERNEY. No proprietary rights on that at all?

Dr. LESHNER. We don’t on the nicotine patch. However, now, as

you may know, we are forming what are called CRADAs, cooperative research and development agreements, with pharmaceutical

companies for the development of antiopium and anticocaine medications. We have a number of those and what we have there is a

share in the developing costs, because the Federal Government believes it’s so important to develop these medications. We don’t actually get money back as a result of it, but we do, in fact, facilitate

treatment, and it keeps the costs down tremendously.

Mr. TIERNEY. Why is it that you don’t get anything back, and

didn’t in particular with Mr. Henningfield’s work?

Dr. LESHNER. In the case of Dr. Henningfield’s work, it was, of

course, the work that produced our understanding that nicotine is

an addicting substance, and he has since gone on to great and famous things. But the technology itself was developed as a part of

the scientific investigation and was not at the time developed predominantly to be a marketable product. Therefore, when it was

published, it went into the public domain and just like many other

technologies that you now have for the application of medicines,

the various parts of your body, have been in the public domain,

that particular technology was also. The approach of trying to

produce sustained nicotine levels as a treatment approach was the

scientific question that Dr. Henningfield was investigating at the

time.

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Mr. TIERNEY. You also made some comments or your remarks

that few of the new treatments that are being developed are yet

to be widely used. Am I correct in quoting you there?

Dr. LESHNER. Yes, sir, you are.

Mr. TIERNEY. Can you tell me what we’re doing about that and

how we’re going to improve that situation?

Dr. LESHNER. There are a variety of things happening. First of

all, it’s important to recognize that many of these treatments are

treatment components. They are not comprehensive programs.

They are pieces that you might incorporate into a comprehensive

program and they have only been developed within the course of

the last 10 years.

However, having said that, we are about to mount the first three

trials in our Clinical Trial Network just 4 months since we made

the first awards. What will happen is we’ll test them in real life

settings, and then if they work, people will use them. In addition

to that, what we’re doing, and again, to use that methamphetamine

matrix example or the addiction technology transfer centers example, SAMHSA’s programs take the results of the scientific research,

and then help disseminate them to community-based providers.

So we have both a relatively permanent research infrastructure,

our Clinical Trials Network. That’s one vehicle. SAMHSA’s addiction technology transfer centers and their KDAs programs that provide another mechanism to help facilitate dissemination of scientific findings. Both of these activities are really quite new, and

my own view is that they are being pretty successful at getting the

information out but there are many thousands of treatment programs in this country, and it’s very hard, of course, to change behavior.

Mr. TIERNEY. Thank you.

Dr. Autry and Dr. Chavez, let me ask you, the chairman made

a comment about block granting everything in your program, which

I don’t think is necessarily going to be the appropriate way to proceed, but I’d like your comments on that. Would it at all help or

hinder your efforts to address the situation for which you’re

formed?

Dr. CHAVEZ. Mr. Congressman, in 1980–1981, that was considered by the Congress—in 1980 and 1981 as well as in 1986. At that

time, in 1980 and 1981, the Congress made a decision that, in addition to block grants, we also needed to have a national presence

through demonstration programs. Then in 1996, the same issue

was addressed, and at that time, the Congress made a decision

that we really needed to ensure that the knowledge or the science

that is being developed by NIDA is translated and carried out into

community programs, and basically that is what our knowledge,

development and application program is about.

What I believe, and I think many of us out in the field and

throughout the community believe, is that in order for us to really

begin to close the treatment gap and to continue to reduce drug use

among youth, we need a balanced approach. As the Congresswoman said earlier in one of her comments, one size does not fit

all. Our approach has been with—the block grant that the States

perform a very, very critical job, and they, too, are limited, as we

all are, in terms of their resources. And in some States the demand

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is so great that it cannot be met for treatment services. That is one

component of a balanced approach.

The other component of a balanced approach is KDA and TCE,

which is our knowledge development and application. Within that,

we take a lot of the research and we build on what NIDA has done

and give it life in communities. We’re asking ‘‘Does it work?,’’ especially in diverse communities. The other area that is also part of

that umbrella is what we call our targeted capacity expansion. The

targeted capacity expansion was created because the Congress of

Mayors, Indian tribes, the Black Caucus, the Hispanic Caucus, and

many groups throughout the communities came to us and said that

they needed our help in ensuring that we were targeting services

specifically to their community.

We have looked at the drug problem as a national problem. However, it’s a regional problem as well and as that map that we have

over on that side clearly indicates, if you look at methamphetamine

as one example, we have the same information for heroin and

many of the other drugs. Methamphetamine, in this particular instance is, as you can see, a very regional problem. What we have

done there is that we have issued announcements to communities

and to mayors and to counties and to Indian tribes. Let them assume the responsibility in terms of identifying what the problem is

in their community and then we will provide short-term dollars to

help them resolve these problems.

Now, having said that one size does not fit all, and I do not believe because of the nature of its formula, and some of the other

issues, that the block grant alone is going to be able to succeed in

terms of solving some of the issues that we’re having to deal with

today.

Joe, do you want to add anything?

Mr. AUTRY. I would just like to add a couple of comments. One,

as Mrs. Mink noted earlier, there really are insufficient funds to

fund the block grant, and insufficient funds at the State level to

entirely close the treatment gap using just a block grant mechanism. On the other hand, the block grant provides the necessary

infrastructure to support treatment systems within the States and

without that, you would be even further behind in closing the treatment gap.

Looking at the regional distribution of drug use in this country,

knowing that there are communities who do not receive sufficient

funds through State coiffeurs, and knowing that many times we

need to have additional funds come in and sometimes people are

reluctant to use the same old mechanisms to provide funds, we try

to tailor programs that meet those emerging needs. We try to tailor

programs that address distribution of drug use, emergence of HIVAIDS infection and the needs of special populations who are not

met many times through the block State funding.

So if we don’t have a balanced approach, we don’t provide Federal leadership, work in conjunction with our State colleagues,

we’re not going to be able to have the effective programs that we

need to address substance abuse in this country.

Mr. TIERNEY. With respect to the amount of money you disseminate through block grants, if you weren’t constrained by the formula, would your agency think of allocating those funds in a difVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00173 Fmt 6601 Sfmt 6601 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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ferent direction? Are there other areas of need or other priorities

that you would address instead of spreading them out by the same

formula?

Mr. AUTRY. Two comments to that. One is, the formula is, in

point of fact, a vehicle created by Congress. I think it’s already

taken into account a lot of those varying competition needs—— Mr. TIERNEY. My question is, do you think it’s effectively doing

that or not?

Mr. AUTRY. I think the block grant is a highly effective mechanism in providing the necessary treatment and prevention infrastructure resources in the State, and I’m pleased to say we work

with our colleagues at NASMPHD and NASADAD to continue to

provide oversight to that to develop common core outcome and performance measures. We look forward to continuing to do that.

Mr. TIERNEY. Thank you all. Thank you, Mr. Chairman.

Mr. MICA. Let me just followup on a couple of things. You said

you tailor programs to assist where there is a problem. This chart

identifies the methamphetamine problem. We just did hearings in

California. I saw the red part, at least the California coast, I

should say the Pacific coast, and what’s going on there. There’s a

meth epidemic. It’s beyond anything. I’ve only been chairman for

14 months, and I had no idea that it was that severe. I have a

chart here that shows the percentage of State money for treatment

services by funding source that was provided to us by GAO, and

it shows State and Federal funding.

Actually, California gets about 25 percent of its funds, if we include this other Federal, we might get up to 39 percent. One of the

lowest in Federal funds and highest in State or other funds. It

would seem to me that a State that would have an epidemic problem should be getting more funds.

Next to it is Florida, which has an epidemic heroin problem. Is

there anything that’s done to make certain that more Federal resources get to where we have these epidemic problems?

Dr. CHAVEZ. Thank you, sir. That’s a great question or a great

comment. First of all, California—in terms of block grant distribution—California, if I remember correctly, gets more dollars than

any other State in their grant block distribution. The question that

you have raised is an excellent one, because that’s exactly what is

at the heart of our treatment capacity expansion.

This is what I said earlier—when communities, when mayors,

when county officials, when Indian tribes, when the Black Caucus,

and when the Hispanic Caucus have said that some of these dollars

are not reaching our communities. We have, in some of our communities, epidemics, and these epidemics range from HIV-AIDS and

substance abuse to methamphetamine, to heroin, to drug overdose

by young people, et cetera.

The idea, in terms of the creation of the targeted capacity expansion, was to give local communities the opportunity to sit with their

political subdivisions and define the problem—in ways that were

truly getting to the heart of that problem. Then they would submit

an application to SAMHSA which, like all of our applications, is reviewed, as required by statute, by peers.

Mr. MICA. The local communities we talked to, almost every one

of them, are first submitting to the State, and then they are subVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00174 Fmt 6601 Sfmt 6601 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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mitting again to SAMHSA under your formula. My question would

be if we do the chart from last year, and I was out Monday in that

area, they are hanging on by their own teeth, only because they

put together patchwork programs with the State agencies.

I’d like to see what we’ve done last year to increase these percentages in some of the target areas. If that’s our purpose, they are

telling me they aren’t getting the assistance. They are already applying to the State, and then we have the State investing over 400

hours preparing its application for block grants possibly. They were

complaining to us that this application process is extensive, burdensome, time-consuming. It needs to be shortened, streamlined.

New York was here and testified. They say they have even higher

standards than you, I think, had set up, and you run them through

a lot of unnecessary hoops. Why can’t some of this be done electronically. We have new technology today, and they said SAMHSA

is still in the dark ages.

From what I see out there, when you go see an epidemic, and

you tell me you set it up so communities can apply to you, and

these people in Washington decide whether they get it, the States

and locals are already ahead of you and not getting the money and

complaining about two and three levels of approval and preparation.

Mr. AUTRY. Mr. Chairman, let me respond to that. Let me start

first by congratulating California. The reason that we’re only 25

percent of the treatment dollars there is because they’ve chosen to

make a significant investment of State funds in the treatment system. Last year California received $217 million in block grant

funds for substance abuse treatment and prevention, and they received an additional $30 million in discretionary grants from us,

and it’s because of the very nature of the emerging problems, the

severity of the problems, the prevalence of the problems, that they

were as successful in competing for those discretionary funds.

Applying to the Federal Government does not require duplicate

methods or duplicate applications with the States. We do require

that communities are applying——

Mr. MICA. A local community program has already received State

approval. They don’t need additional approval, then, for funding

from you or additional evaluation.

Mr. AUTRY. They do need to be peer reviewed. That’s the requirement under our statute and regulations that any discretionary

grant program must have peer review. What we are doing is we are

experimenting with the ways to simplify both the application process, the duration of time from application to review and funding;

and second, we’re experimenting with new ways of doing reviews

to expedite the reviews. And that’s an ongoing commitment on our

part to try and expedite how rapidly we can get dollars out to the

field.

I might also add that many times in the KDA program, we use

the existing service dollars there to continue to fund the services

at the same time that we’re putting in, looking at new interventions, looking at more effective and efficient interventions. So we

build on the service dollars that are there and add dollars on top

of that rather than supplanting the service dollars.

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Mr. MICA. As I understand the process, discretionary KDA grants

awarded by SAMHSA go directly to cities and communities. Why

isn’t this process closely coordinated with the States?

Mr. AUTRY. Mr. Chairman, it is indeed closely coordinated with

the States. We have an agreement with the States that when a

community, a city or sub-State region submits an application, it

must be reviewed and signed off by the State.

The reason we do that is twofold: one, we want to make maximum effective use of all the dollars that are at the State level. Second, we want to build in State awareness of this program, so No.

1, they can learn from the effectiveness of the interventions used;

and No. 2, there will be sustainability as the States can pick up

the funds once our discretionary money has ended.

Mr. MICA. Now, I can’t recall exactly the testimony, and we could

get staff to submit this question, but in KDA review process, they

said that the States are not adequately represented? We have some

testimony on one of those. Some of the review process we had criticism that there wasn’t adequate dollars in the review. We’ll get

that to you and maybe you can respond.

Let’s go a minute to SAMHSA’s contracts in the Washington, DC

area, which is table 4 of the GAO report. And that raised some

questions, particularly with Mrs. Mink and, some of the minority

members from other areas that don’t have any of these contracts.

These are all in Mrs. Morella’s and Mr. Wolf’s district. But 27 of

29 contracts awarded by SAMHSA for over $1 million, those contracts in that range total $64 million awarded to the Washington,

DC area. Why can’t more of these services be contracted across the

country? It looks like it started into a little cottage industry here

for big contracts with the Beltway folks. What’s the story? All the

knowledge is in Washington. We know that.

Dr. CHAVEZ. The contract process that we have at SAMHSA is

open and it’s a competitive process.

Mr. MICA. It doesn’t sound like it’s that competitive. There were

two others. Did either go to Florida or Hawaii?

Dr. CHAVEZ. They adhere strictly to the Federal Acquisition Regulation. They don’t favor any contractor over another. They are all

peer reviewed by panels. They are comprised of experts from

throughout the United States and all of this is required by law.

Can I maybe—I think—— Mr. MICA. Let me tell you, I could probably give a better answer

than that. Congress has imposed a lot of requirements on this

agency for evaluation and for reporting, and we do buildup cottage

industries that do those activities. And they are located right next

to the seat of powers. We need to go back and look at what we’ve

done. I also heard that we created some inflexible overreporting.

But again, it raises eyebrows when you have those kinds of funding

being spent in one locale.

Mr. AUTRY. Two comments. I certainly agree with you that cottage industries tend to grow up at the seat of the money, and this

is an issue that’s faced not only by HHS, but all the other Federal

agencies as well. There are a couple of things I think that we try

to do differently than perhaps some other Federal agencies. One is

we work with our State colleagues to identify not only what needs

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side of the Washington area, be it in there State or adjacent States,

who can work with them to meet those training and TA needs.

So we try to spread the money around, even with the prime contractor maybe here in Washington. Similarly, we work with our colleagues at NASADAD. The contract money they have does not all

get spent for what’s done here. That actually goes out and helps

fund the States to do data collection and whatever elements we

may be needing for that, but we agree with you, we would like to

see a higher distribution of the moneys throughout the United

States.

Mr. MICA. I have another question relating to target populations

and activities. One of the reasons to have Federal programs is to

be able to address the broader picture and then target our resources. In some instances, they are not the largest portion of

funds being expended. Tell me about our national programs. There

was testimony here how important and effective it is to reach the

corrections population, both people entering into the criminal justice system and hopefully giving them an opportunity to find another path and then within the prisons we find that we have tremendous recidivism with drug abusers, users, popping them into

prison and then out of prison. Could you give me a dollar amount,

or is there a program amount? Do we have a target publication

that says we are doing this? Are prisons eligible to apply for these

funds, and do you have programs in that area?

Could you respond, Dr. Chavez?

Mr. AUTRY. If you don’t mind, Mr. Chairman I would like to respond to that. You referenced a 1991 report that HHS, ONDCP and

Justice had done. We had a symposium—assembly, rather, just this

last fall in which those same three groups came back together to

talk about what the current State of knowledge is, what the current State of need is, and what we can do together to work on this.

We have an extensive history of providing both TA and training to

the criminal justice system, and we work on both sides of the black

box, if you will, those that can be diverted from entering into the

criminal justice system or into incarceration, and those who are

coming out——

Mr. MICA. What programs specifically? How many dollars of all

of our drug treatment dollars are going to these? In Florida, my

former district representative now works with the correction system, working with me in Congress and going to the Florida corrections system. But he is now working with them just as an aside,

and if I go to him at this point and say we spent millions at the

Federal level, and we know that there’s a good program to divert

these people, so I don’t have to incarcerate them in Florida prisons at $60,000 or whatever it costs, and I’ve talked to Dr. Autry, and

he said that SAMHSA says this is a good program, what is it and

which one have we spent money on and what do I tell him?

Mr. AUTRY. A couple of things. One, we just agreed with the Department of Justice and ONDCP to start a new $10 million program covering some of the issues you’re concerned about. I can get

you, for the record, additional moneys that are already there. I

would also point out that a recent report by the Department of Justice pointed out that only 40 percent of their prisons have treatment programs for substance addiction.

174

Mr. MICA. Are prisons eligible to apply for funds for treatment?

Mr. AUTRY. Those who are incarcerated get their funds through

the Department of Justice. Those who are not incarcerated work

jointly, and many times fund those programs themselves.

Mr. MICA. I’ve been joined by a gentleman from Maryland, Mr.

Cummings. Let me recognize him at this point.

Mr. CUMMINGS. Thank you very much, Mr. Chairman. I want to

thank our witnesses for being with us today.

Dr. Chavez, in your testimony you said that the drug use among

teens is no longer on the rise. It may just be declining. When will

you know whether it’s, in fact, declining and is this decline in drug

use for all drugs or is this just marijuana?

Dr. CHAVEZ. Mr. Congressman, it’s good to see you. Thank you.

Mr. CUMMINGS. Good to see you also.

Dr. CHAVEZ. We’ve seen a slight improvement in terms of that

decline, but as I said in my testimony, I do not want us to be overly

optimistic. And what I mean by that, sometimes when we see these

declines, we have a tendency to become very relaxed, until we see

the next epidemic. What we are seeing is that—we’re seeing drug

use, especially the increases in the drug use that we have seen in

the past have been among those 12- and 13-year-olds, which is an

age group that we have become very concerned about, and as an

age group where we have targeted many of our efforts. The other

area that is of great concern, as I mentioned earlier, is the regional

nature of the drug.

For example, in some areas, we have seen an increase in the use

of heroin, whereas in other areas we’ve seen an increase in the use

of methamphetamine, and that is one of the reasons that we are

really trying to target many of our programs.

Now, in August of this year, we will have the data on our household survey, and we are hoping that with the expansion of the

Household survey—this is the year it was expanded—we are going

to have information that will be of help to all of us. It gives us specific State-by-State data so that we will have a better picture in

terms of what is happening in some States. Why that becomes

more and more important is because of our KDA and our treatment

capacity expansion in that we’ll be able to focus those dollars more

where we see in some of those States, that it’s more of a problem

than it may be in other States.

Mr. CUMMINGS. Let me ask you, is there a particular type of

child or are there certain characteristics—when you think about a

young child, 12, 13-year-old, that’s pretty young, and I know that

children use drugs even earlier than that. I live in a neighborhood

where I think that happens, in Baltimore. From what you’ve seen,

are there any particular characteristics or type of settings? In other

words, home life or neighborhood or how they are doing in school,

parental supervision, activities, being involved in activities or lack

thereof? Is there a typical young person that if you looked at a certain set of characteristics, you say based upon what we know, this

child is, I hate to use those words, ‘‘at risk?’’ They just bother me,

but you get what I’m saying. You understand?

Mr. AUTRY. Let me speak to that. One of the things I think you

know as well as the rest of us is that substance abuse is really an

equal opportunity disease. It doesn’t strike any particular ethnic

175

group, doesn’t strike any particular geographic group or strike any

particular socioeconomic group. It’s across the board. There are,

however, both resiliency and risk factors that do predict when

someone is likely or less likely to abuse substances. Children who

grow up with high family bonds is a case in point. Good role models

with respect for their parents are less likely to use drugs than

those who don’t.

Children who grow up with families where there’s an emphasis

on communication, emphasis on education, are less likely to grow

up using drugs than those who do not get that. Kids who are engaged in activities such as good school bonding and the performance in school is important to them are less likely to engage in

drug use than those who do not. Children who are engaged in postschool activities or entering programs are less likely to grow up to

use drugs than those who do not. I think as we look at prevention,

you’ve seen a shift in recent years from talking so much about risk

factors to talking more about resiliency factors and the things we

need to promote good mental health, good physical health and decrease substance abuse.

Mr. CUMMINGS. In Baltimore, we have a situation, where, because of budget circumstances, we have had to cut back on recreation, and unfortunately, I mean, we’re approaching the drug problem from a criminal standpoint. But I’m of the opinion that you

need to do both because I think the recreation keeps children busy,

and a lot of times recreation centers have become almost substitutes, and important substitutes for children whose mothers and

fathers may be working or may be part of a single head of household family where the one person just can’t be there all the time,

particularly the summertime when you’re out on vacation and

things of that nature. That’s why I was just wondering about that.

Did you have something that you wanted to add?

Dr. CHAVEZ. Yes, Mr. Cummings. What you’ve described is what

we’re really looking in terms of drug problems—drug issues as public health issues that involve many, many components. We know

from the research, we know what works. We know what are some

of the things that are very, very critical, and as Dr. Autry indicated, one of the strongest things that we have found in terms of

the research that has been done is that the family bonding becomes

very critical at a very early age. Unfortunately, what we see happening in terms of the need for prevention services and treatment

services is that there are not enough services to provide for the

need that is out there. We have a great need. What we are finding

in many communities is that parents can’t find treatment for their

young people, for their adolescents.

Many times what happens is that they do commit a crime and

they become part of the juvenile or criminal justice system. Then

there will be some treatment which may have been unneccessary

if we had more interventions, early interventions, prevention and

treatment programs targeted specifically to many of these communities. But again, it’s the parent, it’s the family, the school, it’s the

community. It’s not one.

It’s the responsibility of all of us, including the clergy, to be part

of developing systems within communities that work for those communities.

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Mr. CUMMINGS. Yesterday, when I was at the Post Office, I ran

into a fellow who was a former drug addict. He’s a recovering addict. One of the things he said to me was very interesting. You

know, he said, ‘‘Cummings, I wish people would come to my barbershop. I haven’t used drugs in 15 years.’’ He said, ‘‘But every time

they show people on television and they talk about drug treatment,

they always show people who look like they’re down and out. I’m

doing fine.’’ He said, ‘‘I can show you thousands, literally, there’s

a whole community out there who are former drug users who, because of treatment, are now doing fine, raising their families, supporting, contributing to our taxes.’’ That leads me to the question that was one of the things that

was on my mind at our last SAMHSA hearing. This is a continuation. And I asked a question of how do we make sure and what

does SAMHSA do, and what can we do to assure that the treatment that is being rendered, moving on to sort of another subject

now, is effective treatment.

I’m one of these people that run around the Congress with a flag

that says treatment and prevention and begging my colleagues to

look at treatment. But the thing that we get over and over again,

and I hear, and in many instances this is a legitimate argument,

I hear the argument, well, is the treatment effective? How do we

measure it? Are people just setting up shop and going through

some motions? To be very frank with you, there are people who are

recovering addicts like the fellow I talked to yesterday who told me,

and I’ve heard this in my community over and over again.

There are some shops that are not effectively addressing the

drug problem. They set it up, and I think that does a disservice,

not only to the good programs, but to the addict because the addict

goes through this process, he or she thinks she’s supposed to be

getting well. It’s not legit. When I say ‘‘legit,’’ I mean it’s not being

effective.

I think it’s going to be very important for States and for this

Congress to try to hold programs to some kind of standard, because

as I see it, and I’ve just been watching, I just don’t think we’re

going to be able to get those treatment dollars unless we really can

show that these programs are being effective, that we need some

kind of mechanism that makes sense. I think we could probably

have a whole lot more of the Congress saying hey, we’ve got to give

treatment if they know that’s real and it’s going to be effective. So

I leave you with that. I ask you, do you have any comments?

Mr. AUTRY. First of all, let me applaud you for your advocacy.

Second, we have over there one of the charts that shows, as Dr.

Leshner referenced earlier, that treatment does, in point of fact,

work. It reduces criminal activity, reduces illicit drug use and alcohol use. It improves housing situations, and most importantly perhaps in the Congress’s perspective, it also increases employability.

We rely very heavily on the research that NIDA has done in order

to look at more effective and efficient treatments. We put these out

into treatment services. We’re working with our colleagues in the

States to define appropriate performance and outcome measures

that we use, not only across our discretionary grant programs, but

also across the block grant programs that they will be funding, that

they do fund in the States. So we’re very concerned about the perVerDate 11-MAY-2000 10:09 Apr 03, 2001 Jkt 000000 PO 00000 Frm 00180 Fmt 6601 Sfmt 6601 C:\DOCS\67551.TXT HGOVREF1 PsN: HGOVREF1
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formance and outcomes measures, and it’s as—one of our highest

priorities is to continue to improve the effectiveness and efficiency

in treatment.

Alan, you want to add anything to that?

Dr. LESHNER. I think the point is well made. I think the problem

is, sir, is that just as in any treatment enterprise, there are people

who deliver well and people who don’t deliver well. We have the

problem that we have no mechanisms by which to evaluate every

single program and to be able to ensure what they provide, but I

would say the overall quality of drug abuse treatment in this country is extraordinarily high, and comparisons that have been done

on the effectiveness of drug addiction treatment compared to other

medical illnesses that are similar in nature, drug addiction treatment is as effective as the treatment for hypertension, as the treatment for asthma, the treatment for other chronic, often relapsing

disorders. The problem is people don’t know it.

Mr. CUMMINGS. Last question, Mr. Chairman. At the last hearing, we had representatives from three States. I can’t remember

which States they were, but I know they earned reputations nationally as having good treatment, or very good treatment, and

when I say very good, I mean effective. And one of the things that

they all had in common is that they had a standard by which they

were able to measure, which is very interesting. And I asked them,

I said, ‘‘Well, does every State have these standards?’’ They said, ‘‘Well, no, I don’t think so.’’ I know you share Mr. Mica’s concerns and Mrs. Mink’s concerns,

and we want all of our tax dollars to be spent efficiently and effectively. I’m just wondering, do States come to SAMHSA and say,

look, what kind of standards can we use or does SAMHSA go to

States and say, look, this is something you might take into consideration in measuring these programs because I’m telling you, I

mean this, it just irks me. It would really upset me. We are setting

up shops that are not being effective, but then it bothers me if we

don’t have any standards to even determine what effective is.

Those are search questions under one question, but I’m finished

after this.

Mr. AUTRY. Let me try and focus on what I think is the most important one, that is, how effective are these treatment programs

and what do we do to make sure we’re using the most effective

interventions we have, whether it be prevention or treatment, but

treatment in particular? We worked with the States through our

TOPS 1 and TOPS 2 program to look at and define outcome measures, what sort of performance we expect from a treatment provider, what sort of performance we expect from a treatment system.

We’ve done this now in 19 States. And we’re working with

NASADAD to try and collect data across all the States that measure outcome measures in the four domains I mentioned earlier:

criminal activity, decreased drug and alcohol use, housing situation, and employability. Those are the elements that say is somebody doing well or not. And working with the States, we are trying

to implement these across all the States. Their instrument is vulnerable in terms of the States to provide that information at the

present time.

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But that’s an ongoing commitment on our part and the part of

NASADAD to continue to work to upgrade the data infrastructure

so that all States can provide that kind of accountability data. Currently we are doing this on a voluntary basis. In the future we will

be doing this on a mandatory basis. Again, building on what we’ve

done with NASADAD and the States to this point in time rather

than mandating something on high sum.

Mr. CUMMINGS. How soon do you think it will be mandatory?

Mr. AUTRY. We have high hopes this will be 2001.

Mr. CUMMINGS. So what authority do you have to make it mandatory?

Mr. AUTRY. We recently have an all radioing from our own counsel, Office of General Counsel, and also from the GAO that we do

have the authority to do that. We will work on that this year, and

if we can’t do it for 2001, we hope to move to mandatory by 2002,

which will be a year from this October 1.

Mr. CUMMINGS. What would be the holdup?

Mr. AUTRY. The holdup is going to be the States’ ability to provide the information because of the variability and lack of infrastructure support. We’re currently in discussions with the Office of

Management and Budget because we have had some disagreement

within OMB as to whether or not we have the authority. We hope

to resolve that very shortly in the next month or two.

Mr. CUMMINGS. Do you anticipate the possibility, not probability,

that you may need authority there in the Congress?

Mr. AUTRY. As Dr. Chavez referenced earlier, we have been approved in the Senate for reauthorization, we are certainly looking

for approval in the House. If that does indeed happen, I think we

will have all the authority we need, sir.

Mr. CUMMINGS. Thank you.

Mr. MICA. Thank you. Just a couple of wrap-up questions here.

In surveys of Department of Health and Human Services, employees over the past 3 years, the reported morale of SAMHSA employees has not been among the lowest ratings for HHS for the entire

agency. You made some comments, Dr. Chavez, at the beginning

about morale. Did you say that it’s improving? Where are we with

the problem of morale in the agency? All the errors I’ve gotten said

it ranks among the lowest of any agency.

Dr. CHAVEZ. We have taken several steps as we outlined in the

report that we submitted to you to try to lift morale. One of the

big issues that we have faced that we had mentioned to you earlier

has been that even though there seems to be a sense that maybe

our administrative costs have been very high in our program management fund, we have reduced our staffing in so many areas, and

this has had a tremendous impact on staffing because of the increased workload. We have increased our workload tremendously

in the past 5 years. There are more specific things that we are involved in that I would like Dr. Autry to respond to, because this

is something that he’s been working with very carefully.

Mr. AUTRY. Thank you, Dr. Chavez. We’re very concerned about

staff morale, and one of the key things that we’ve noted is that morale relates to two key elements. One is the workload that people

have received, and that has been increased, as you saw, from the

decrease in staff going back to 1993. We’ve also absorbed a number

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of programs, high-risk programs, most notably, and school violence

programs that came to us from Congress. We’ve done that within

the existing staff levels. So that has increased the workload. We

also find that when ideas that staff have developed are put forward

are either not supported in the administration or not supported in

the Congress, that also leads to low morale.

Quite frankly, I don’t know of a harder working, more dedicated

staff across any Federal agency than we have in SAMHSA, and

they really believe in what they do and they put their heart and

soul into doing it. We have established a quality-of-worklife committee that’s made up of both management and employees to look

at things that we can do to improve morale. We’re in the process

of implementing a transit subsidy program that would help in that

regard. We’re looking at redistributing workload across the agency.

We’ve also started a process of management called appreciative inquiry, which is where you take the elements within the agency that

are working well, and you look at the lessons that you can learn

for what made that work well and apply it in areas where things

might not be working quite so well.

We’ve also started doing cross-center and also cross-agency collaboration on projects to make sure that all staff are involved as

we go forward in planning and budgeting implementation. We also

have had a series of focus groups, some with management employees mixed with some employees by themselves have honest and

frank discussion of the difficulties that they’ve encountered that,

perhaps, have contributed to low morale.

We do fully expect to see that there will be an increase in morale, and it certainly is a commitment on our part as we go forward

to try to have SAMHSA to be the kind of place that not only you

want to work at because of the important work we do, but because

of the atmosphere we create as we work with one another.

Mr. MICA. The centers you talked about earlier, did you have 22

regional centers and combined them into 7? Is that it?

Mr. AUTRY. Those were administrative offices, some within the

Office of the Administrator, and some within the centers. They

were collapsed into seven.

Mr. MICA. What about regional operations?

Mr. AUTRY. We don’t have regional operations at the present

time. There are many days, quite frankly, we wish we did have.

Mr. MICA. All of that is located here?

Mr. AUTRY. Correct.

Mr. MICA. I just wondered if anything had been sent out to regional centers. But that’s OK.

Mr. AUTRY. I’ll make one comment on that we have worked closely with the regional offices and HRSA, the Health Resources and

Services Administration, to make sure that the regional offices are

informed of the activities that we do. We find them an invaluable

resource looking at treatment needs across the region and State,

and they were very instrumental to us in our national treatment

system regional meetings and national prevention system regional

meetings.

Mr. MICA. Dr. Chavez, it took 18 months to develop guidelines

for urinalysis in 1987 to 1988. It’s my understanding that

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view process for hair analysis or other methodologies. I’m told now

it’s put off to 2003. What’s the problem?

Dr. CHAVEZ. I would like to have Dr. Autry respond to that because he’s the expert on the hair analysis. I think he’s testified before you in the past.

Mr. AUTRY. Mr. Chairman, it’s a pleasure to revisit this subject

with you. One of the things that we put in place going back now

about 21⁄2 years ago is that we developed a matrix of all of the

standards that any drug testing methodology must meet in order

to be certified for use in the Federal program. We have worked

with industry, worked with laboratories, worked with medical review officers to assess the current state of the science of all the different testing technologies and methodologies to identify the gaps

that exist in terms of meeting those standards and have laid out

protocols that are necessary to fill in those gaps. All of our meetings have been open to the public, involved both industry as well

as Feds, and laboratory people. You can find summaries of all the

meetings that we’ve had in the current state of the science

www.health.org/workpl.htm.

Mr. MICA. My understanding that some agencies like the Federal

Reserve already use hair testing and have settled on that.

Mr. AUTRY. A number of companies do. One of the largest manufacturers of hair testing in this country is a company called Psychometrics. They estimate they have about 2,000 employers of various sizes who do use this. That is actually a small proportion of

those individuals that are subject to testing. We make available to

whoever wants the latest scientific evidence about the effectiveness

of that. One of our big concerns is that there is not an appropriate

quality assurance or quality review mechanism in place to assess

the accuracy of the ongoing testing.

Mr. MICA. Finally, for the record, and I’d like for it to appear at

the end of the record, request the agency to provide us with detail

relating to their programs which were briefly outlined dealing with

our corrections and criminal population and the proposal, more details relating to the $10 million proposal that we’ve heard a little

bit about today. Additionally, I’d like them to list the top 20 programs in the country for treatment and we can use the successes

treatment 1 year drug free, or 2 years drug free, and we can categorize those into sort of tough cases or average drug treatment

cases because I know some were repetitive, tough every instance

and I always hear you can’t compare one with the other; first, second-time offender or drug abuser versus someone who’s been repetitive. I would just like those to appear at the end of the record of

this hearing. That would be helpful also as a guideline to offer. We

will leave the record open for at least 3 weeks to accomplish getting

those responses.

We have additional questions for the witnesses. Our intent is not

to call you in here and just give you grief. Our intent is to try to

assess what’s going on. We requested the GAO report. They came

back with information. We have a responsibility to conduct oversight. When I have members of the package like Mr. Cummings

who has 60,000, at least he told me in that range, people addicted

and has a community, we’ll be going there in a week or so, 2

weeks. We’re going next week to Honolulu, can’t wait for 18 hours

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of flight, Sunday, Monday, to do that for Mrs. Mink, but our purpose is not to give the agency a hard time. It’s to see how we can

improve the expenditure of funds.

When you go to California as I did last week at the request of

members and you see what’s going on, I wish some others could

have seen it, the methamphetamine problem was just beyond anything, so much child abuse, 40 percent of murders, hundreds of

children literally abandoned by their families. It does such devastation to these folks. We need to even rededicate ourselves more to

finding workable cost effective solutions to this problem. So if it

takes having hearings every day, or twice a week or whatever,

wherever we have to go we’re going to get this done. When we get

complaints about how things are operating and some of those

things have been imposed by Congress, we need to see that corrective measures are taken. We will do our best to work in that regard.

I appreciate the witnesses coming forward today. We look forward to working with you.

Mrs. Mink.

Mrs. MINK. I just want to make a comment. I am a little bit troubled with the emphasis on the need to evaluate the effectiveness

of any specific treatment methodology because I think we know

that in all kinds of diseases, that because you don’t have 100 percent cure rate doesn’t necessarily mean that the particular treatment is not a suitable one. It may not be suitable for the specific

individual because of the individual’s own unique propensities or

other kinds of mental pressures. So I do want to say that while it’s

important to evaluate the outcomes and to determine which ones

have the best outcomes, I don’t think, however, that necessarily

leads to a conclusion that the treatment that has the lower outcomes is necessarily not proven to be satisfactory for a variety of

clientele.

Mr. MICA. Thank you. That’s why I asked for this sort of the

tougher-than-average cases. This is for my own information. We

have thousands of treatment programs out there, and I’m interested in what are successful models. We heard some. We have

Washington, I think New York and several other States, and I

think Mr. Cummings rightfully pointed out that there are some

commonalities to have standards of certain things that we can

point to where programs are successful and maybe we can replicate

this, maybe we can’t. Maybe we should go home.

Mr. CUMMINGS. Mr. Chairman, my ranking member and I, we

agree on most things, and I think we agree on this. I guess my concern, Mrs. Mink, in my community and the way this even came up

for me was just listening to recovering addicts whose really saw

what was effective for them. And I know that everybody may be

different, but they actually said, ‘‘Cummings, if it was up to us,

we’d close down that program, that program, that program, and

then we would keep these open.’’ And these are people who have

nothing to gain. They want to make sure that programs are effective because they feel, and a lot of them are very angry because

they saw what they went through and then they look at what other

people go through. The other thing that they said was a lot of these

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people who go through the programs and that they consider shams,

then come back and they are trying to help them get off of drugs.

So they see it in every which way. I agree with you. I think we

have to be very careful because you can evaluate to the degree that

you destroy. You can take something apart so much that you destroy it. But on the other hand, I think we hold people to standards

constantly, and I think we have to have at least some general

standards to look at and say, OK, are we having some effectiveness, are we accomplishing something here?

And I guess the reason why I’m so concerned about this is I

think it goes to the credibility of the entire process. I think it’s

easier to make the case for more Federal dollars if we do have

some standards, and we’re able to do some measuring. That way— you know what they say, Mrs. Mink. People will on come back and

say, oh, treatment doesn’t work. At least we’ll be able to say we’ve

got some standards, those standards are being met and we are

being effective. So when we see tragic stories like the chairman

just mentioned, we can say there is something we can do about

that. It worked in Nevada, it worked in Idaho and damn it, it will

work here. That’s what I was concerned about.

Mr. MICA. I thank the gentleman. I thank the ranking member.

Being no further business to come before the subcommittee on

criminal justice drug policy and human resources this meeting is

adjourned.

[Whereupon, at 12:25 p.m., the subcommittee was adjourned.]

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