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[House Hearing, 106 Congress]
[From the U.S. Government Publishing Office]

      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

                                 ______

                    U.S. GOVERNMENT PRINTING OFFICE
67-551 DTP                  WASHINGTON : 2001
_______________________________________________________________________
 For sale by the Superintendent of Documents, U.S. Government Printing 
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                     COMMITTEE ON GOVERNMENT REFORM

                     DAN BURTON, Indiana, Chairman
BENJAMIN A. GILMAN, New York         HENRY A. WAXMAN, California
CONSTANCE A. MORELLA, Maryland       TOM LANTOS, California
CHRISTOPHER SHAYS, Connecticut       ROBERT E. WISE, Jr., West Virginia
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
STEPHEN HORN, California             PAUL E. KANJORSKI, Pennsylvania
JOHN L. MICA, Florida                PATSY T. MINK, Hawaii
THOMAS M. DAVIS, Virginia            CAROLYN B. MALONEY, New York
DAVID M. McINTOSH, Indiana           ELEANOR HOLMES NORTON, Washington, 
MARK E. SOUDER, Indiana                  DC
JOE SCARBOROUGH, Florida             CHAKA FATTAH, Pennsylvania
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
MARSHALL ``MARK'' SANFORD, South     DENNIS J. KUCINICH, Ohio
    Carolina                         ROD R. BLAGOJEVICH, Illinois
BOB BARR, Georgia                    DANNY K. DAVIS, Illinois
DAN MILLER, Florida                  JOHN F. TIERNEY, Massachusetts
ASA HUTCHINSON, Arkansas             JIM TURNER, Texas
LEE TERRY, Nebraska                  THOMAS H. ALLEN, Maine
JUDY BIGGERT, Illinois               HAROLD E. FORD, Jr., Tennessee
GREG WALDEN, Oregon                  JANICE D. SCHAKOWSKY, Illinois
DOUG OSE, California                             ------
PAUL RYAN, Wisconsin                 BERNARD SANDERS, Vermont 
HELEN CHENOWETH-HAGE, Idaho              (Independent)
DAVID VITTER, Louisiana

                      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                    PATSY T. MINK, Hawaii
BENJAMIN A. GILMAN, New York         EDOLPHUS TOWNS, New York
CHRISTOPHER SHAYS, Connecticut       ELIJAH E. CUMMINGS, Maryland
ILEANA ROS-LEHTINEN, Florida         DENNIS J. KUCINICH, Ohio
MARK E. SOUDER, Indiana              ROD R. BLAGOJEVICH, Illinois
STEVEN C. LaTOURETTE, Ohio           JOHN F. TIERNEY, Massachusetts
ASA HUTCHINSON, Arkansas             JIM TURNER, Texas
DOUG OSE, California                 JANICE D. SCHAKOWSKY, Illinois
DAVID VITTER, Louisiana

                               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

                            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

 
      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 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 
faith-based 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.
    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.
    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 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:]
    [GRAPHIC] [TIFF OMITTED] T7551.009
    
    [GRAPHIC] [TIFF OMITTED] T7551.010
    
    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 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 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 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.
    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 
received $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 faith-based 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.
    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 faith-based 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 faith-based 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. 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 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 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 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.
    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 
faith-based 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?
    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?
    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.
    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?
    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?
    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.
    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-effective 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.
    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 
2\1/2\ 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 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 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-grant-funded prevention and treatment programs.
    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 community 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 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 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 set-asides 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.
    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 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-to-day 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 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.
    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?
    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 
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 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?
    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.
    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 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 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 first-time, 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 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 multi-level 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 self-help kind of discussion kind of thing, 
what we discovered is that 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.
    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.]

      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 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 
faith-based 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.''
    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 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 
development 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 Wolf-Jones from the Therapeutic Communities 
of America; Jennifer Pike 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.
    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.
    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.
    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 
administering $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 responsibility, 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 put that out into the 
community, and I can tell you as a practitioner, 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 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 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.
    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.
    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.
    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 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 HIV-AIDS 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 different 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 submitting 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.
    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 they may have for training or for 
TA, but also to find people outside 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.
    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 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 post-school 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.
    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 performance 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.
    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 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 SAMHSA has now contemplated what will turn 
into a 10-year review 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 2\1/2\ 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 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 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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