Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program Coordination
Published: 2013-03-26T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: ONDCP is responsible for coordinating implementation of drug control policy across the federal government to address illicit drug use. ONDCP developed the 2010 Strategy, which sets forth a 5-year plan to reduce illicit drug use through programs intended to prevent or treat drug abuse or reduce the availability of drugs. GAO was asked to review Strategy implementation and drug abuse prevention and treatment programs. This report assesses, among other things, the extent to which progress has been made toward achieving Strategy goals; ONDCP has mechanisms in place to monitor progress; fragmentation, overlap, and duplication exist across prevention and treatment programs; and ONDCP and federal agencies coordinate efforts to reduce the potential for unnecessary overlap or duplication. GAO analyzed the Strategy and its updates, available data on progress toward achieving Strategy goals, and documents about ONDCP's monitoring mechanisms. GAO also analyzed data from questionnaires sent to the 15 federal agencies that administer prevention and treatment programs that collected information on services provided and coordination efforts.
section_title: What GAO Found
paragraphs: The Office of National Drug Control Policy (ONDCP) and federal agencies have not made progress toward achieving most of the goals articulated in the 2010 National Drug Control Strategy (the Strategy), but are reported to be on track to implement most Strategy action items intended to support these goals. ONDCP established seven Strategy goals related to reducing illicit drug use and its consequences by 2015. As of March 2013, GAO's analysis showed that of the five goals for which primary data on results are available, one shows progress and four show no progress. For example, no progress has been made on reducing drug use among 12- to 17-year-olds by 15 percent. This is primarily due to an increase in the rate of reported marijuana use, offset by decreases in the rates of reported use of other drugs. Nevertheless, ONDCP reported that 107 of the 112 action items in the Strategy are complete or on track. ONDCP officials stated that implementing these action items is necessary but may not be sufficient to achieve Strategy goals.
ONDCP primarily intends to address the extent of progress in achieving Strategy goals through its new Performance Reporting System (PRS)--a monitoring mechanism intended to provide specific, routine information on progress toward Strategy goals and help identify factors for performance gaps and options for improvement. ONDCP officials stated that they plan to report on PRS results for the first time in 2013. They also said that they plan to assess the system's reliability and effectiveness. This could help increase accountability for improving results and identify ways to bridge the gap that currently exists between the lack of progress toward Strategy goals and the strong progress made on implementing Strategy actions.
Drug abuse prevention and treatment programs are fragmented across 15 federal agencies and provide some overlapping services, which could increase the risk of duplication. Specifically, GAO identified overlap in 59 of the 76 programs included in its review. These programs could provide or fund one or more drug abuse prevention or treatment service that at least one other program could also provide or fund, either to similar population groups or to reach similar program goals. Such fragmentation and overlap may result in inefficient use of resources among programs providing similar services.
GAO's prior work has found that inefficiencies created by fragmentation and overlap can be minimized through coordination. However, many prevention and treatment programs that GAO surveyed did not report coordination efforts, and ONDCP has not assessed the extent of overlap, duplication, and coordination. Agency officials who administer the 21 programs that GAO reviewed in detail-- programs for youth and offenders--reported making various efforts to coordinate program activities, but 29 of 76 (about 40 percent) surveyed programs reported no coordination with other federal agencies on drug abuse prevention or treatment activities. Moreover, ONDCP has not assessed all drug abuse prevention or treatment programs to identify the extent of overlap and potential duplication and any opportunities for coordination. Such an assessment would better position ONDCP to help ensure that agencies better leverage and more efficiently use limited resources.
section_title: What GAO Recommends
paragraphs: GAO recommends that ONDCP assess the extent of overlap and the potential for duplication across federal programs engaged in drug abuse prevention and treatment activities and identify opportunities for increased coordination. ONDCP concurred and stated that it will work with agencies administering these programs to further enhance coordination.

section_title: Letter
paragraphs: Illicit drug use endangers public health and safety and depletes financial  resources, and the scale of the problem has not improved over the past  decade. An estimated 22.5 million Americans aged 12 or older were illicit  drug users in 2011, representing 8.7 percent of this population, according  to the National Survey on Drug Use and Health. In addition, illicit drug  use rates among Americans aged 12 and older from 2009 through 2011  were among the highest since trend data were available in 2002. Abuse  of illicit drugs results in significant public health, social, and economic  consequences for the United States. For example, the Department of  Justice’s (DOJ) National Drug Intelligence Center estimated that the  economic impact of illicit drug use, including the costs of health care,  crime, and lost productivity, was more than $193 billion in 2007.
The Office of National Drug Control Policy (ONDCP) is responsible for,  among other things, overseeing and coordinating implementation of  national drug control policy across the federal government to address  illicit drug use.  In this role, ONDCP is required annually to develop a  National Drug Control Strategy (the Strategy), which sets forth a  comprehensive plan to reduce illicit drug use through programs intended  to prevent or treat drug use or reduce the availability of illegal drugs, as  well as to develop a National Drug Control Program Budget proposal for  implementing the Strategy. ONDCP reported that about $25.2 billion was  provided for drug control programs in fiscal year 2012. Of this, $10.1  billion, or 40 percent, was allocated to prevention and treatment  programs.prevent the initiation of illicit drug use or treat the abuse, or problematic  use, of illicit drugs and provide or fund such services as outreach efforts  to discourage first-time drug use and assessment and intervention to  assist regular users to become drug-free.
Specifically, these programs are intended, in all or in part, to  Nineteen federal departments, agencies, and components (collectively  referred to as agencies) funded a range of drug abuse prevention and  treatment programs included in the fiscal year 2013 Drug Control Budget.  As we previously reported, the range of programs across federal  agencies could result in a fragmented service system, with more than one  federal agency involved in the same broad area of national interest. Such a system could lead to some programs offering similar services and  serving similar populations, and thus to inefficiencies in program  administration and service delivery across the federal government. In light  of the rate of illicit drug use among Americans and the nation’s current  budgetary constraints, efforts to oversee progress toward achieving  national drug policy goals, coordinate drug control program activities to  mitigate potential inefficiencies, and conduct evaluations of program  effectiveness become increasingly important.
You asked us to review an array of issues related to the Strategy and  drug abuse prevention and treatment programs. In July 2012, we issued a  report with the results of our initial review of these issues.report reflects our completed work and addresses the extent to which (1)  progress has been made toward achieving Strategy goals and ONDCP  has mechanisms in place to monitor progress; (2) fragmentation, overlap,  and duplication exist across drug abuse prevention and treatment  programs, and ONDCP and federal agencies coordinate efforts to reduce  the potential for overlap or duplication; and (3) federal agencies that have  drug abuse prevention and treatment programs conduct evaluations of  these programs, including assessments of program effectiveness. We  also reviewed what available research suggests about the potential effect  of societal factors, such as state laws allowing the use of marijuana for  medical purposes, on youth drug use. Appendix I summarizes the results  of this work.
The National Institutes of Health includes the National Institute on Drug Abuse and the  National Institute on Alcohol Abuse and Alcoholism. OJP includes the Bureau of Justice  Assistance, Bureau of Justice Statistics, National Institute of Justice, and Office of  Juvenile Justice and Delinquency Prevention. supply reduction missions. While these seven agencies are not  representative of all drug control agencies, they are responsible for  implementing a majority of activities in the Strategy and provided a range  of perspectives about its implementation and progress. We also  interviewed officials from ONDCP and these agencies to obtain  information about progress on the Strategy’s goals, implementation of the  Strategy, and mechanisms to monitor progress. We compared these  documents and information with criteria for performance management  indentified in our prior work.experts to discuss their perspectives on the Strategy and performance  management. We selected these experts based on our review of drug  policy literature, their expertise in drug policy issues and work conducted  in this area, and recommendations from these and other researchers. The  information we obtained cannot be generalized to other experts; however,  they provided us with a range of views about the Strategy and ONDCP’s  monitoring mechanisms.
Finally, we interviewed seven drug policy  To address the second objective, we assessed 76 drug abuse prevention  and treatment programs that provide or fund prevention and treatment  services, such as education and outreach activities, drug testing, and  intervention. We excluded programs that, for example, exclusively  conduct research, fund overhead costs, or reimburse services as part of a  health benefit plan. These 76 programs are administered by 15 of the 19 agencies that are included in the fiscal year 2013 Drug Control  Budget. We distributed a questionnaire to program officials at these 15  agencies to collect information on program activities in fiscal year 2011,  such as program purpose, allowable services provided, and population  served. We received responses to all the questionnaires we distributed,  for a 100 percent response rate, and analyzed information for 76  prevention and treatment programs. To assess the reliability of the  information we received, we incorporated questions about the reliability of  data on the programs’ obligated funds, performed internal reliability  checks, and conducted follow-up as necessary with agency officials. As a  result, we determined that the data used in our report were sufficiently  reliable for our purposes. We analyzed responses to identify potential  fragmentation, overlap, or duplication based on criteria established in our  previous work. To assess coordination efforts, we analyzed  questionnaire responses regarding agency efforts to coordinate drug  abuse prevention and treatment program activities. We also analyzed the  2010 Strategy and interviewed ONDCP and agency officials about actions  taken to coordinate these activities. We compared these reported actions  with criteria for coordinating interagency efforts identified in our prior  work.
To address the third objective, we analyzed documents, such as  completed program evaluations and agency policies and procedures, and  interviewed officials from the 15 agencies who are responsible for  overseeing the programs included in the second objective to identify the  number of program evaluations completed, under way, or planned since  2007. We selected 2007 as the starting point for our review in order to  provide a long enough time frame to include evaluations that may take  multiple years to complete. We reviewed completed evaluations to  determine whether these evaluations included assessments of  effectiveness (i.e., determining the extent to which a program is achieving  its objectives) described in our prior work in this area.interviewed ONDCP officials responsible for Strategy implementation to  obtain their perspectives on how program evaluations were used to  inform policy and resource allocation decisions. In addition, through our  review of agency documents and interviews, we identified other ways in  which agencies are attempting to ensure that programs are effective.
Finally, to describe the available research about the potential effect of  societal factors on drug use among youth—individuals 17 years old and  under—we conducted a literature search to identify studies, published as  of June 2012, that addressed the following: (1) state laws allowing the  use of marijuana for medical purposes, (2) marijuana decriminalization,  and (3) the favorable portrayal of drugs in the media on youth drug use.  We reviewed the studies on medical marijuana laws and decriminalization  from our initial search results and identified those that met our established  criteria for these factors, such as using comparison groups or statistical  analysis to assess their effects. We selected the studies on medical  marijuana laws and marijuana decriminalization to include in this report  based on the sufficiency of their methodologies; therefore, our results  cannot be generalized to all research about the potential effect of these  factors on youth drug use. The media studies we identified did not assess  the effect of prodrug messages on youth drug use, but we included them  because they provide useful context regarding the portrayal of drugs in  the media. Additional information about our scope and methodology is  included in appendix II.
We conducted this performance audit from July 2012 to March 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
subsections: section_title: Office of National Drug Control Policy
paragraphs: ONDCP was established by the Anti-Drug Abuse Act of 1988 to, among  other things, enhance national drug control planning and coordination and  represent the drug policies of the executive branch before Congress. In  this role, the office is responsible for (1) developing a national drug  control policy, (2) developing and applying specific goals and  performance measurements to evaluate the effectiveness of national drug  control policy and National Drug Control Program agencies’ programs, (3)  overseeing and coordinating the implementation of the national drug  control policy, and (4) assessing and certifying the adequacy of the  budget for National Drug Control Programs.
The 2010 Strategy is the inaugural strategy guiding drug policy under  President Obama’s administration. According to ONDCP officials, it  sought a comprehensive approach to drug policy, including an emphasis  on drug abuse prevention and treatment efforts and the use of evidence- based practices or interventions—approaches to prevention or treatment  that are based in theory and have undergone scientific evaluation. For  the 2010 Strategy, ONDCP changed its approach and moved from  publishing a 1-year Strategy to publishing a 5-year Strategy, which  ONDCP is to update annually. The annual updates, which ONDCP has  issued for 2011 and 2012, are to provide an implementation progress  report as well as an opportunity to make adjustments to reflect policy  changes.
ONDCP established two overarching policy goals in the 2010 Strategy for  (1) curtailing illicit drug consumption and (2) improving public health by  reducing the consequences of drug abuse, and seven subgoals under  them that delineate specific quantitative outcomes to be achieved by  2015, such as reducing drug-induced deaths by 15 percent. the achievement of these two policy goals and seven subgoals  (collectively referred to as goals), the Strategy and annual updates  include seven strategic objectives. These objectives are to be achieved  by implementing 112 action items, with lead and participating agencies  designated for each action item.
See figure 1 for additional details.
When developing the Strategy, ONDCP identified data sources for each of the seven  subgoals, such as SAMHSA’s National Survey on Drug Use and Health.
Thirty-day prevalence is defined as having used within the past 30 days.  Lifetime prevalence is defined as having ever used.   Morbidity refers to incidence of disease.
We previously reported that ONDCP developed the objectives and action  items in the Strategy through a consultative process with drug control  agencies and other stakeholders because these agencies have primary  responsibility for implementing them. The objectives represent broad  policy areas, such as prevention, treatment, and domestic law  enforcement, and collectively contribute to all of the Strategy’s goals. The  action items under each objective represent the activities needed to  accomplish the objective and may highlight specific drug control program  activities or call for agencies to perform a specific task, such as preparing  a report on the health risks of youth drug abuse.
section_title: Drug Abuse Prevention and Treatment Programs
paragraphs: The Strategy’s drug abuse prevention and treatment objectives are  supported by action items implemented through programs across multiple  agencies. Specifically, the 15 federal agencies we selected to include in  our review collectively allocated about $4.5 billion in fiscal year 2012 to  programs that provide drug abuse prevention and treatment services  (drug abuse prevention and treatment programs) as shown in figure 2.
In 2010, Congress directed us to conduct routine investigations to identify  programs, agencies, offices, and initiatives with duplicative goals and  activities within departments and government wide and report annually to  Congress. In March 2011 and February 2012, we issued our first two  annual reports to Congress in response to this requirement.basis of the framework established in these reports, we used the following  definitions for assessing drug abuse prevention and treatment programs:
Fragmentation occurs when more than one federal agency (or more  than one organization within an agency) is involved in the same broad  area of national interest.
Overlap occurs when fragmented agencies or programs have similar  goals, engage in similar activities or strategies to achieve them, or  target similar beneficiaries.
Duplication occurs when two or more agencies or programs are  engaged in the same activities or provide the same services to the  same beneficiaries.
section_title: Results Show Lack of Progress on Strategy Goals, although Implementation of Most Action Items Is Complete or On Track; ONDCP Established a New Mechanism to Monitor Progress
paragraphs: Our analysis indicates that ONDCP and federal agencies have not made  progress toward achieving four of five goals established in the 2010  Strategy for which primary data are available. However, ONDCP reported  strong progress in implementing most of the action items in the Strategy  intended to support achievement of these goals. ONDCP officials stated  that implementing these action items is necessary but may not be  sufficient to achieve Strategy goals. ONDCP’s Performance Reporting  System (PRS) is a new monitoring mechanism intended to provide more  specific, routine information on progress and help identify causal factors  for performance gaps and options for improvement. According to ONDCP  officials, the office plans to report on PRS results for the first time in 2013  and assess the system’s reliability and effectiveness, which could help  increase accountability for improving results and identify ways to bridge  the gap between the lack of progress toward Strategy goals and the  strong progress on implementing actions in the Strategy.
subsections: section_title: Results Show Lack of Progress toward Achieving Strategy Goals
paragraphs: ONDCP officials responsible for overseeing the development of the 2010  Strategy stated that they established the Strategy’s seven quantitative  goals based in part on the availability and quality of data sources to  measure the effects of drug control policy and what they considered could  realistically be achieved within designated time frames, among other  things. Nonetheless, these officials said that the goals are aggressive  given that drug use trends for some of the measures were increasing  prior to their establishment. As of March 2013, our analysis indicates that  of the five goals for which data on results were available, one shows  progress and four show either no change or movement away from the  2015 goals—for example, drug-induced deaths have increased, instead  of decreased, from the 2009 baseline, as shown in table 1.
ONDCP and federal drug control agencies have made progress toward  achieving the goal for decreasing the lifetime prevalence of eighth  graders who have used drugs, alcohol, or tobacco, which consists of  three separate measures. In addition, while results from the primary  data source for the goal to reduce drugged driving are not available,  results from ONDCP’s secondary data source indicate progress toward  achieving this goal. However, progress has not been made on the other  four goals for which primary data are available. For example, the 30-day  prevalence of reported drug use among 12- to 17-year-olds has not  changed from the 2009 baseline to 2011. According to the data source for   this measure—SAMHSA’s National Survey on Drug Use and Health—this  is due primarily to an increase in the rate of reported marijuana use, offset  by decreases in the rates of reported non-medical use of prescription  drugs and inhalants. The survey indicates that marijuana accounts for  almost 80 percent of illicit drug use among 12- to 17-year-olds. In  addition, drug-related morbidity, as measured by the number of  emergency room visits for drug misuse and abuse and HIV infections  attributable to drug use, increased from 2009 to 2010 and is higher than  the established goals for these measures. The data source for the  number of emergency room visits for drug misuse and abuse— SAMHSA’s Drug Abuse Warning Network—indicates that misuse and  abuse of prescription drugs accounted for the majority of these visits in  2010 (58 percent).
section_title: ONDCP Monitors Progress on Implementing Strategy Action Items and Reported That Most Are Complete or on Track
paragraphs: In August 2010, ONDCP instituted a process to track the implementation  status of action items established to achieve the objectives, and ultimately  the goals, of the Strategy. Agencies that have lead responsibility for  implementing action items submit progress reports to ONDCP on an  annual basis. The office reviews these updates and information from  other sources, such as interagency meetings and agency budget  submissions, and classifies action items into five categories—complete,  on track, delayed but progressing, facing budget issues, and at risk.  Despite the lack of progress we found toward meeting the Strategy’s  goals, ONDCP reported in its most recent publication of results in July  2012 that 96 percent (107 of 112) of the action items are complete or on  track, as shown in figure 3.
We previously reported in July 2012 that ONDCP monitors and reports on  the implementation status of action items to, among other things, help  hold agencies accountable for implementing the action items; give credit  to agencies for progress made; and motivate them, if needed, to take  steps to address delays. Officials we interviewed from all seven  agencies we selected stated that Strategy action items reflect their  already existing priorities or activities. According to ONDCP officials, this  alignment helps facilitate implementation. ONDCP officials stated that the  implementation of Strategy action items is necessary to achieve Strategy  goals but may not be sufficient. According to these officials, a variety of  factors could affect achievement of these goals, such as worsening  economic conditions, changing demographics, or changing social or  political environments; the passage of state laws that decriminalize  marijuana use or allow its use for medical purposes; failure to obtain  sufficient resources to address drug control problems; insufficient  commitment from agency partners; and the need for new action items that  include initiatives or activities beyond those that are under way or   ONDCP officials stated that the PRS is to provide more  planned.specific information about where the Strategy is on or off track and  prompt diagnostic reviews to identify causal factors contributing to any  problems identified, as discussed below.
section_title: ONDCP Has a New System in Place to Monitor Progress toward Goals and Plans to Define How the System Will Be Used to Assess Progress and Review Its Effectiveness
paragraphs: In April 2012, ONDCP established the PRS to monitor and assess  progress toward meeting Strategy goals and objectives, and the office  issued a report (the PRS report) describing the system with the 2012  Strategy update. The PRS includes interagency performance measures   For example, one of the six  and targets under each Strategy objective.performance measures under the objective to strengthen efforts to  prevent drug use in our communities is the average age of initiation for all  illicit drug use, which has a 2009 baseline of 17.6 years of age and a  2015 target of 19.5 years of age. Similarly, one of the four performance  measures under the objective to seek early intervention opportunities in  health care is the percentage of respondents, aged 12 to 17, who have  used prescription-type drugs nonmedically in the past year. This measure  has a 2009 baseline of 7.7 percent and a 2015 target of 6.5 percent.  According to ONDCP officials, the PRS augments ONDCP’s current  method of examining performance by allowing the office to assess the  effectiveness of interagency efforts to achieve the Strategy’s objectives.ONDCP officials stated that they plan to release the results of the PRS  measures for the first time in 2013. According to the PRS report, system  information is to be used to inform budget formulation and resource  allocation, Strategy implementation, and policy making, among other  things.
We assessed PRS measures and found them to be generally consistent  with attributes of effective performance management identified in our prior  work as important for ensuring performance measures demonstrate   For example, the PRS  results and are useful for decision making. measures are clear, have limited overlap, and have measurable targets.  Specifically, the measures are clearly stated, with descriptions included in  the 2012 PRS report, and all 26 of them have or are to have numerical  targets. In addition, the measures were developed with input from  stakeholders through an interagency working group process, which  included participants from Education, DOJ, and HHS, among others.According to the PRS report, the working groups brainstormed candidate  performance measures for each Strategy objective and assessed them  based on criteria such as being clear, quantifiable, and valid indicators for  the objective. The groups also identified data sources, such as national  surveys on drug use and treatment services, to use to report on these  measures and evaluated the data sources to determine if they were  unbiased and collected data routinely, among other things.
The PRS report states that the system is to provide early warning about  progress toward achieving Strategy objectives. However, it does not  clearly define how progress toward 2015 targets for PRS measures is to  be assessed and what actions are to be taken if intermediate results are  not on track to meet these targets. ONDCP officials stated that they plan  to provide information about the process to assess intermediate  performance results in the PRS report that is to be issued in 2013. These  officials said that the report is still in development, but that for each PRS  measure, they plan to compare the linear trend line from the baseline to  the 2015 target with results to date; examine auxiliary data sources, such  as other relevant national surveys, to refine the assessment; and work  with interagency subject area experts to arrive at a final assessment.  ONDCP officials stated that when results are determined to not be on  track to meet 2015 targets, the PRS is to serve as a trigger for an  interagency review of potential causes of performance gaps and options  for improvement. These proposed actions are consistent with leading  practices that we have previously identified regarding using intermediate  goals and measures to show progress or contributions to intended results  and clearly documenting significant events to help ensure that  management directives are carried out.
According to ONDCP officials, information collected through the PRS is to  provide valuable insights to help identify where the Strategy is on track  and when further problem solving and evaluation are needed. However,  the system is still in its early stages and, as of March 2013, operational  information is not available to evaluate its effectiveness. ONDCP officials  stated that as part of the annual process to assess PRS results, they plan  to review the measures to determine the extent to which they reliably  capture agency performance and whether there is a need to modify  them. Further, the 2012 PRS report states that ONDCP plans to continue to improve measures as better data sources become available.  Officials said that they plan to address any modification of the measures  in the 2013 PRS report. According to these officials, ONDCP plans to  assess the effectiveness of the PRS more comprehensively to determine  how well it is working and whether any adjustments need to be made  after the system has been operational for a longer period of time. Such  actions are consistent with Standards for Internal Control in the Federal  Government which calls for reviewing established performance measures  to validate their propriety and integrity.
ONDCP’s plans to clearly define and document its performance  assessment process and evaluate how well the PRS and its measures  are working should help increase accountability for improving results and  enhance the system’s effectiveness as a mechanism to monitor progress  toward Strategy goals and objectives and assess where further action is  needed to improve progress. These actions could also help ONDCP  identify ways to bridge the gap between the lack of progress toward  Strategy goals and the reported strong progress agencies are making in  implementing action items intended to facilitate the achievement of those  goals.
section_title: Drug Abuse Programs Are Fragmented and Overlapping; Many Reported That They Did Not Coordinate, and ONDCP Has Not Assessed Extent of Overlap and Coordination Opportunities
paragraphs: Drug abuse prevention and treatment programs are fragmented across  15 federal agencies that funded or administered 76 programs in fiscal  year 2011, and we identified overlap in 59 of these programs. Agency  officials who administer programs in two areas that we reviewed in  detail—that is, programs for youth and programs for offenders—reported  making various efforts to coordinate program activities, which, according  to our previous work, can minimize the risk of duplication. However, 29 of  76 (about 40 percent) surveyed programs reported no coordination with  other federal agencies on drug abuse prevention or treatment activities.  ONDCP has not assessed all drug abuse prevention or treatment  programs to identify the extent of overlap and potential duplication and  opportunities for coordination.
subsections: section_title: Drug Abuse Programs Are Fragmented across 15 Federal Agencies, and Many Are Overlapping, Which May Result in Inefficiencies
paragraphs: Federal drug abuse prevention and treatment programs are fragmented  across 15 federal agencies that administered 76 programs in fiscal year  2011. Agencies reported that they administered four types of programs,  specifically:
22 programs were drug abuse prevention programs;
21 programs were drug abuse treatment programs;
13 programs were both drug abuse prevention and treatment
20 programs were neither drug abuse prevention nor treatment  programs, but programs that may provide or fund drug abuse  prevention or treatment services to support other program  objectives.
Table 2 provides the number of these types of programs within the 15  federal agencies, and appendix III provides additional information on the  programs each agency administered in fiscal year 2011.
Furthermore, we identified overlap among the prevention and treatment  programs we reviewed. As we have previously reported, overlapping  programs can lead to target populations being eligible for similar services  through multiple programs. However, overlapping programs are not  necessarily duplicative, if the services provided and the populations   Of the programs we reviewed, 59 of  served differ in meaningful ways.the 76 programs (nearly 80 percent) are overlapping because they can  provide or fund at least one drug abuse prevention or treatment service  that at least one other program can provide or fund, either to similar  population groups or to reach similar program goals. For example, six  programs reported that they can provide or fund drug abuse prevention  services for students and youth in order to support program goals of  preventing drug use and abuse among young people. All six of the  programs reported that they can provide or fund services to conduct  outreach and educate youth on drug use. In addition, all of these  programs also reported that they can provide or fund other similar  services—such as public advertising and media campaigns or workplace  education and training—with at least one other program. (See fig. 4.)
In addition, 15 programs reported that they can provide or fund many of  the same prevention and treatment services provided to the offender  population, that is, those individuals involved in the criminal justice  system. Specifically, these programs reported that they can provide or  fund many of the same treatment services in order to support similar  program goals of identifying and meeting the treatment needs of  offenders and providing services to reduce recidivism and facilitate  reentry. For example, 12 of the 15 programs can provide or fund  medical evaluations and different forms of therapy, including individual  and family therapy, as shown in figure 5.
In addition, programs with the goals of (1) expanding state and  community capacity to prevent drug abuse and (2) addressing underage  drinking also demonstrated overlap. For example, 9 programs reported  that they can provide or fund drug abuse prevention and treatment  services to almost all population groups listed in our survey in support of  program goals to expand the capacities of state- and community-level  entities to prevent drug abuse. Prevention services that could be provided  by these programs included youth education, family education and  support services, and public outreach activities. Furthermore, 4 programs  with the goal of reducing underage drinking also reported providing  similar types of prevention services, including youth education and public  outreach activities.
Fragmentation and overlap in some programs have resulted from agency  efforts to meet specific areas of national need, among other things. For  example, SAMSHA officials told us that DOJ’s and states’ expansion of  funding for drug courts in the 1980s resulted in a strain on the number of  community substance abuse treatment services available to drug courts.  SAMHSA recognized the need for additional funding in this area and  began to fund the expansion and enhancement of substance abuse  treatment services specifically available to drug courts. In addition, having  multiple programs that can provide similar services to similar beneficiaries  can help to fill gaps in services for beneficiaries. However, this  fragmentation and overlap could also make it challenging to develop a  coordinated federal approach to providing drug abuse prevention and  treatment services because of the number of different federal agencies  involved, and could result in potential inefficiencies among programs  providing similar services. Specifically, our body of work on fragmentation  and overlap has found that agencies often can realize a range of benefits,  such as improved customer service and decreased administrative  burdens and cost savings from addressing issues related to  fragmentation and overlap, as we discuss below.
section_title: Many Programs Reported That They Do Not Coordinate, and ONDCP Has Not Assessed the Extent of Overlap and Identified Coordination Opportunities to Help Improve Efficiencies
subsections: section_title: Coordination Efforts in Two Areas with Overlap Helped Minimize Risk of Duplication, but Not All Programs Reported Such Efforts
paragraphs: Agency officials who administer programs in two areas that we reviewed  in more detail—specifically, programs for youth and programs for  offenders—reported making various efforts to coordinate overlapping  program activities or services, which can serve to minimize the risk of  duplication. However we found that not all programs surveyed reported  coordinating with other federal agencies on drug abuse prevention or  treatment activities in the year prior to our survey. For those areas that we  reviewed in more detail, we found the following:
Prevention services for student and youth: While 6 programs that  provide services to youth are overlapping, the risk of potential  duplication among these programs may be low because of  interagency coordination efforts. Officials overseeing these  programs from Education, ONDCP, and SAMHSA reported that the  agencies coordinate to improve program efficiencies. For example,  using an interagency agreement, Education jointly administers the  Safe Schools/Healthy Students program with DOJ and HHS to  provide complementary educational, mental health, and law  enforcement services to help prevent youth violence and drug use.  Similarly, SAMHSA and ONDCP maintain an interagency agreement  to jointly administer the Drug Free Communities Support program.  Officials from SAMHSA said that the agreement defines the roles and  responsibilities of the two agencies, and establishes agreed-upon  standard operating procedures.
In addition, officials from Education, ONDCP, and SAMHSA reported  that some programs and the services they can provide or fund are  distinct because they target specific subgroups among students and  youth, or they differ in scope. For example, the 21st Century  Community Learning Center program allows for additional uses of  funds that are not related to drug abuse prevention, like tutoring and  mentoring, and does not require that grantees include drug abuse  prevention as a program component. Officials from Education said  that this indicates a difference in scope from the Safe Schools/Healthy  Students program, which requires grantees to include drug abuse  prevention services as a main program component. These officials  also reported taking steps to identify opportunities for increasing  efficiencies. For example, in its fiscal year 2013 budget justification,  Education proposed consolidating several existing programs that seek  to help schools provide programs and activities including alcohol,  drug, and violence prevention. According to Education officials, the  consolidation would more effectively target resources and address the  needs of grantees.
Prevention and treatment services for offenders: Officials from the  four agencies overseeing the programs that can provide or fund  treatment and prevention services to the offender population also said  that the agencies conduct coordination efforts to help ensure that  programs provide complementary services to this population, which  can minimize the risk for potential duplication. OJP and SAMHSA  officials reported that both agencies coordinate to ensure that these  programs provide funding for different program elements.  For  example, according to OJP and SAMHSA officials, SAMHSA funding  for drug courts is used for treatment services, while OJP funding for  drug courts is used for administrative or case management purposes.  While OJP is not restricted from funding the same treatment services  SAMHSA can fund, officials from both agencies said that they use  multiple coordination mechanisms to help minimize the risk of  potential duplication. For example, OJP and SAMHSA jointly  administer two drug court programs. For the agencies’ other programs  serving offenders that are not jointly administered, SAMHSA officials  told us they share requests for grant applications and information on  potential awardees with OJP officials to ensure that grants are not  awarded to the same grantee for the same purpose. We also  previously reported that program overlap is minimal and the risk of  potential duplication is low among OJP’s and SAMHSA’s offender  programs that assist former inmates or inmates preparing for release  from federal, state, and local correctional facilities.
Additionally, officials from OJP and SAMHSA reported that their  programs specifically serve offenders in the state and local justice  systems, while the Bureau of Prisons and the Administrative Office of  the United States Court’s programs specifically serve offenders who  are or were incarcerated in federal prisons, which results in these  programs having a low risk for duplication. In addition, these officials  reported that the two agencies regularly share information and  coordinate on prerelease planning for inmates in federal prisons and  on transitioning inmates from prison to court-ordered drug testing and  treatment after release, or vice versa.
Coordination efforts among the programs included in the two areas we  reviewed in detail were consistent with practices that we have previously  reported federal agencies use to implement collaborative efforts. These  efforts could address crosscutting issues that may reduce potentially  duplicative, overlapping, or fragmented efforts. However, 29 of the 76  programs (about 40 percent) surveyed reported no coordination with  other federal agencies on drug abuse prevention or treatment activities.  As we have previously reported, because fragmentation across agencies  can create an environment in which programs are not delivered as  efficiently and effectively as possible, coordination across government is  essential.interagency coordination efforts among the programs that did not report   Therefore, there may be additional opportunities to implement  any of these efforts, to identify potential efficiencies that better leverage  available resources and minimize overlap and potential duplication.
While ONDCP has identified activities related to the development and  implementation of the Strategy and Drug Control Budget that promote  coordination, it has not systematically assessed all drug abuse prevention  or treatment programs to examine the extent of overlap and potential for  duplication and identified opportunities for coordination among programs  to more efficiently use limited resources. According to ONDCP officials,  the office’s current processes are sufficient to determine the extent of  overlap and potential for duplication. Specifically, officials from ONDCP  and other agencies with whom we spoke reported that they have made  efforts to promote coordination through the Strategy, which emphasizes  the importance of agencies collaborating on the Strategy’s goals. In  addition, ONDCP officials stated that as part of the office’s annual  process for developing the National Drug Control Budget submission,  they review prevention and treatment programs for which funding is  requested to verify that the programs serve unique needs and  populations. ONDCP officials stated that their familiarity with the  programs and information obtained from outreach at the programmatic  level and interagency meetings, among other things, help in this review.
However, the purpose of the interagency meetings and other efforts to  facilitate coordination is to develop and implement the Strategy and not to  identify overlap or potential duplication. Furthermore, the purpose of the  budget process is to develop a consolidated funding request to implement  the Strategy and help ensure that the Strategy is adequately resourced  rather than to identify overlap or potential duplication across all programs.  Accordingly, ONDCP has not conducted a systematic assessment of all  federal drug abuse prevention and treatment programs, including those  not captured in the budget, and the services they are allowed to provide  to determine the extent to which they overlap and where opportunities  exist to pursue coordination strategies in order to more efficiently use  limited resources. Further, ONDCP officials stated that there is no  overlap among these programs, but our analysis of prevention and  treatment services identified overlap in 59 of them. Standards for Internal  Control in the Federal Government highlights the importance of having  access to operational and other data to determine whether programs are  meeting goals for accountability and efficient use of resources.  Additionally, The Standard for Project Management states that to ensure  related projects are managed to achieve more benefits than could be  achieved with stand-alone efforts, management should coordinate  common activities or programs and the efficient use of resources across  activities.activities across organizations are to achieve desired benefits.
This can include such efforts as mapping out how various  Further, our previous work on characteristics of effective national  strategies states that such strategies should include mechanisms for  coordinating agency implementation efforts, which could entail the  identification of specific processes for coordination. As discussed earlier, officials from 29 of the 76 programs (about 40 percent) surveyed  reported that they did not participate in any coordination efforts over the  past year. Additionally, there may be other opportunities for improved  efficiencies among agencies that have some coordination efforts in place.  For example, while SAMHSA and OJP officials have made efforts to  provide complementary drug court services, a SAMHSA official stated  that a drug court awardee using SAMHSA funds to provide treatment  services and OJP funds to administer the drug court still must meet  complex, separate reporting requirements to each agency for such things  as budget and performance management information. Our previous work  has shown that fragmented services with separate agency requirements  can be burdensome, difficult, and costly for service providers. ONDCP  is uniquely situated to conduct an assessment across the 76 programs  engaged in drug abuse prevention and treatment activities to identify the  extent of overlap and potential for duplication and prospective processes  for coordination. ONDCP could use the results of our analysis as a  starting point for conducting this assessment. Such actions would better  position ONDCP to help ensure that federal agencies undertaking similar  prevention and treatment efforts identify opportunities for increased  efficiencies, such as using coordination mechanisms to mitigate the risk  of duplication and reducing administrative burdens on grantees, and  better leverage available resources. These mechanisms could include, for  example, joint program administration established through interagency  agreements, sharing requests for grant applications, or joint performance  measurement reporting among programs serving the same grant or  cooperative agreement awardees.
section_title: Agencies We Reviewed Have Completed Few Program Evaluations, with Three Looking at Program Effectiveness, but Have Taken Other Steps to Ensure Programs Are Effective
paragraphs: While agencies in our review had completed few program evaluations  since 2007, in part because of funding constraints, more are under way or  planned. ONDCP officials stated that because few programs have  completed program evaluations, they rely on a range of available  performance information, including agency performance metric data, to  inform development and implementation of the Strategy. In addition,  agency officials said that they have taken other steps to help ensure that  programs supporting the Strategy are effective, such as requiring or  encouraging the use of interventions—drug abuse prevention or  treatment practices—in their programs for which there is research or  evidence that the interventions work.
subsections: section_title: Agencies in Our Review Have Completed Few Program Evaluations, but More Are Under Way or Planned
paragraphs: Program evaluations allow for comprehensive assessments of whether  programs are achieving desired results to help allocate scarce resources  to effective interventions, among other things. Program evaluation is  closely related to performance measurement and reporting; evaluations  have been used to supplement performance reporting by measuring  results that are too difficult or expensive to assess annually or by  exploring why program goals were not met. Program evaluations can tell  agencies how well their programs are working, suggest options for  improving program performance, and assist in program management.  However, the drug control agencies in our review had completed few  program evaluations since 2007, although more are under way or  planned. Specifically, we found that 3 of the 15 agencies had completed  evaluations of 6 programs since 2007, which accounts for about 8 percent  of the 76 drug abuse prevention and treatment programs included in our  review, and 8 agencies had started or planned 22 additional program  evaluations.one or more of their programs.
section_title: Conclusions
paragraphs: The public health, social, and economic consequences of illicit drug use,  coupled with the constrained fiscal environment of recent years, highlight  the need to ensure that federal programs efficiently and effectively use  their resources to address this problem. ONDCP has developed a 5-year  Strategy to reduce illicit drug use and its consequences, but our analysis  shows lack of progress toward achieving four of the Strategy’s five goals  for which primary data are available. ONDCP established the PRS in April  2012 to monitor progress toward the Strategy’s goals and objectives and  provide information to guide efforts to meet these goals. While this is  promising, ONDCP does not plan to report on results until later in 2013,  and until then, operational information is not available to evaluate its  effectiveness.
A wide range of federal drug abuse prevention and treatment programs  support the achievement of the Strategy’s goals. While some  fragmentation and overlap of program services may be beneficial, they  also entail potential inefficiencies that programs may not be able to afford  in this era of resource constraints. Because of its responsibility for  coordinating implementation of national drug control policy across the  federal government, ONDCP is uniquely situated to conduct an  assessment to identify overlap and potential duplication among  prevention and treatment programs and coordination opportunities. Our  work has identified specific areas of fragmentation and overlap of  services among these programs that could be used by ONDCP, along  with other information such as results from agencies’ program evaluation  efforts, to help agencies begin or improve coordination efforts to help  reduce or eliminate potential inefficiencies. For example, ONDCP could  identify the causes for the lack of coordination among the 29 agencies  that reported conducting no coordination and further examine the overlap  we identified in programs focused on capacity building and underage  alcohol use, as a starting point for a broader assessment across federal  agencies. Such an assessment would better position ONDCP to identify  opportunities for increased efficiencies, such as using coordination  mechanisms to mitigate the risk of duplication, and help ensure that  federal agencies undertaking similar prevention and treatment efforts  better leverage available resources to achieve Strategy goals.
section_title: Recommendation for Executive Action
paragraphs: To identify opportunities to increase efficiencies and therefore better  leverage agency prevention and treatment resources, we recommend  that the Director of ONDCP assess the extent of overlap and potential for  duplication across federal programs engaged in drug abuse prevention  and treatment activities and identify opportunities for increased  coordination. ONDCP could use our work as a starting point for this  assessment.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to ONDCP; the Departments of Health  and Human Services, Justice, Education, Defense, Housing and Urban  Development, Labor, Transportation, Veterans Affairs, and Homeland  Security; and the Federal Judiciary for review and comment. ONDCP  provided written comments, which are reprinted in appendix V and  summarized below. ONDCP concurred with our recommendation, and  also provided perspectives on overlap among drug abuse prevention and  treatment programs and progress toward achieving Strategy goals.
In its comments, ONDCP reiterated that we reported finding overlap but  not actual instances of duplication among the drug prevention and  treatment programs we reviewed. The office also made the points, with  examples, that some overlapping programs (1) may not serve identical  populations and may target different specific subgroups of a large  population category, such as different types of youth age groups, and (2)  may provide distinct services. We acknowledged these factors in our  report, and maintain that this is why it is important to systematically  review the extent of overlap among prevention and treatment programs,  taking into account targeted subgroups and allowable services, to help  ensure that they efficiently use limited resources to deliver these  important services. ONDCP also reiterated, as we stated, that  overlapping programs may provide positive benefits, such as reinforcing  key prevention messages. Further, the office agreed that coordination  efforts among programs can help avoid duplication and maximize  program effectiveness. This is consistent with our report, which noted that  overlap and fragmentation may not necessarily lead to duplication, but  can create an environment in which programs are not delivered as  efficiently and effectively as possible, and that coordination among  programs helps to reduce the risk of duplication and increase efficiencies.
ONDCP stated that while extensive coordination of prevention and  treatment programs is already taking place, there is always room for  improvement, and that it will work with agencies administering these  programs to further enhance coordination.
With regard to progress toward achieving Strategy goals, ONDCP stated  that it is important to analyze trends for each drug category separately  and noted that we recognized this in our discussion of ONDCP’s goal to  reduce drug use among 12- to 17-year-olds by 15 percent by 2015. As  the report states, marijuana accounts for almost 80 percent of drug use in  this age group, and the lack of progress on this goal is due primarily to an  increase in the rate of reported marijuana use, offset by decreases in the  rates of other drug use. We also state that misuse and abuse of  prescription drugs is the primary factor for one of the measures for the  goal to reduce drug-related morbidity by 15 percent, which also shows  lack of progress. Finally, ONDCP noted, as we did in the report, that while  results from the primary data source for the goal to reduce drugged  driving by 10 percent are not available, results from ONDCP’s secondary  data source indicate progress.
ONDCP and the Departments of Health and Human Services, Justice,  Education, Defense, Transportation, and Housing and Urban  Development provided technical comments on this report that we  incorporated as appropriate.
As agreed with your offices, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to selected congressional  committees; the Director of ONDCP; Secretaries of Health and Human  Services, Education, Defense, Housing and Urban Development, Labor,  Transportation, Veterans Affairs, and Homeland Security; Attorney  General; Director of the Administrative Office of United States Courts; and  other interested parties. In addition, the report will be available at no  charge on GAO’s website at http://www.gao.gov. If you or your staff have   any questions about this report, please contact Eileen R. Larence at (202)  512-8777 or larencee@gao.gov or Linda T. Kohn at (202) 512-7114 or  kohnl@gao.gov. Contact points for our Offices of Congressional Relations  and Public Affairs may be found on the last page of this report. Key  contributors to this report are listed in appendix VI.
section_title: Appendix I: Relatively Few Studies Have Assessed the Effect of Societal Factors on Youth Marijuana Use, and These Studies Had Limitations
paragraphs: Prior studies have found that a number of factors may affect marijuana  use among youth, that is, individuals 17 years old and under. For  example, we reported in 1993 that several risk factors were associated  with marijuana use based on our review of a national longitudinal survey.  Specifically, we found that young people who had reported that they  engaged in delinquent activities, such as running away from home,  truancy, fighting, and theft, were more likely to have used marijuana;  however, we also noted that underlying factors may be associated with  both drug use and delinquent activities. More recently, in 2000, a meta- analysis of 101 longitudinal studies from around the world identified a  number of risk factors that predicted future marijuana use, including the  availability of illicit drugs and guns, family history of antisocial behavior,  positive attitudes toward substance use, low perceived risk of drug use,  and rebelliousness.
subsections: section_title: Review of Studies on the Effect of Societal Factors on Youth Marijuana Use
paragraphs: Other factors, including state laws and changing attitudes and social  norms regarding drugs, may also affect drug use. We examined studies  on three of these other factors, which we refer to as societal factors,  which may affect youth marijuana use. Specifically, we examined studies  that addressed: (1) the passage of laws allowing for the use of marijuana  for medical purposes (medical marijuana laws); (2) the reduction in  penalties for marijuana possession (decriminalization); and (3) the  favorable portrayal of drugs in the media (prodrug media), such as  movies, television, music, and music videos. For instance, a number of  states have passed varying degrees of laws related to the production,  possession, or use of marijuana for varying purposes. In addition,  separate from laws that may allow for the use of marijuana for certain  medical purposes, some states and local governments have taken  actions to reduce or eliminate certain criminal penalties for the  possession of small amounts of the drug. Finally, some speculate  whether media depictions of illicit drugs influence youth drug use. For  example, according to one study, frequent viewing of media messages  may increase the likelihood of the adoption of ideas or beliefs reflected in  the media portrayals, which may influence subsequent behaviors, such as  the use of illicit substances.
Through searches of databases, Internet websites, and other sources  available as of June 2012, we identified 476 documents that addressed  possible factors relating to youth drug use, including the societal factors  described above, as well as others such as alcohol use and mental  illness. We reviewed these documents to determine if the studies met  our literature review criteria, which required that the study (1) address one  of the three societal factors included in our review, specifically medical  marijuana laws, decriminalization, or prodrug media; (2) report results on  U.S. youth (age 17 and under); (3) have a national or multiple state  scope; and (4) assess the effect of the factor on youth marijuana use  through the use of methods such as comparison groups or statistical  analyses. We identified 10 studies that assessed the effect of medical  marijuana laws or decriminalization. We also identified 10 studies on  prodrug media that focused on U.S. youth; however, 4 of the latter 10  studies did not have a national or multiple state scope, and none of these  10 studies assessed the effect of media on youth marijuana use.  Specifically, 4 assessed the association between media and youth  marijuana use, and 6 provide descriptive statistics on, for example, the  prevalence of drugs and prodrug representations in various forms of  media. While these studies may not assess the effect of media on youth  marijuana use or include a national or a multiple state scope, we included  them because they provide useful context regarding the portrayal of drugs  in the media. Two social scientists and, as applicable, a statistician  reviewed each of the 20 studies to determine whether the design,  implementation, and analyses of the study were sufficiently sound to  support the study’s results and conclusions based on generally accepted  social science principals. On the basis of these reviews, we excluded 3  studies on medical marijuana laws and 1 study on decriminalization.  Below, we provide information on 2 medical marijuana studies, 4  decriminalization studies, and the 10 media studies from our review.selected these studies on medical marijuana laws and marijuana  decriminalization to include in this report based on the sufficiency of their  methodologies; therefore, our results cannot be generalized to all  research about the potential effect of these factors on youth drug use.
The studies that assessed the effect of medical marijuana laws that met  our review criteria found mixed results on effects of the laws on youth  marijuana use. These studies are described in table 4 below. One  potential limitation to these studies may be the variation in implementation  of medical marijuana laws across states. We discuss this and other  potential limitations, as well as the ways that some studies addressed this  issue, later in this appendix.
Three of the four studies that assessed the effect of marijuana  decriminalization that met our review criteria found little to no effect of the  laws on youth marijuana use. These studies, as well as one study that  found an increase, are described in table 5. One potential limitation to  these studies is that all four studies contained data on marijuana use that  had been collected in 1990 or earlier, which may mean that their findings  are not applicable to current youth drug use patterns; however, we  included them in our review because they provide useful information  regarding the previous effects of decriminalization. We discuss this and  other potential limitations later in this appendix.
None of the studies we identified on prodrug media assessed whether  exposure to prodrug media caused changes in marijuana or other drug  use. Of the 10 studies we identified that address prodrug media, 4  assessed the association between such media and youth marijuana use  (see table 6). Three of the four studies found that exposure to various  forms of media (e.g., rap music, music, and media depicting the positive  aspects of marijuana use) were associated with higher rates of marijuana  or other drug use. The fourth study found that information obtained from  the Internet changed reported drug-using behavior, but did not determine  whether marijuana or other drug use increased or decreased as a result.
Six of the 10 studies that addressed prodrug media provided descriptive  statistics on, for example, the prevalence of drugs and prodrug  representations in various forms of media. Five of these studies described  the nature and frequency of illicit drugs in various forms of media,  including movies, television, music videos, and music. The media content  from these studies ranges from 1996 through 2005, and may not reflect  the current content of media. Some of the findings from these descriptive  studies are described in table 7.
The sixth study assessed the perceived value of “the media” and other  sources as credible providers of drug information, based on anonymous  interviews with 223 high school students across two states. This study  found that adolescents reported listening to their parents and teachers the  most about drugs and alcohol, as compared with movie, television, music,  or sports celebrities, but the results of this study cannot be generalized to  a larger population.
We identified several challenges related to inherent difficulties in  analyzing this subject matter or with the study designs that may limit the  generalizability of these studies. For example, a study’s design may have  been sufficiently sound to support the study’s results and conclusions, but  it could have used old data, which may mean that the study’s findings are  not applicable to current youth drug use patterns. We describe these  limitations below:
Variation in implementation of medical marijuana laws: Office of  National Drug Control Policy (ONDCP) officials stated that states  implement medical marijuana laws differently and that these  differences may influence the effect of the laws on youth marijuana  use. For example, according to these officials, some states enacted  laws where medical marijuana has had a very visible presence  throughout the state, while other states’ laws have low visibility or  have not been implemented yet. Further, ONDCP officials stated that  some studies incorrectly looked at the changes in marijuana use  before and after medical marijuana laws are passed instead of before  and after such laws are implemented. The officials noted that this is  an important distinction because the implementation of medical  marijuana laws after passage can be a lengthy process. ONDCP  officials also noted that the states that eventually passed medical  marijuana laws tended to have higher rates of youth marijuana use  before such laws were passed. However, some of the studies we  reviewed attempted to account for these issues in their study designs.  For example, one study used a model that controlled for unmeasured  state characteristics that do not change over time, such as differences  in social norms, and that might affect marijuana use and the likelihood  of a state passing a medical marijuana law.
Self-reported data: As we have previously reported, research about  drug use among youth is limited, in part, because most studies rely on  self-reported data, and low estimates are likely because drug use is  illegal. For example, youth may be unlikely to report their drug use  in the survey for fear of negative repercussions, regardless of whether  the results of the survey are shared with law enforcement. For our  analysis, all of the 6 studies on the effects of medical marijuana laws  or decriminalization on youth marijuana use as well as the 4 studies  on the association between media and youth marijuana use employ  self-reported data.
Use of historical data: While 4 of the 10 studies on the effect of or  association between societal factors and youth marijuana use data  collected since 2000 (2 medical marijuana and 2 media studies), the  remainder of the studies used older data (the oldest being collected in  1975). In particular, all 4 studies on decriminalization, as well as 2 of  the media studies, contained data on marijuana use that had been  collected before 2000, which may mean that their findings are not  applicable to current youth drug use patterns.
section_title: Appendix II: Objectives, Scope, and Methodology
paragraphs: This report addresses the following objectives:  1.  To what extent has progress has been made toward achieving  Strategy goals and does ONDCP have mechanisms in place to  monitor progress?  2.  To what extent does fragmentation, overlap, and duplication exist  across drug abuse prevention and treatment programs, and do  ONDCP and federal agencies coordinate efforts to reduce the  potential for unnecessary overlap or duplication?  3.  To what extent do federal agencies that have drug abuse prevention  and treatment programs conduct evaluations of these programs,  including assessments of program effectiveness?
In addition, we provide information on what the available research  suggests about the potential effect of societal factors, such as state laws  allowing the use of marijuana for medical purposes, on youth drug use.
subsections: section_title: Assessing Progress toward Strategy Goals and Mechanisms to Monitor Progress
paragraphs: To assess progress toward Strategy goals and the extent to which  ONDCP has mechanisms in place to monitor progress, we analyzed the  2010 Strategy and 2011 and 2012 annual updates, the National Drug  Control Budget, and ONDCP documentation about its Performance  Reporting System and associated performance measures. We also  analyzed ONDCP documents on the implementation status of Strategy  action items and implementation plans and reports from selected federal  drug control agencies. In addition, we analyzed agency budget  justifications and strategic plans. We also reviewed information provided  by ONDCP and publicly available data sources, such as the National  Survey on Drug Use and Health, to determine progress toward Strategy  goals.
On the basis of such factors as the number of Strategy action items for  which agencies are responsible, the size of agency drug control budgets,  and inclusion of a balance of drug prevention, treatment, and supply  reduction missions, we selected the following seven agencies to focus on  in our review: within the Department of Health and Human Services (HHS), the  Substance Abuse and Mental Health Services Administration,  National Institutes of Health—specifically, the National Institute on  Drug Abuse and the National Institute on Alcohol Abuse and  Alcoholism—and Centers for Disease Control and Prevention; within the Department of Justice (DOJ), the Office of Justice  Programs (OJP)— specifically, the Bureau of Justice Assistance,  Bureau of Justice Statistics, National Institute of Justice, and Office of  Juvenile Justice and Delinquency Prevention—and Drug Enforcement  Administration; within the Department of Homeland Security, U.S. Customs and  Border Protection; and   the Department of Education (Education).
While these seven agencies are not representative of all federal drug  control agencies, they are responsible for implementing a majority of  activities in the Strategy and provide a range of perspectives about  Strategy implementation and progress. Specifically, our selected  agencies and ONDCP have lead implementation responsibilities for  approximately 70 percent of the 112 action items in the Strategy. We also  interviewed officials from ONDCP and these agencies to obtain  information about progress on the Strategy’s goals, the Performance  Reporting System, how ONDCP monitors progress on Strategy objectives  and action items, the implementation status of these action items, and the  effect of the Strategy on agencies’ drug control activities. We compared  the information we obtained from documents and agency officials about  the Strategy and ONDCP’s monitoring mechanisms with criteria for  performance management identified in our prior work. We also reviewed  ONDCP’s categorizations for a nonprobability sample of 24 out of 82  action items led by ONDCP and our seven selected agencies to validate  ONDCP’s characterization of their implementation statuses. Although we  cannot generalize the results to all action items led by these agencies,  this allowed us to determine the extent to which we agreed with ONDCP’s  categorizations of the action items we reviewed. Finally, we interviewed  seven drug policy experts to discuss their perspectives on the Strategy  and performance management.  We selected these experts based on our  review of drug policy literature, their expertise in drug policy issues and  work conducted in this area, and recommendations from these and other  researchers. The information from these seven policy experts cannot be  generalized to other experts; however, they provided us with a range of  views about the Strategy and ONDCP’s monitoring mechanisms.
section_title: Assessing Fragmentation, Overlap, and Duplication across Drug Abuse Prevention and Treatment Programs and Agency Coordination Efforts
subsections: section_title: Identifying Programs
paragraphs: To identify federal drug abuse prevention and drug abuse treatment  programs, and programs that include drug abuse prevention or treatment  activities, we developed a preliminary list based on the agencies included  in our previous work in this area and a review of ONDCP and agency  information, such as the fiscal year 2013 National Drug Control Budget,  the 2010 National Drug Control Strategy, and publically available  information on agency websites. We also reviewed the Catalogue of  Federal Domestic Assistance. On the basis of ONDCP guidance, we  defined a drug abuse prevention program as a federal program that  provides services, allocates funding, or allows for activities focused on  discouraging the first-time use of controlled substances—specifically illicit  drugs and the problematic use of alcohol—and encouraging those who  have begun to use controlled substances to cease their use. We defined  a drug abuse treatment program as a federal program that provides  services, allocates funding, or allows for activities focused on identifying  and assisting users of controlled substances—specifically illicit drugs and  the problematic use of alcohol—to become drug-free and remain drug- free.
We focused our review on programs that directly administer or fund drug  abuse prevention or treatment programs, or programs that include these  activities, and therefore excluded programs that, for example, exclusively  focus on law enforcement or policy, conduct research, or fund overhead  costs. In addition, we also excluded programs that reimbursed drug  abuse treatment services as part of a health benefit plan, such as HHS’s  Medicare and Medicaid programs and the Department of Defense’s  Defense Health Program, which includes military health benefit plans like  TRICARE. Our initial review determined that 3 of 19 agencies included in  the National Drug Control Budget for funding drug abuse prevention and  treatment programs did not administer programs that met our scope of  review. As a result, we excluded these agencies from our review. In total,  our initial search identified 91 potential programs that 16 federal agencies  administered.
Next, we shared our preliminary list of programs with agency officials and  asked them to verify that the included programs met our criteria and if any  should be added or deleted. During initial meetings with agency officials,  we asked them to clarify program names, descriptions, and services  offered. We used the information obtained to make additional refinements  to the list of agencies and programs included in our review. For example,  some programs were removed from the list because they were no longer  in operation in fiscal year 2012 or were part of a larger program already  listed, and other programs were added. We also excluded one additional  agency from our review. Specifically, we excluded the Court Services and  Offender Supervision Agency for the District of Columbia because its  programs are primarily for residents of the District of Columbia. Thus the  number of agencies in the scope of this study decreased from 16 to 15.  After completing these refinements our list identified a total of 95  programs.
To obtain program-specific information, we sent a total of 95 web-based  questionnaires to the 15 agencies included in our review.questionnaires are described in detail below. We included several  screening questions in the questionnaire to further verify that programs  met our definition of a drug abuse prevention program, drug abuse  treatment program, or a program that includes these activities, and were  in operation in fiscal year 2012. Fourteen programs did not pass our  screening questions and therefore were excluded from our analysis. We  also removed 4 programs from our analysis after reviewing the responses  and determining that the program did not meet one or more of our criteria   These  for inclusion, and consolidated the responses of 1 program at the request  of agency officials. In total, 76 programs were included in our final  analysis of questionnaire responses.
We developed a web-based questionnaire to collect detailed information  on federal drug abuse prevention and drug abuse treatment programs,  and programs that include these activities, for fiscal year 2011. The  questionnaire included questions on program objectives, target groups  served, services provided, and coordination activities with other federal  agencies. We also collected data on program obligations—defined as  definite commitments that create a legal liability of the government for the  payment of goods and services ordered or received—as available, for  fiscal year 2011. Specifically, we asked programs to provide the amount  of federal funds obligated specifically for their drug abuse prevention or  treatment activities, and the total amount of federal funds obligated for all  program activities in fiscal year 2011. In many cases, programs were not  able to provide data on funds obligated specifically for their drug abuse  prevention or treatment activities because agency officials told us that  they did not report budgetary data at this level, among other reasons.
To minimize errors arising from differences in how questions may be  interpreted and to reduce variability in responses, we conducted pretests  with four agencies and 6 programs from July to August 2012. To ensure  that we obtained a variety of perspectives on our questionnaire, we  selected programs that differed in program scope, services provided, and  target groups served. We included budget staff as well as program  officials in the pretest to ensure budget-related terms in the survey were  understandable. An independent reviewer also reviewed a draft of the  questionnaire prior to its administration. After completing the pretests, we  administered the survey to 95 programs. We received completed surveys  for 95 programs, for a 100 percent response rate. telephone calls to officials and sent them follow-up e-mail messages, as  necessary, to clarify their responses or obtain additional information.
We consolidated questionnaire responses for SAMHSA’s Substance Abuse and Mental  Health block grant program at the request of agency officials. As a result, we ultimately  received responses for 94 unique programs.
We used standard descriptive statistics to analyze responses to the  questionnaire. Because this was not a sample survey, there were no  sampling errors. To minimize other types of errors, commonly referred to  as nonsampling errors, and to enhance data quality, we employed survey  design practices in the development of the survey and in the collection,  processing, and analysis of the survey data. For instance, as previously  mentioned, we pretested the questionnaire with federal officials to  minimize errors arising from differences in how questions might be  interpreted and to reduce variability in responses. We further reviewed  the questionnaire to ensure the ordering of sections was appropriate and  that the questions within each section were clearly stated and easy to  comprehend. To reduce nonresponse, another source of nonsampling  error, we sent out e-mail reminder messages to encourage officials to  complete the questionnaire. In reviewing the questionnaire data, we  performed automated checks to identify inappropriate answers. We  further reviewed the data for missing or ambiguous responses and  followed up with agency officials when necessary to clarify their  responses. To assess the reliability of obligations data, we incorporated  questions about the reliability of the programs’ data systems and if there  were any limitations to reporting the data. On the basis of our application  of recognized survey design practices and follow-up procedures, we  determined that the data were of sufficient quality for our purposes. All  data analysis programs were also independently verified by a data  analyst for accuracy.
To determine the extent of fragmentation, overlap, and duplication, we  compared data from the 76 drug abuse prevention and treatment  programs to review the types of services offered across the federal  government and used the following definitions from our prior work:
Fragmentation occurs when more than one federal agency (or more  than one organization within an agency) is involved in the same broad  area of national interest.
Overlap occurs when fragmented agencies or programs have similar  goals, engage in similar activities or strategies to achieve them, or  target similar beneficiaries.
Duplication occurs when two or more agencies or programs are  engaged in the same activities or provide the same services to the  same beneficiaries.
To determine the extent of fragmentation, we used the questionnaire data  to identify the number of agencies that deliver similar types of drug abuse  prevention and treatment programs. To determine the potential for  overlap, we identified the number of programs with similar goals that  provided similar services to similar populations. We also conducted an in- depth analysis of two areas—prevention services for students and youths  and treatment services for the offender populations—to further assess the  potential for overlap among these programs. We selected these areas  because of the number of programs and extent of overlap in these areas.  For those areas in which we completed our in-depth review, we also  determined the potential for duplication by reviewing programmatic  information and holding meetings with program staff to determine whether  the programs were providing the same services to the same beneficiaries.
To assess coordination efforts to reduce the potential for unnecessary  overlap or duplication, we analyzed questionnaire responses from the 76  programs regarding agency efforts to coordinate drug abuse prevention  and treatment program activities. We also analyzed the 2010 Strategy  and interviewed ONDCP and agency officials about actions taken to  coordinate activities. We compared these reported actions with criteria for  coordinating interagency efforts, internal controls, and desirable  characteristics of effective national strategies identified in our prior work.
section_title: Assessing Evaluations of Drug Abuse Prevention and Treatment Programs
paragraphs: To identify which of the 76 drug abuse prevention and treatment  programs at the 15 agencies included in our review had program  evaluations, including assessments of effectiveness, we first conducted  Internet and library searches to identify any reports or other documents  that described evaluations that had been completed or for which interim  reports had been issued since 2007. We then interviewed or received  written responses from agency officials responsible for administering the  76 programs, in which they confirmed the evaluations that we found  through our searches and identified additional evaluations of the  programs that had been completed, were under way or had interim  reports completed, or were planned since 2007. We selected 2007 as the  starting point for our review in order to provide a long enough time frame  to include evaluations that may take multiple years to complete. We  obtained copies of all completed program evaluations and reviewed each  to determine whether these evaluations included assessments of  effectiveness (i.e., determining the extent to which a program is achieving  its objectives) as described in our Designing Evaluations: 2012 Revision,  which provides guidance on evaluation methodologies. For each  program evaluation, we reviewed its objectives, scope, and any  description of how its findings were used by the agency. Furthermore, we  interviewed agency officials about factors affecting the lack of program  evaluation. We also reviewed agency documents and interviewed agency  officials to identify whether the agencies took other steps to help ensure  that their programs are effective, such as requiring programs or their  grantees to use evidence-based interventions, and whether the agencies  prescribed specific evidence-based interventions that must be used in  their programs.  We also interviewed ONDCP officials to determine how  program evaluations were used to inform policy and resource allocation  decisions.
We conducted this performance audit from July 2012 to March 2013 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
section_title: Appendix III: Fiscal Year 2011 Obligations for Drug Abuse Prevention and Treatment Programs in Our Review
subsections: section_title: Agency or subagency Program name Department of Defense (DOD) DOD civilian agencies
section_title: Department of Justice Bureau of Prisons
section_title: Agency or subagency Program name Department of Transportation Federal Aviation Administration
section_title: Department of Education
section_title: Agency or subagency Program name Indian Health Service
section_title: Agency or subagency Program name
paragraphs: Targeted Capacity Expansion  General—Recovery Oriented  Systems of Care  Targeted Capacity Expansion  General—Technology Assisted Care  Treatment Drug Courts—Adults    (SAMHSA only)
Treatment Drug Courts—Juvenile   (SAMHSA only)
Treatment Drug Courts—Adult (joint  with the Bureau of Justice Assistance)
Treatment Drug Courts—Juvenile   (joint with the Office of Juvenile  Justice and Delinquency Prevention)
section_title: Agency or subagency Program name Department of Housing and Urban Development
paragraphs: For the purpose of our review, we identified a drug abuse prevention program as a federal program  that provides services, allocates funding, or allows for activities focused on discouraging the first-time  use of controlled substances—specifically illicit drugs and the problematic use of alcohol—and  encouraging those who have begun to use controlled substances to cease their use. We defined a  drug abuse treatment program as a federal program that provides services, allocates funding, or  allows for activities focused on identifying and assisting users of controlled substances—specifically  illicit drugs and the problematic use of alcohol—to become drug-free and remain drug-free.The Drug Demand Reduction program funds, at least in part, the National Guard Bureau Prevention,  Treatment, and Outreach program; the Air Force Drug Demand Reduction program; the Army  Substance Abuse Program; the Marine Corps Substance Abuse Program; and the Navy Alcohol and  Drug Abuse Prevention program, as well as drug testing for the department’s civilian employees. The  military services use Drug Demand Reduction program funds to provide drug abuse prevention  services, including drug testing, education, and outreach. The Drug Demand Reduction Program  does not fund drug abuse treatment services or services related to the prevention or treatment of  alcohol abuse. However, the military services may use other funding sources to provide those  services. For example, the U.S. Army uses funds from its Operations and Maintenance Account to  provide some drug abuse treatment services.   We requested that surveyed programs provide the total amount of federal funds obligated  specifically for drug abuse prevention and treatment activities in fiscal year 2011. For those agencies  that were unable to provide this information, we reported that this information was not available.  Program officials reported that they were unable to provide the total amount of federal funds obligated  specifically for their program’s drug abuse prevention or treatment activities in fiscal year 2011 for a  variety of reasons, such as that the programs do not collect this type of budgetary data.   The Bureau of Prisons reported obligations for its drug abuse prevention and treatment programs in  total, but was not able to report obligations for individual programs.
Under 20 U.S.C. § 7164, funds may not be used for medical services, drug treatment, or  rehabilitation, except for pupil services or referral to treatment for students who are victims of, or  witnesses to, crime or who illegally use drugs with regard to Safe and Drug-Free Schools and  Communities. Under 20 U.S.C. § 7175, with regard to 21st Century Community Learning Centers,  each eligible entity that receives an award may use the award funds to carry out a broad array of  before and after school activities that advance student academic achievement that are listed in the  statute.
For the purpose of our review, we assessed the activities of Education’s Safe and Supportive  Schools and Safe Schools/Healthy Students programs separately; according to officials from  Education, they are considered to be activities within a single program–the Safe and Drug-Free  Schools and Communities National Activities.
section_title: Appendix IV: Information about Completed Program Evaluations Conducted by Agencies in Our Review
paragraphs: We found that the agencies included in our review have completed six  evaluations of drug abuse prevention and treatment programs since  2007, three of which examined effectiveness and three of which  examined program implementation. The completed program evaluations  that included assessments of effectiveness examined the following:
Office of Justice Program’s (OJP) Drug Courts Program.examined 23 adult drug courts across the United States and  compared them with 6 sites in the same geographic areas. The  evaluation focused on four main issues: (1) whether drug courts  reduce drug use and other problems associated with drug abuse, (2)  how drug courts work, (3) how offender attitudes and behaviors  change when they are exposed to drug courts and how these  changes help explain the effectiveness of drug courts, and (4)  whether drug courts generate cost savings. OJP officials told us that  as a result of the study, the major findings of the evaluation were  translated into seven evidence-based design features that OJP is  including in drug court grant solicitations. When making awards, OJP  gives priority to applicants that include the seven design features in  their proposals, as OJP considers these design features to be  indicators of an effective program. The seven design features are (1)  screening and assessment, (2) target population (3) procedural and  distributive justice, (4) judicial interaction, (5) monitoring, (6) treatment  and other services, and (7) relapse prevention, aftercare, and  community integration.
The Department of Veterans Affairs’ (VA) Substance Use Disorder  Outpatient Program and Substance Use Disorder Residential  Program. The study looked at the quality of VA substance abuse and  mental health care for veterans diagnosed with substance use  disorder (SUD) or one or more other mental health conditions. The  evaluation asked the following questions: (1) To what extent is VA  achieving the program outcomes for veterans with SUD or other  mental health conditions? (2) How do the outcomes for VA patients  compare with outcomes for comparable veterans treated in non-VA- funded care? (3) How does the availability of care compare across  Veterans Health Administration medical centers? (4) When there is a  diagnosis of SUD and a mental health condition, are both conditions  being managed? (5) What factors influence the use of VA specialty  mental health services by veterans whose condition is a result of or  aggravated by their service? (6) How widespread is the use of the  strongest evidence-based models of care for SUD and the other  mental health diagnoses? The study identified areas for further  research and recommended strategies to improve SUD and mental  health care in VA.
Substance Abuse and Mental Health Services Administration’s  (SAMHSA) Substance Abuse Prevention and Treatment Block Grant  Program. The study assessed the extent to which this program is  effective, functioning as intended, and achieving desired outcomes.  The program provides funds to 50 states, nine territories (including the  District of Columbia), and one Indian tribe for activities to prevent and  treat substance abuse. The evaluation examined (1) the processes  and activities by which states implement the legislative and policy  requirements of the Substance Abuse Prevention and Treatment  Block Grant program, (2) activities associated with the federal  administration of the program and how they support program  implementation and accountability, (3) state system processes and  capacity for the collection and submission of data on block grant- funded activities, (4) specified outcomes associated with states’  treatment and prevention services, and (5) the ways in which states  used and leveraged program funds. The study identified program  successes, as well as challenges and areas for improvement.
The other completed program evaluations examined:
SAMHSA’s Underage Drinking Prevention Education Initiative.evaluations examined implementation and perceived outcomes of  2008 and 2010 Town Hall meetings intended to raise public  awareness of underage drinking and engage communities in its  prevention. The evaluation also reviewed the barriers and challenges  in planning and convening the Town Hall meetings. The evaluations  reviewed, among other things, changes over time in the numbers of  Town Hall meetings held and participation by community-based  organizations. The evaluations also examined Town Hall attendees  and presenters and the settings, formats, and contents of the Town  Halls. Officials from SAMHSA, which administers the program, said  they would use the evaluation results to shape future program  proposals and inform and improve technical assistance and training  activities. SAHMSA plans to share the results with participants and  use the results in presentations on best practices.
SAMHSA’s Assertive Adolescent and Family Treatment Program.The study focused on the third cohort of Assertive Adolescent and  Family Treatment Program grant recipients and had two overarching  goals: (1) to document the program implementation process, and (2)  to explore how implementation supports, such as training and  technical assistance for the clinical and assessment components of  the project, guide how the funded programs evolve. The report  findings addressed the characteristics of agency, staff, and clients and  their relationship with program implementation, grantees’ use of  implementation activities, implementation barriers, strategies used  and lessons learned, and the overall impact of the program on  program sites and their clients.
section_title: Appendix V: Comments from the Office of National Drug Control Policy
section_title: Appendix VI: GAO Contacts and Staff Acknowledgments
subsections: section_title: GAO Contacts
section_title: Staff Acknowledgments
paragraphs: In addition to the contacts named above, Karen Doran, Assistant Director;  Mary Catherine Hult, Assistant Director; David Alexander; Willie  Commons III; Elizabeth Curda; Susan Czachor; Lorraine Ettaro; Michele  Fejfar; Jill Lacey; Kelly Liptan; Emily Loriso; Linda Miller; Erin O’Brien;  Dae Park; Emily Ryan; C. Jenna Sondhelm; and Johanna Wong made  significant contributions to the work.