Drug Control Policy: Information on Status of Federal Efforts and Key Issues for Preventing Illicit Drug Use
Released: 2017-07-26T00:00:00

Letter

Background

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.

ONDCP is required annually to develop the National Drug Control Strategy, which sets forth a plan to reduce illicit drug use through prevention, treatment, and law enforcement programs, and to develop a National Drug Control Program Budget for implementing the strategy. National Drug Control Program agencies follow a detailed process in developing their annual budget submissions for inclusion in the National Drug Control Program Budget, which provides information on the funding that the executive branch requested for drug control to implement the strategy. Agencies submit to ONDCP the portion of their annual budget requests dedicated to drug control, which they prepare as part of their overall budget submission to the Office of Management and Budget for inclusion in the President’s annual budget request. ONDCP reviews the budget requests of the drug control agencies to determine if the agencies have acceptable methodologies for estimating their drug control budgets, and includes those that do in the Drug Control Budget. In FY 2016, the budget contained 38 federal agencies or programs.

There are five priorities for which resources are requested across agencies: substance abuse prevention and substance abuse treatment (which are considered demand-reduction areas), and domestic law enforcement, drug interdiction, and international partnerships (which are considered supply-reduction areas) as shown in figure 1. ONDCP manages and oversees two primary program accounts: the High Intensity Drug Trafficking Areas (HIDTA) Program and the Other Federal Drug Control Programs, such as the DFC Support Program. ONDCP previously managed the National Youth Anti-Drug Media Campaign which last received appropriations in fiscal year 2011. Also, from fiscal year 1991 to fiscal year 2011, ONDCP managed the Counterdrug Technology Assessment Center (CTAC).

According to ONDCP, federal drug control spending increased from $21.7 billion in FY 2007 to the approximately $27.5 billion that was allocated for drug control programs in FY 2017 as shown in figure 2. Spending on supply reduction programs, such as domestic law enforcement, interdiction, and international programs increased 16 percent from $13.3 billion in FY 2007 to $15.4 billion in FY 2017. However, federal spending for demand programs—treatment and prevention— increased at a higher rate from FY 2007 through FY 2017. Spending in these two programs increased 44 percent from $8.4 billion in FY 2007 to $12.1 billion in FY 2017. As a result, the proportion of funds spent on demand programs increased from 39 percent of total spending in FY 2007 to 44 percent in FY 2017.

According to ONDCP’s National Drug Control Budget Fiscal Year 2018 Highlights, the proposed budget supports $1.3 billion in investments authorized by the Comprehensive Addiction and Recovery Act (CARA), the 21st Century Cures Act, and other opioid-specific programs to help address the opioid epidemic, including funding prevention and treatment efforts. Allocated funding for treatment increased in FY 2017 to approximately $10.6 billion, a 7.5 percent increase over FY 2016. Funding for prevention increased slightly in FY 2017 to about $1.5 billion, a 1.4 percent increase from FY 2016.

According to its FY 2018 Budget Highlights document, ONDCP considers three main functions to address the drug supply: Domestic Law Enforcement, Interdiction, and International. For Domestic Law Enforcement, ONDCP noted that federal, state, local, and tribal law enforcement agencies play a key role in the Administration’s approach to reduce drug use and its associated consequences. ONDCP also stated that interagency drug task forces, such as the HIDTA program, are critical to leveraging limited resources among agencies. Allocated funding for domestic law enforcement in FY 2017 is approximately $9.3 billion, which is similar to its FY 2016 spending level.

According to ONDCP, the United States continues to face a serious challenge from the large-scale smuggling of drugs from abroad which are distributed to every region in the nation. Interdiction funds support collaborative activities between federal law enforcement agencies, the military, the intelligence community, and international allies to interdict or disrupt shipments of illegal drugs, their precursors, and their illicit proceeds. Allocated funding in support of Interdiction for FY 2017 is approximately $4.6 billion, a decrease of 3.5 percent from FY 2016.

International functions place focus on collaborative efforts between the U.S. government and its international partners around the globe. According to ONDCP, illicit drug production and trafficking generate huge profits and are responsible for the establishment of criminal networks that are powerful, corrosive forces that destroy the lives of individuals, tear at the social fabric, and weaken the rule of law in affected countries. In FY 2017, approximately $1.5 billion was allocated to international functions, which is similar to its FY 2016 spending level.

The Federal Government Has Made Mixed Progress But Has Not Fully Achieved the Overall 2010 Strategy Goals

As we previously have stated, the 2010 National Drug Control Strategy was the inaugural strategy guiding drug policy under the previous 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— approaches to prevention or treatments that are based in theory and have undergone scientific evaluation. 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 overall sub goals under them that delineate specific quantitative outcomes to be achieved by 2015, such as reducing drug- induced deaths by 15 percent. To support the achievement of these two policy goals and seven sub goals (collectively referred to as overall goals), the Strategy included seven strategic objectives and multiple action items under each objective, with lead and participating agencies designated for each action item. Strategy objectives include, for example, “Strengthen Efforts to Prevent Drug Use in Communities” and “Disrupt Domestic Drug Trafficking and Production.” Subsequent annual Strategies provided updates on the implementation of action items, included new action items intended to help address emerging drug- related problems, and highlighted initiatives and efforts that support the Strategy’s objectives.

In March 2013, we reported that ONDCP and the federal agencies lacked progress on achieving the Strategy goals and were in the process of implementing a new mechanism to monitor progress. As we reported in May 2016, ONDCP and the federal agencies had made moderate progress toward achieving one goal, limited progress on three goals, and no demonstrated progress on the remaining three goals. For example, we reported that the rate of drug use for young adults aged 18 to 25 had increased since 2009, moving in the opposite direction of the goal. However, we also reported that HIV infections attributable to drug use, one of the strategy’s sub-measures, had decreased from 2009 to 2014 and had exceeded the strategy’s established target. In many instances, the data used to assess progress, while the most up to date at the time, were several years old. Based on the most recent data available, although some of the sub-measures, such as decreasing tobacco use by eighth graders, were achieved, none of the seven overall goals in the Strategy have been fully achieved as of July 2017. Table 1 shows the 2010 Strategy goals and progress toward meeting them as of July 2017.

Federal drug control agencies made mixed progress but did not fully achieve any of the four overall Strategy goals associated with curtailing illicit drug consumption. For example:

Progress was made on the goal to decrease the 30-day prevalence of drug use among 12- to 17-year-olds by 15 percent. The data source for this measure— SAMHSA’s National Survey on Drug Use and Health (NSDUH)— indicated that in 2015, 8.8 percent of 12- to 17- year-olds reported having used illicit drugs in the past month.

Progress was not made on the goal to decrease the 30-day prevalence of drug use among young adults aged 18 to 25 by 10 percent. Specifically, the reported rate of drug use for young adults was 21.4 percent in 2009 and 22.3 percent in 2015, moving in the opposite direction of the goal. Marijuana remained the drug used by the highest percentage of young adults. According to the 2015 NSDUH, 19.8 percent of young adults reported having used marijuana in the past month. The rates of reported marijuana use for this measure increased by 9 percent from 2009 to 2015.

Progress was also mixed on the remaining three overall Strategy goals associated with reducing the consequences of drug use. For example:

Progress was not made on the goal to reduce drug-induced deaths by 15 percent. According to the CDC’s National Vital Statistics System, which collects information on all deaths in the United States, 55,403 deaths were from drug-induced causes in 2015, an increase of 41.5 percent compared to 2009 and 66.5 percent more than the 2015 goal. The CDC’s December 30, 2016 Morbidity and Mortality Weekly Report stated that 52,404 of these deaths were from drug overdoses, the majority of which (63 percent) involved opioids.

The goal to reduce drug-related morbidity by 15 percent has two sub- measures, and progress had been made on one but not the other. Specifically, HIV infections attributable to drug use decreased by 29 percent from 2010 to 2015, exceeding the established target. However, the number of emergency room visits for substance use disorders increased by 19 percent from 2009 to 2011. The data source for this measure— SAMHSA’s Drug Abuse Warning Network—indicated that pharmaceuticals alone were involved in 34 percent of these visits and illicit drugs alone were involved in 27 percent of them. According to the 2013 Drug Abuse Warning Network report, the increase in emergency room visits for drug misuse and abuse from 2009 to 2011 was largely driven by a 38 percent increase in visits involving illicit drugs only.

Themes from a Comptroller General Forum on Preventing Illicit Drug Use

To advance the national dialogue on preventing illicit drug use, including preventing individuals from using illicit drugs for the first time, we convened and moderated a diverse panel of health care, education, and law enforcement experts, including from ONDCP, on June 22, 2016. The panel focused on (1) common factors related to illicit drug use; (2) strategies in the education, health care, and law enforcement sectors to prevent illicit drug use; and (3) high priority areas for future action to prevent illicit drug use, and our November 2016 report summarized the themes from the forum.

Forum participants identified a number of common factors related to illicit drug use. For example, the participants agreed that first time illicit drug use typically starts in adolescence and typically involves marijuana, however, prescription pain relievers are increasingly a pathway to illicit drug use. Other common factors include: a family history of substance abuse, conflict within the family, and the early onset of anxiety disorders or substance use, among others.

Forum participants also noted several strategies available in the education, health care, and law enforcement sectors for preventing illicit drug use:

Education. Forum participants championed the use of school-or community-based prevention programs that research has shown to be successful in preventing illicit drug use and other behaviors. These programs include: Life Skills, Strengthening Families Program: For Parents and Youth 10-14, and Communities That Care. These programs focus generally on combatting a range of risky behaviors, giving participants skills to recognize and manage their emotions, and strengthening family and community ties.

Health care. Forum participants identified and discussed three principle health care strategies for preventing illicit drug use: (1) having providers adhere to the CDC’s guideline for prescribing opioids for chronic pain, (2) having providers use prescription drug monitoring programs (PDMP)—state-run electronic databases used to track the prescribing and dispensing of prescriptions for controlled substances—and (3) having primary care providers screen and intervene with patients at risk for illicit drug use.

Law Enforcement. Forum participants identified four law enforcement strategies for preventing illicit drug use: (1) enforcing laws prohibiting underage consumption of alcohol and tobacco, (2) building trust between law enforcement and local communities, (3) using peers to promote drug-free lifestyles, and (4) closing prescription drug “pill mills” — medical practices that prescribe controlled substances without a legitimate medical purpose—and other efforts to reduce the supply of illicit drugs.

Forum participants also identified several high priority areas for future action to help prevent illicit drug use, including the misuse of prescription drugs. Some examples include: supporting community coalitions comprising the health care, education, and law enforcement sectors that work in concert to prevent illicit drug use at the local level; consolidating federal funding streams for multiple prevention programs into a single fund used to address the risk factors for a range of unhealthy behaviors, including illicit drug use; increasing the use of prevention programs that research has shown to be effective, such as those that are well-designed and deliver persuasive drug prevention messages on a regular basis; identifying and pursuing ways to change perceptions of substance abuse disorders and illicit drug use, such as emphasizing that a substance abuse disorder is a disease of the brain and can be treated like other diseases; supporting drug prevention efforts in primary care settings, such as exploring ways to reimburse providers for conducting preventative drug screenings; and reducing the number of prescriptions issued for opioids.

Agencies Have Strengthened Collaboration of Drug- Free Communities Support Program but Could Enhance Grantee Compliance and Performance Monitoring

In February 2017, we issued a report on the Drug-Free Communities Support Program (DFC)—a program that ONDCP and SAMHSA jointly manage. This program aims to support drug abuse prevention efforts that engage schools, law enforcement, and other sectors of a community to target reductions in the use of alcohol, tobacco, marijuana, and the illicit use of prescription drugs. We examined the extent to which the two agencies (1) use leading processes to coordinate program administration and the types of activities funded, and (2) have operating procedures that ensure DFC grantee compliance and provide a basis for performance monitoring.

In 2008 we had previously reported that ONDCP and SAMHSA needed to establish stronger internal controls and had not fully defined each agency’s roles and responsibilities for the management of the DFC program. In our February 2017 report, we found that ONDCP and SAMHSA had improved their joint management of the program. Specifically, we found that ONDCP and SAMHSA employed leading collaboration practices to administer the DFC program and fund a range of drug prevention activities. For example, ONDCP and SAMHSA had defined and agreed upon common outcomes, such as prioritizing efforts to increase participation from under-represented communities. The two agencies also had funded a range of DFC grantees’ activities and report on these activities in their annual evaluation reports. For example, ONDCP reported that from February through July 2014, grantees educated more than 156,000 youth on topics related to the consequences of substance abuse. Other examples of grantees’ efforts included those that enhanced the skill sets of community members, including parents, to identify drug abuse or limit access to prescription drugs and those that reduced language barriers precluding non-English speakers from understanding drug prevention campaigns.

We also found that ONDCP and SAMHSA had operating procedures in place, but SAMHSA did not consistently follow documentation and reporting procedures to ensure grantees’ compliance and had not accurately reported to ONDCP on grantee compliance. Based on a file review we conducted, we found that SAMHSA followed all processes for ensuring that the grant applicants whose files we reviewed had submitted required documentation before SAMHSA awarded them initial grant funding. However, SAMHSA was less consistent in adhering to procedures for confirming documentation in later years of the program. We found that the majority of grantees whose files we reviewed were missing required paperwork to document how they planned to sustain their programs after grant funds expired. Prior to our review, ONDCP and SAMHSA officials were not aware of the missing data in the grant files. We concluded that without close adherence to existing procedures, and a mechanism to ensure that the documentation it reports to ONDCP is accurate and complete, SAMHSA’s performance monitoring capacity was limited. Moreover, SAMHSA could not be certain that grantees were engaging in intended activities and meeting their long-term program goals.

We made recommendations that SAMHSA develop an action plan to strengthen the agency’s grant monitoring process and ensure ONDCP gets complete and accurate information, among other things. SAMHSA concurred with our recommendations and reported to us in April 2017 that it is implementing actions to address our recommendations that should be completed by this fall.

Chairman Gowdy, Ranking Member Cummings, and Committee members, this concludes my prepared statement. I would be happy to respond to any questions you may have.

GAO Contact and Staff Acknowledgements

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