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 National Drug Control 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—approaches to prevention or treatments that are based in theory and have undergone scientific evaluation. Drug abuse prevention includes activities focused on discouraging the first-time use of controlled substances and efforts to encourage those who have begun to use illicit drugs to cease their use. Treatment includes activities focused on assisting regular users of controlled substances to become drug free through such means as counseling services, inpatient and outpatient care, and the demonstration and provision of effective treatment methods. 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. To support the achievement of these two policy goals and seven subgoals (collectively referred to as 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. 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 Drug Control Budget for implementing the strategy. National Drug Control Program agencies follow a detailed process in developing their annual budget submissions for inclusion in the Drug Control 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 contains 38 federal agencies or programs. There are five priorities for which resources are requested across agencies: substance abuse prevention and substance abuse treatment (both of which are considered demand-reduction areas), and drug interdiction, domestic law enforcement, and international partnerships (the three of 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. ONDCP previously managed the National Youth Anti-Drug Media Campaign which last received appropriations in fiscal year 2011. In the 2010 National Drug Control Strategy, ONDCP established seven goals related to reducing illicit drug use and its consequences to be achieved by 2015. As of May 2016, our analysis indicates that ONDCP and federal agencies have made moderate progress toward achieving one goal, limited progress on three goals, and no demonstrated progress on the remaining three goals. ONDCP officials stated that they intend to report on updated progress toward meeting the strategic goals in summer 2016. As of May 2016, overall, none of the goals in the Strategy have been fully achieved. Table 1 shows the 2010 Strategy goals and progress toward meeting them. ONDCP and federal drug control agencies have made mixed progress but have not fully achieved any of the four Strategy goals associated with curtailing illicit drug consumption. For example, progress has been 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)— indicates that in 2014, 9.4 percent of 12- to 17-year-olds reported having used illicit drugs in the past month. This represents a 7 percent decrease from the 2009 baseline for this measure. However, progress has not been 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 rate of drug use for young adults increased from 21.4 percent in 2009 to 22 percent in 2014, moving in the opposite direction of the goal. This increase was primarily driven by marijuana use. According to the 2014 NSDUH, 19.6 percent of young adults reported having used marijuana in the past month and 6.4 percent reported having used illicit drugs other than marijuana. The rates of reported marijuana use for this measure increased by 8 percent from 2009 to 2014 while the rates of reported use of illicit drugs other than marijuana decreased by 24 percent. Progress has also been mixed on the remaining three Strategy goals associated with reducing the consequences of drug use. For example, the goal to reduce drug-related morbidity by 15 percent has two measures, and progress has been made on one but not the other. Specifically, HIV infections attributable to drug use decreased by 34 percent from 2009 to 2014, 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—indicates 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. In addition, progress has not been made on the goal to reduce drug-induced deaths by 15 percent. According to the CDC’s National Vital Statistics System, 49,714 deaths were from drug-induced causes in 2014, an increase of 27 percent compared to 2009. This represents a significant departure from the 2015 goal. The CDC’s January 2016 Morbidity and Mortality Weekly Report stated that 47,055 of these deaths were from drug overdoses, the majority of which (61 percent) involved opioids. In March 2013, we reported that ONDCP established the Performance Reporting System (PRS) to monitor and assess progress toward meeting Strategy goals and objectives and issued a report describing the system with its 2012 Strategy. The PRS includes interagency performance measures and targets under each of the Strategy’s seven objectives, which collectively support the overarching goals discussed above. For example, one of the six performance measures under the Strategy’s first objective—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. These PRS measures were established to help assess progress towards each objective. According to ONDCP, they are a tool to help indicate where the Strategy is on track, and when and where further attention, assessment, evaluation, and problem‐solving are needed. As part of our review for our March 2013 report, we assessed the PRS measures for the Strategy’s seven objectives 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 results and are useful for decision making. For example, we found that the PRS measures for the objectives were clearly stated, with descriptions included in the 2012 PRS report, and all 26 of them had or were to have measurable numerical targets. In addition, the measures were developed with input from stakeholders through an interagency working group process, which included participation by the Departments of Education, Justice, and Health and Human Services, among others. The groups assessed the validity of the measures and evaluated data sources, among other things. At the time of our review, the PRS was in its early stages and ONDCP had not issued its first report on the results of the system’s performance measures. ONDCP released its most recent annual PRS report in November 2015. The 2015 report assesses progress on the Strategy’s goals and the 28 performance measures and submeasures related to each of the Strategy’s seven objectives, which support the achievement of the goals. For each objective, the report classifies results on performance measures into five categories and identifies areas of progress on and challenges with achieving objectives. For example: Objective 1—Strengthen Efforts to Prevent Drug Use in Our Communities. The report indicates that sufficient progress has been made on reducing the average age of initiation for all illicit drugs to enable meeting the 2015 target. However, it notes that accelerated effort is needed to prevent youth marijuana use and counter youth perceptions that marijuana (including synthetic marijuana) use is not harmful. The report shows that the percent of respondents aged 12 to 17 who perceive a great risk in smoking marijuana once or twice a week decreased from 2009 to 2013, moving in the opposite direction of the 2015 target. Objective 3—Integrate Treatment for Substance Use Disorders into Health Care and Expand Support for Recovery. The report shows that the percent of treatment facilities offering at least four specified recovery support services, such as child care, employment assistance, and housing assistance, increased from 2008 to 2013 and exceeded the 2015 target. However, the report states that challenges persist in the integration of substance abuse treatment services into mainstream health care. For instance, the percent of the Health Resources and Services Administration’s Health Center Program grantees providing substance use counseling and treatment services decreased from 2009 to 2013. According to the report, implementation of the Affordable Care Act presents opportunities to provide greater access to treatment for substance use disorders by, for example, efficiently integrating such treatment into the health care system and providing non-discrimination for coverage for preexisting conditions. Objective 5—Disrupt Domestic Drug Trafficking and Production. According to the report, progress is being achieved in domestic law enforcement and efforts to disrupt or dismantle domestic drug trafficking organizations. The 2015 targets for both measures related to these efforts have been exceeded. The report also indicates that progress has been made on reducing the number of methamphetamine lab seizure incidents (a proxy for lab activity) from 2009 to 2013 but accelerated progress is needed to meet the 2015 target. Objective 6—Strengthen International Partnerships and Reduce the Availability of Foreign Produced Drugs in the United States. According to the report, key source and transit countries continue to demonstrate increased commitment to reducing drug trafficking and use through demand and supply reduction efforts. The targets for the two measures related to such commitments have both been met. However, the report states that accelerated progress is needed in working with partner countries to reduce the cultivation of drugs and their production potential in Afghanistan, Burma, Laos, Mexico, and Peru. See attachment I for performance measures under each Strategy objective, progress toward 2015 targets, and ONDCP’s assessment categorizations. ONDCP officials stated that actions taken in response to PRS results include Department of Education grants for school-based prevention activities to help educate students on the risks of using marijuana and increased funding to expand access to treatment to help address the rise in drug-induced deaths from opioid use, as discussed below. According to ONDCP, federal drug control spending increased from $21.7 billion in FY 2007 to approximately $30.6 billion that was allocated for drug control programs in FY 2016 as shown in figure 2. Though, total federal drug control spending increased from FY 2007 through FY 2016, spending on supply reduction programs, such as domestic law enforcement, interdiction, and international programs remained relatively constant at $13.3 billion in FY 2007 and $15.8 billion in FY 2016. However, federal spending for demand programs—treatment and prevention steadily increased from FY 2007 through FY 2016 and spending in these two programs went from $8.4 billion in FY 2007 to $14.7 billion in FY 2016. As a result, the proportion of funds spent on demand programs increased from 39 percent of total spending in FY 2007 to 48 percent in FY 2016. According to ONDCP’s Fiscal Year 2016 Budget and Performance Summary, ONDCP has prioritized treatment and recovery support services stating that they are essential elements of the Strategy’s efforts to support long-term recovery among people with substance use disorders. Allocated funding for treatment increased in FY 2016 to approximately $13 billion, a 5 percent increase over FY 2015. These funds are used for early intervention programs, treatment programs, and recovery services. For example, according to ONDCP, approximately $8.8 billion was the amount estimated for benefit outlays by the Department of Health and Human Services’ (HHS) Centers for Medicare and Medicaid Services for substance use disorder treatment in both inpatient and outpatient settings for FY 2016. ONDCP also stated that preventing drug use before it starts is a fundamental element of the Strategy. Funding for prevention increased in FY 2016 to about $1.5 billion, a 10 percent increase from FY 2015, as shown in figure 3. Funding for treatment also increased from $12.5 billion in FY 2015 to $13.2 billion in FY 2016 in allocated funding. Figure 3 shows the increase in treatment and prevention spending for fiscal years 2007 through 2016. Additionally, in FY 2017, HHS’ Substance Abuse and Mental Health Services Administration (SAMHSA) requested $460 million for a new program (State Targeted Response Cooperative Agreements) to help expand access to treatment for opioid use disorders, as well as $15 million for evaluating the effectiveness of medication-assisted treatment programs to improve service delivery and decrease the incident of opioid- related overdose and death (Cohort Monitoring and Evaluation of Medication Assisted Treatment Outcomes). These programs could result in increasing SAMHSA’s budget request for treatment programs to approximately $3 billion in FY 2017 from $2.5 billion enacted in FY 2016. Addressing the drug supply is categorized by three main functions, which are 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 associate consequences. ONDCP also stated that interagency drug task forces, such as the High Intensity Drug Trafficking Areas (HIDTA) program, are critical to leveraging limited resources among agencies. Allocated funding for domestic law enforcement in FY 2016 is approximately $9.7 billion, a 4 percent increase from FY 2015 funding. Regarding Interdiction, 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. These 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 2016 is approximately $4.5 billion, an increase of 12 percent from FY 2015. 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 2016, approximately $1.6 billion was enacted, a 0.4 percent decrease from FY 2015. Figure 4 shows federal drug spending for Domestic Law Enforcement, Interdiction, and International activities. In addition to advising the President on drug-control issues and coordinating drug-control activities and related funding across the Federal government, ONDCP also directly oversees two drug-related functions for which it receives federal drug control funding —HITDAs and other federal drug control programs, such as the Drug Free Community (DFC) coalition grant program. Based on ONDCP’s spending in FY 2012 through its allocated funding in FY 2016 for these two functions, ONDCP’s drug- related spending account for 1 percent of the total federal drug control spending in the federal government. ONDCP’s requested funding for FY 2017 is 1 percent of the total federal drug control request. See figure 5 for allocated percentages. Chairman Johnson, Ranking Member Carper, and Committee members, this concludes my prepared statement. I would be happy to respond to any questions you may have. If you or your staff members have any questions about this testimony, please contact Diana Maurer at (202) 512-8777 or maurerd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this statement. Other contributors included Kevin Heinz, Assistant Director, Aditi Archer, Lyle Brittan, Eric Hauswirth, Justin Snover, and Johanna Wong. Attachment I: ONDCP 2015 Performance Reporting System Report—Performance Measures for Strategy Objectives, Progress toward 2015 Targets, and Assessment Categorizations Measure Objective 1—Strengthen Efforts to Prevent Drug Use in Our Communities Measure 1.1: Percent of respondents, ages 12–17, who perceive a great risk in smoking marijuana once or twice a week. 49.0 percent (2009) 39.5 percent (2013) Measure 1.2: Percent of respondents, ages 12–17, who perceive a great risk in consumption of one or more packs of cigarettes per day 65.5 percent (2009) 64.3 percent (2013) Measure 1.3: Percent of respondents ,ages 12–17, who perceive a great risk in consuming four or five drinks once or twice a week 39.6 percent (2009) 39.0 percent (2013) Measure 1.4: Average age of initiation for all illicit drugs 17.6 years (2009) 19.0 (2013) Measure 1.5: Average age of initiation for alcohol use 16.9 years (2009) 17.3 (2013) Measure 1.6: Average age of initiation for tobacco use 17.5 years (2009) 17.8 (2013) Progressing, accelerated progress required to meet 2015 target 20.7 years (2009) 21.6 (2013) Target met or exceeded, progress should be maintained through 2015 18.9 years (2009) 18.4 (2013) Objective 2—Seek Early Intervention Opportunities in Health Care Measure 2.1: Percent of Health Center Program grantees providing SBIRT services 10.3 percent (2009) 16.9 percent (2013) Measure 2.2: Percent of respondents in the past year using prescription-type drugs non- medically, age 12–17 7.7 percent (2009) 5.8 percent (2013) Measure 2.3: Percent of respondents in the past year using prescription-type drugs non- medically, age 18–25 15 percent (2009) 12.2 percent (2013) Measure 2.4: Percent of respondents in the past year using prescription-type drugs non- medically, age 26+ Objective 3—Integrate Treatment for Substance Use Disorders into Health Care and Expand Support for Recovery Measure 3.1: Percent of treatment plans completed 2015 target 4.7 percent (2009) 4.8 percent (2013) 4.0 percent No progress to date, accelerated progress required to meet 2015 target 45.1 percent (2007) 43.7 percent (2011) Baseline 21.6 percent (2009) Progress to date 20.0 percent (2013) Measure 3.3: Percent of treatment facilities offering at least 4 of the standard spectrum of recovery services (child care, transportation assistance, employment assistance, housing assistance, discharge planning, and after- care counseling) Objective 4—Break the Cycle of Drug Use, Crime, Delinquency, and Incarceration Measure 4.1: Percent of residential facilities in the juvenile justice system offering substance abuse treatment 35.5 percent (2008) 41.0 percent (2013) 39.0 percent Target met or exceeded, progress should be maintained through 2015 38.8 percent (2008) 45.3 percent (2012) Measure 4.2: Percent of treatment plans completed by those referred by the criminal justice system 48.8 percent (2007) 47.5 percent (2011) Objective 5—Disrupt Domestic Drug Trafficking and Production Measure 5.1: Number of domestic Consolidated Priority Organization Targets linked organizations disrupted or dismantled* 296 (2009) 473 (2013) Measure 5.2: Number of Regional Priority Organization Targets linked organizations disrupted or dismantled 119 (2009) 153 (2014) Target met or exceeded, progress should be maintained through 2015 Measure 5.3: Methamphetamine lab activity (as measured by number of methamphetamine lab seizure incidents) Objective 6—Strengthen International Partnerships and Reduce the Availability of Foreign Produced Drugs in the United States Measure 6.1: Percent of selected countries that increased their commitment to supply reduction 12,852 (2009) 11,329 (2013) Progressing, accelerated progress required to meet 2015 target 2009 or earliest available [Baseline not provided in PRS report] 100 percent (progress to date) Measure 6.2: Percent of selected countries that increased their commitment to demand reduction 2009 [Baseline not provided in PRS report] 100 percent (progress to date) Measure 6.3: Percent of selected countries showing progress since 2009 in reducing either cultivation or drug production potential 2009 [Baseline not provided in PRS report] 29 percent (progress to date) Baseline 65 (2009) Progress to date 72 (2014) Measure 7.1: Increase timeliness (year‐end to date‐of‐release) of select Federal data sets Objective 7—Improve Information Systems for Analysis, Assessment, and Local Management 17.5 Months 23.5 (2011) Measure 7.2: Increase the utilization (number of annual web hits, or number of documents referencing the source) of select Federal data sets by 10percent from the baseline Substance Abuse and Mental Health Data Archive (SAMHDA) National Survey of Drug Use and Health (NSDUH) (Journal articles referencing NSDUH) 113 (2014) Measure 7.3: Increase Federal data sets that establish feedback mechanisms to measure usefulness (surveys, focus groups, etc.)— SAMHSA Funded Data Sets 1 (progress to date) Target met or exceeded, progress should be 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Summary: Policymakers, health care providers, and the public are concerned about the nation's current drug epidemic and its effects, as drug overdose deaths surpassed auto accidents as the leading cause of death or injury in recent years. To help address national drug control policy efforts, ONDCP coordinates and oversees implementation of a National Drug Control Strategy to reduce illicit drug use, among other things. This statement addresses (1) what progress has been made toward achieving National Drug Control Strategy goals and how ONDCP monitors progress and (2) trends in federal drug control spending. This statement is based upon findings GAO reported in March 2013 and December 2015, analysis of ONDCP's Budget and Performance Summaries and selected updates in 2016. For the updates, GAO analyzed publically available data sources that ONDCP uses to assess progress on Strategy goals, reviewed ONDCP Performance Reporting System reports, and interviewed ONDCP officials. The Office of National Drug Control Policy (ONDCP) and federal agencies have made mixed progress toward achieving the goals articulated in the 2010 National Drug Control Strategy (Strategy) and ONDCP has established a mechanism to monitor and assess progress. In the Strategy, ONDCP established seven goals related to reducing illicit drug use and its consequences by 2015. As of May 2016, our analysis indicates that ONDCP and federal agencies have made moderate progress toward achieving one goal, limited progress on three goals, and no progress on the three other three goals. Overall, none of the goals in the Strategy have been fully achieved. In March 2013, GAO reported that ONDCP established the Performance Reporting System to monitor and assess progress toward meeting Strategy goals and objectives. GAO reported that the system's 26 new performance measures were generally consistent with attributes of effective performance management. A 2015 ONDCP report on progress towards these measures similarly identified some progress towards overall achievements—some of the measures had met or exceeded targets, some had significant progress underway, and some had limited or no progress. Federal drug control spending increased from $21.7 billion in fiscal year (FY) 2007 to approximately $30.6 billion in allocated funding in FY 2016 as shown in figure 1. Although total federal drug control spending increased from FY 2007 through FY 2016, spending on supply reduction programs, such as domestic law enforcement, interdiction, and international programs remained relatively constant at $13.3 billion in FY 2007 and $15.8 billion allocated in FY 2016. However, federal spending for—treatment and prevention has steadily increased from FY 2007 through FY 2016 and spending in these two programs went from $8.4 billion in FY 2007 to $14.7 billion allocated in FY 2016. GAO made a prior recommendation to ONDCP to assess overlap in drug prevention and treatment programs. ONDCP concurred and has implemented it. GAO is not making new recommendations in this testimony.