The federal government uses grants to address national priorities—such as substance use prevention, treatment, and recovery—through nonfederal parties, including state and local governments, federally recognized tribes, educational institutions, and nonprofit organizations. While there is variation among different grant program goals and grant types, most federal grants follow a common life cycle that includes an award, implementation, and closeout stage for administering the grants. During the award stage, the federal awarding agency enters into an agreement with the grantee stipulating the terms and conditions for the use of grant funds including the period that funds are available for the grantee’s use. During the implementation stage, the grantee carries out the requirements of the agreement and requests payments, while the awarding agency monitors the grantee and approves or denies payments. The grantee and the awarding agency close the grant once the grantee has completed all the work associated with a grant agreement, the grant period of performance end date (or grant expiration date) has arrived, or both. Federal grant programs may fund various types of grants, including discretionary grants, formula grants, and cooperative agreements. Discretionary grants are generally awarded on a competitive basis for specified projects that meet eligibility and program requirements. Formula grants are noncompetitive awards based on a predetermined formula, typically established in statute, and are provided to eligible applicants that meet specified criteria outlined by statute or regulation, such as a state. A cooperative agreement is a type of federal financial assistance similar to a grant, except the federal government is more substantially involved with the implementation. Substance use prevention programs and services (which we refer to collectively as “prevention services” in this report) are designed to prevent or delay the early use of substances and stop the progression from use to problematic use or to a substance use disorder. Prevention services generally focus on reducing a variety of risk factors and promoting a broad range of protective factors through various activities that include, for example, setting policies that reduce the availability of substances in a community, teaching adolescents how to resist negative social influences, and communicating the harms of substances such as the nonmedical use of prescription opioids and marijuana through media campaigns. In addition, prevention services can be targeted at all members of a given population without regard for risk factors, such as all adolescents, or to particular subgroups of individuals or families, such as those who are at increased risk of substance use due to their exposure to risk factors. Targeted audiences for such services may include families living in poverty or children of substance-using parents. When substance use progresses to a point that it is clinically diagnosed as causing significant impairments in health and social functioning, it is characterized as a substance use disorder. Treatment services for substance use disorders are designed to enable an individual to reduce or discontinue substance use and to address health problems, and typically include behavioral therapy. Behavioral therapies use various techniques to modify an individual’s behaviors and improve coping skills, such as incentives and reinforcements to reward individuals who reduce their substance use. For opioid use disorders, treatment may involve combining behavioral therapy with medications—an approach commonly referred to as medication-assisted treatment. Some of these treatment services may be paid for by private insurers, public health coverage programs, nonprofit organizations, or consumers (out-of-pocket), but federal grant programs and various state and local programs also provide funding for these services. Substance use recovery services are designed to help engage and support individuals with substance use disorders in treatment and provide ongoing support after treatment. There are a variety of recovery services such as peer recovery coaching, which involves the use of coaches— peers who identify as being in recovery and use their knowledge and experience to inform their work—to help individuals who are transitioning out of treatment to connect with community services and address barriers that may hinder the recovery process. Other examples include recovery housing, which provides a substance-free environment and support from fellow recovering residents, and recovery high schools, which help students recovering from substance use disorders focus on academic learning. Some recovery services may be paid for through various sources, including Medicaid programs in certain states, some private insurers, and federal grant programs. In addition, some recovery services may be offered by member-led, voluntary associations that charge no fees, such as 12-step groups. We identified 12 federal grant programs within three of the four agencies in our review that funded substance use prevention, treatment, and recovery services in fiscal year 2017 and targeted adolescents’ and young adults’ use of illicit substances. Eight of these programs focused on prevention, and all 8 remain active in fiscal year 2018. The 8 grant programs have varying purposes and were administered by two entities within HHS—SAMHSA or IHS—or by ONDCP. For example, the Drug- Free Communities Support Program is funded and directed by ONDCP to support community coalitions in preventing and reducing substance abuse among youth aged 18 and younger. As another example, the Strategic Prevention Framework for Prescription Drugs program, administered by SAMHSA, is designed to raise awareness about the dangers of sharing prescription medications such as opioids, and to promote collaboration between states and pharmaceutical and medical communities to understand the risks of overprescribing to youth (aged 12 to 17) and adults (aged 18 and older). In addition, this program is intended to provide prevention activities and education to schools, communities, and parents. In total, the 8 grant programs targeting the prevention of substance use among adolescents and young adults had 1,146 active grantees in fiscal year 2017. The Drug-Free Communities Support Program had the largest number of active grantees—713 community coalitions—and the other 7 programs had a combined total of 434 that included states and federally recognized tribes. The total number of active grantees in fiscal year 2017 includes those that received a single- or multi-year award in fiscal year 2017, as well as those that received a multi-year award in fiscal year 2016 for a project that was ongoing in fiscal year 2017. Grantees were awarded a total amount of about $266 million in fiscal year 2017, with SAMHSA’s Strategic Prevention Framework-Partnerships for Success program providing the largest amount of funding (about $95 million). (See table 1.) All 8 prevention grant programs had ongoing or planned evaluations to assess the effectiveness of their grantees in accomplishing a variety of program goals, according to agency officials. For example, ONDCP is overseeing the ongoing evaluation of the Drug-Free Communities Support Program through semi-annual progress reports and through the collection of data, such as data on past 30-day substance use, from coalitions that received awards. A recent evaluation of this program found that coalitions included about 19,000 community members who were targeting prevention services to about 20 percent of the population in the United States (including 2.5 million middle school and 3.5 million high school youth) in fiscal year 2015. In addition, this evaluation found that middle and high school youth in communities with a coalition reported a significant decrease in the past 30-day use of marijuana, prescription drugs, alcohol, and tobacco, from 2002 to 2016. However, at the same time, the perceptions of the risk of marijuana use decreased significantly among high school youth in communities with community coalitions, according to the evaluation. As another example, IHS’s planned evaluation of the Methamphetamine and Suicide Prevention Initiative- Generation Indigenous grant program will focus on measures such as the types of services that grantees implemented to prevent methamphetamine use and promote positive development among American Indian and Alaska Native youth, according to agency officials. For the other 6 prevention grant programs, planned evaluations will examine the extent to which reductions in substance use are observed over time among the grantees’ targeted adolescents or young adults. Of the 12 federal grant programs targeting adolescents’ and young adults’ use of illicit substances, we identified 4 that focused on the provision of substance use treatment and recovery services and had active grantees in fiscal year 2017. Two of the 4 programs ended at the close of fiscal year 2017 and the other 2 remained active in fiscal year 2018. The 4 programs had different purposes and were administered by OJJDP or SAMHSA, within DOJ and HHS, respectively. For example, the Cooperative Agreements for Adolescent and Transitional Aged Youth Treatment Implementation, administered by SAMHSA, is still active, and intends to increase the capacity of states to provide treatment and recovery services to adolescents (aged 12 to 18) and transitional-aged youth (aged 16 to 25) that have substance use disorders or co-occurring substance use disorders and mental disorders. This program aims to increase states’ capacity by increasing the number of qualified treatment providers. The other 3 grant programs were designed to improve different aspects of the existing juvenile drug treatment courts, which DOJ defines as a court calendar or docket that provides specialized treatment and services for youth with substance use or co-occurring mental health disorders. As an example, the Fiscal Year 2017 Juvenile Drug Treatment Court Program, which is still active and administered by OJJDP, aims to deliver services that are consistent with DOJ’s Juvenile Drug Treatment Court Guidelines—a set of best practices for effective juvenile drug treatment courts. In total, the 4 grant programs that targeted substance use treatment and recovery services among adolescents and young adults had 57 active grantees in fiscal year 2017. SAMHSA’s Cooperative Agreements for Adolescent and Transitional Aged Youth Treatment Implementation had the largest number of active grantees (36), which included state substance abuse agencies and federally recognized tribes. The three juvenile drug treatment court programs had a total of 21 active grantees that included, for example, county juvenile drug treatment courts and a state judicial department. The total number of active grantees in fiscal year 2017 included those that received a single- or multi-year award in fiscal year 2017 as well as active grantees that received multi-year awards in prior years. In total, active grantees from 2 of the 4 programs were awarded about $23 million in fiscal year 2017. (See table 2.) Two of the 4 treatment and recovery grant programs had ongoing or planned evaluations to assess the effectiveness of their grantees in accomplishing a variety of program goals, according to agency officials. SAMHSA officials told us that its ongoing evaluation of the Cooperative Agreements for Adolescent and Transitional Aged Youth Treatment Implementation is assessing the types of treatment services provided to adolescents and young adults as well as the extent to which they abstained from substance use. Officials added that the evaluation is examining grantees’ efforts to expand the qualified workforce of treatment providers for adolescents and young adults. A recent evaluation that was completed for this program found that most grantees provided training to treatment providers on evidence-based treatment services and other topics, and about one-third of grantees identified additional training needs such as training on co-occurring disorders and trauma-informed services. This evaluation also found a decrease in substance use among adolescents and young adults who received treatment services after 6 months and that enhanced provider training was associated with this decrease. OJJDP’s Fiscal Year 2017 Juvenile Drug Treatment Court Program includes a planned evaluation of the impact of the DOJ juvenile drug treatment court guidelines on participant outcomes. That is, OJJDP plans to compare the outcomes of participants in courts aligned with the guidelines to participants in other court programs that will serve as “comparison courts.” OJJDP officials told us that the evaluation plans to assess youth outcomes such as recidivism in substance use, quality of relationships with parents and peers, and mental wellbeing. OJJDP officials stated that while they are not evaluating their fiscal year 2015 and 2014 juvenile drug treatment court grant programs, grantees must report on various performance measures related to substance use to assist DOJ with fulfilling its responsibilities under the Government Performance and Results Act of 1993 and the GPRA Modernization Act of 2010. For example, grantees must report on a semiannual basis the number of drug and alcohol tests performed on juveniles and the number of positive tests recorded. Other federal grant programs beyond the 12 we identified provide funds for substance use prevention, treatment, and recovery services across age groups but do not specifically target adolescents and young adults. The Substance Abuse Prevention and Treatment Block Grant is the largest of such grant programs that fund prevention, treatment, and recovery services across age groups. SAMHSA, which administers this grant, awarded a total of $1.8 billion in fiscal year 2017 to grantees which included states, the District of Columbia, territories, and one federally recognized tribe. The amount of awards that states receive is based on a formula that takes into account a grantee’s: population at risk of substance abuse; relative costs of providing prevention and treatment services; and relative ability to pay for prevention and treatment services. States have some flexibility in determining how to use their Substance Abuse Prevention and Treatment Block Grant funds, and our analysis shows variation in the extent to which grantees used these funds to provide prevention, treatment, and recovery services to adolescents and young adults in 2014, the most recent year for which data were available. For prevention services that target individuals, such as those delivered to middle school students in the classroom, the percentage of persons served that grantees could identify as being adolescents and young adults ranged from 0.1 percent (Oklahoma) to 100 percent (American Samoa and United States Virgin Islands). However, most of the grantees reported percentages that fell in the range of 23 to 61 percent. For prevention services that target populations rather than individuals, such as media campaigns, grantees similarly reported that the percentage of adolescents and young adults served ranged from 0.1 percent (Indiana) to 100 percent (United States Virgin Islands). However, most of the grantees reported percentages that fell in the range of 18 to 46 percent. For treatment and recovery services, grantees reported that the percentage of all persons served who were adolescents and young adults ranged from 8 percent (District of Columbia) to 100 percent (Red Lake Band of Chippewa Indians). However, most of the grantees reported percentages that fell in the range of 17 to 26 percent. (See app. I for the percentages of persons served that were adolescents and young adults, by grantee.) In addition to the Substance Abuse Prevention and Treatment Block Grant, other federal grant programs provide funds for prevention, treatment, and recovery services across age groups, but do not specifically target adolescents and young adults. For example, the State Targeted Response to the Opioid Crisis grant program, administered by SAMHSA, aims to help states and others reduce the number of opioid overdose related deaths by providing funds for prevention, treatment, and recovery services for opioid use disorders. In fiscal year 2017, SAMHSA awarded about $485 million in grants to 50 states, the District of Columbia, and 6 territories through this program. As another example, the Targeted Capacity Expansion: Medication Assisted Treatment – Prescription Drug and Opioid Addiction grant program, also administered by SAMHSA, provides funding to states to expand access to medication- assisted treatment services as well as recovery services among individuals with opioid use disorders. In fiscal year 2017 SAMHSA awarded $31 million in additional grants to 6 states through this program. Our analysis found that HHS’s NIDA had 186 active grant-funded research projects focused on illicit substance use prevention, treatment, or recovery among adolescents and young adults in October and November 2017, and most of these projects addressed substance use prevention. Specifically, 126 research projects, or about 68 percent of NIDA’s ongoing research projects for this population, involved research related to preventing the use of illicit substances, such as the use of marijuana or nonmedical use of opioids and other prescription drugs. The remaining 60 projects, or about 32 percent, involved research related to treatment for or recovery from the use of illicit substances among adolescents and young adults, or a combination of categories (e.g., substance use prevention, treatment, and recovery). Among the categories of research projects, the fewest involved research exclusively about recovery (4 out of 186 projects, or about 2 percent), as shown in table 3. Our analysis also found that about 12 percent of the ongoing projects (22 of 186) involved the use of brain imaging in research on prevention, treatment, or recovery. In total, of the 186 research projects that were active in October and November 2017, 135 received $61.3 million in grants from NIDA in fiscal year 2017. NIDA did not provide awards in fiscal year 2017 for the remaining 51 projects that were active in October and November 2017. The following examples illustrate the types of research activities funded by the prevention, treatment, and recovery grants identified in our review: Prevention research projects. One research project involved testing whether a parenting intervention is associated with lower substance use and other high-risk behaviors among adolescents in the long term, including how such outcomes relate to genetic risk factors. The project’s participants included 731 adolescents to be assessed over multiple years. The project planned to collect DNA; observations of family interaction; parent, youth, and teacher reports regarding adolescents’ conduct; and assessments of their peer environments. Treatment research projects. One research project involved testing the effectiveness of the use of the medication naltrexone (extended release), compared to the use of buprenorphine in treating adolescents and young adults with opioid use disorders. The project’s participants included 340 adolescents and young adults and the project planned to provide counseling to the participants during the course of the study. The project planned to assess a variety of outcomes after 3 and 6 months, including the number of days participants were in treatment, participants’ use of opioids as well as other drug and alcohol use, and the cost- effectiveness of the treatment. Recovery research projects. One research project involved testing the effectiveness of a smartphone application to deliver recovery services to adolescents after they received treatment for a substance use disorder, compared to a control group of adolescents that received recovery services via traditional methods. Examples of recovery services delivered with a smartphone application include participating in online recovery group discussions and receiving motivational messages. The project’s participants included 400 adolescents to be assessed over a 9-month period. The project planned to collect a variety of information, such as how frequently participants used the smartphone application, how long they abstained from substance use, and their quality of life. In fiscal year 2017, NIDA and nine other entities within HHS provided grant funding for a large study—the Adolescent Brain Cognitive Development study—designed to examine the effects of substance use and other factors on development of the adolescent brain. This study was established as a result of the collaboration of several federal agencies that determined such a study was needed because of gaps in knowledge about how substance use and other factors affect brain development. This study is a longitudinal study that plans to collect data from a sample of about 11,000 children across the country for 10 years, beginning when they are 9 or 10 years old. Twenty-one research sites across the country were selected to collect information from children about their brain development, genetics, substance use, mental health, physical health, environment, and other measures. In addition, this study is funding a data analysis and informatics center to develop the procedures for data collection, create and maintain a common database pooling data from all of the research sites, and conduct data analysis. According to NIDA officials, data from the Adolescent Brain Cognitive Development study will be made available to researchers for future use through a data archive. In fiscal year 2017, 15 federal grants provided funding for this study, of which NIDA contributed $18.1 million. Stakeholders that we interviewed identified various gaps in services, and among the most frequently cited were a lack of available recovery services and treatment providers for adolescents and young adults with substance use disorders. They also identified gaps in substance use prevention services such as a lack of prevention services tailored for certain subgroups within these ages. In general, officials from the agencies in our review agreed that these gaps exist, and described actions the agencies are taking that may help address them. Stakeholders that we interviewed commonly identified gaps in research concerning adolescent-specific substance use treatment approaches, as well as in recovery services for both adolescents and young adults. They also identified other gaps, such as a lack of knowledge about how to effectively communicate to adolescents and young adults the harms of substance use. Officials from HHS’s NIDA agreed that such gaps in research exist. Gaps in substance use research related to adolescents and young adults. Stakeholders commonly identified the following gaps in research: Substance use disorder treatment with adolescents. Four of the stakeholders we interviewed identified gaps in adolescent- specific substance use disorder treatment research. Officials from one research organization said that it can be challenging to recruit a sufficient number of adolescents with a substance use disorder to participate in research studies focused on substance use treatment, both because fewer adolescents have such disorders compared to adults, and because adolescents—or potentially their parents—may be in denial about the need for treatment. These officials further stated that having too few funding announcements that focus on adolescent-specific research contributes to the gaps in research in this area, because it is easier for researchers to simply work with adults when announcements do not specify an age group of interest. An official from another research organization said there is also a gap in knowledge about how to deliver treatment services to adolescents in ways that are developmentally appropriate. The official stated that adolescents who receive treatment services generally are less likely to complete substance use disorder treatment, and, as a result, additional research is needed to identify how to engage and retain adolescents in a developmentally appropriate way. The official explained that adolescents often do not believe they need treatment and are not certain they want to stop using substances. Recovery services. Three of the stakeholders we interviewed identified gaps in recovery service research for adolescents and young adults. Officials from one advocacy and education organization said there has been little research conducted to determine the types of recovery services that are most effective for adolescents in preventing relapse. Officials from one research organization said that it would be beneficial to develop a variety of recovery services, since services are likely to vary in effectiveness for different groups of adolescents and young adults. Translating research into practice. Three of the stakeholders we interviewed identified gaps in knowledge about how to translate evidence-based services from research into sustainable, real world practices. For example, an official from one research organization explained that translating evidence-based treatment services from research into real world settings can be difficult for a variety of reasons—such as, because services that are grant- funded may have components that are impractical to implement or are not reimbursable. The official said one example of such an impractical component would be having an expert observer periodically rate the fidelity of providers’ implementation of the service—a component that makes sense when testing the efficacy of the service under the grant, but which can be disruptive to workflow and may not be reimbursable by insurers once the grant ends. Officials from another research organization similarly commented that more research is needed to identify which components of services make them effective. Communicating harms of substance use. Officials from two of the three research organizations identified a gap in knowledge about how to effectively communicate the harms of substance use to adolescents and young adults. They stated that it is particularly difficult to effectively communicate the harms of cannabis to adolescents and young adults. One official explained that societal changes in attitudes towards cannabis have made it more difficult to convince adolescents of both its harm and of the need for treatment when its use develops into a substance use disorder. Federal response to gaps in research. Officials from NIDA agreed that these gaps in research exist and explained that while additional research is needed to address them, the process by which NIDA funds research through grants ultimately relies on researchers to submit proposals for consideration. While NIDA officials stated that researchers can submit proposals for research projects addressing adolescent or young adult substance use prevention, treatment, or recovery under general funding announcements for grants, NIDA also had eight funding announcements (as of May 2018) that either focused on these age groups or included them as a population of interest, three of which were new as of fiscal year 2018. We provided a draft of this report to HHS, DOJ, ONDCP, and Education for comment. HHS, DOJ, and ONDCP provided technical comments, which we incorporated as appropriate. Education did not have comments on our draft. We are sending copies of this report to the appropriate congressional committees; the Secretaries of the Departments of Health and Human Services, Justice, and Education; the Director of the Office of National Drug Control Policy; and other interested parties. In addition, the report is available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or dickenj@gao.gov. Contact points for Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix II. Table 4 shows the percentage of persons who were provided services with Substance Abuse Prevention and Treatment Block Grant funds in 2014, and who were also identified by grantees as being adolescents or young adults. Percentages are listed for two broad types of substance use prevention services (individual and population-based), as well as substance use disorder treatment and recovery services. Substance Abuse Prevention and Treatment Block Grant grantees include states, territories, and one federally recognized tribe. In addition to the contact named above, Gerardine Brennan, Assistant Director; Pamela Dooley, Analyst-in-Charge; Spencer Barr; and Brandon Nakawaki made key contributions to this report. Also contributing were Kaitlin Farquharson, Derry Henrick, and Laurie Pachter.

Summary: According to the Surgeon General, adolescence and young adulthood are critical at-risk periods for illicit substance use, and such use can harm the developing brain. Congress included a provision in law for GAO to review how federal agencies, through grants, are addressing substance use prevention, treatment, and recovery among adolescents and young adults. Related to prevention, treatment, and recovery targeting adolescents (aged 12 to 17) and young adults (aged 18 to 25), this report describes (1) grant programs to provide services; (2) NIDA grant-funded research, and (3) gaps stakeholders identified in related services or research. GAO selected four agencies to review—HHS, ONDCP, DOJ, and Education—the key agencies that fund grant programs for services for adolescents and young adults. GAO analyzed documents on grant programs and on research funded by NIDA. GAO interviewed officials from the four agencies and 20 stakeholder groups (including advocacy and education, and research organizations, as well as a non-generalizable selection of state substance abuse, education, and judicial agencies in four states) about gaps in services or research and agency efforts to help address them. States were selected for variation in geography and overdose rates. HHS, DOJ, and ONDCP provided technical comments on a draft of this report, which GAO incorporated as appropriate. GAO identified 12 federal grant programs within three federal agencies that funded substance use prevention, treatment, and recovery services in fiscal year 2017 and targeted adolescents' and young adults' use of illicit substances such as marijuana and nonmedical use of prescription opioids. The three agencies included the Department of Health and Human Services (HHS), the Office of National Drug Control Policy (ONDCP), and the Department of Justice (DOJ). While the Department of Education (Education) has grant programs that can fund prevention services for adolescents, they do not specifically target such services. Eight programs targeted substance use prevention. In total, they had 1,146 active grantees in fiscal year 2017 and provided about $266 million in awards that year. Four programs targeted treatment and recovery services. In total, they had 57 active grantees in fiscal year 2017. Two of the 4 grant programs awarded about $23 million in funding in that year (the other two awarded funding in prior years). In addition, other grant programs beyond these 12 also fund substance use prevention, treatment, and recovery services across age groups, but are not specifically targeted to adolescents and young adults. HHS's National Institute on Drug Abuse (NIDA)—the agency that is the primary funder of research on illicit substance use—also had 186 active grant-funded research projects focused on substance use prevention, treatment, and recovery among adolescents and young adults as of October and November 2017. Most of these research projects—126—were examining prevention, 45 were examining treatment, 4 were examining recovery, and 11 were examining a combination of research categories. In total, these 186 research projects received about $61 million from NIDA in fiscal year 2017. Most of the 20 stakeholders GAO interviewed identified gaps in services for adolescents and young adults, including insufficient access to recovery services and a shortage of treatment providers, and described financial and other reasons that likely contribute to these gaps. Federal agency officials GAO interviewed agreed that these gaps exist, and described grant programs and other efforts to help address them, such as a grant program that HHS established in 2018 to expand recovery services for these age groups. Stakeholders also identified gaps in research, such as too few treatment studies with adolescent participants, and described reasons for these gaps, including too few federal grants focused on adolescent research. NIDA officials agreed that these gaps exist, and stated that NIDA had eight grant opportunities (as of May 2018) that focused on these age groups or included them as a population of interest, three of which were new in 2018.