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

          HHS DRUG TREATMENT SUPPORT: IS SAMHSA OPTIMIZING RESOURCES?

    =======================================================================

                                    HEARINGS

                                   before the

                       SUBCOMMITTEE ON CRIMINAL JUSTICE,
                        DRUG POLICY, AND HUMAN RESOURCES

                                     of the

                                  COMMITTEE ON
                               GOVERNMENT REFORM

                            HOUSE OF REPRESENTATIVES

                           ONE HUNDRED SIXTH CONGRESS

                                 SECOND SESSION

                                   __________

                         FEBRUARY 17 AND MARCH 14, 2000

                                   __________

                               Serial No. 106-153

                                   __________

           Printed for the use of the Committee on Government Reform

      Available via the World Wide Web: http://www.gpo.gov/congress/house
                          http://www.house.gov/reform

                                     ______

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                         COMMITTEE ON GOVERNMENT REFORM

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

                          Kevin Binger, Staff Director
                     Daniel R. Moll, Deputy Staff Director
               David A. Kass, Deputy Counsel and Parliamentarian
                        Lisa Smith Arafune, Chief Clerk
                     Phil Schiliro, Minority Staff Director
                                     ------

       Subcommittee on Criminal Justice, Drug Policy, and Human Resources

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

                                   Ex Officio

    DAN BURTON, Indiana                  HENRY A. WAXMAN, California
               Sharon Pinkerton, Staff Director and Chief Counsel
                    Mason Alinger, Professional Staff Member
                              Lisa Wandler, Clerk
                        Cherri Branson, Minority Counsel

                                C O N T E N T S

                                  ----------
                                                                       Page
    Hearing held on:
        February 17, 2000............................................     1
        March 14, 2000...............................................   109
    Statement of:
        Chavez, Nelba R., Administrator, Substance Abuse and Mental
          Health Services Administration, Department of Health and
          Human Services, accompanied by Joseph Autry, Deputy
          Administrator for SAMHSA; and Dr. Alan I. Leshner,
          Director, National Institute on Drug Abuse, Department of
          Health and Human Services..................................   129
        Heinrich, Janet, Associate Director, Health Finance and
          Public Health Issues, U.S. General Accounting Office; Paul
          Puccio, executive deputy commissioner, Alcoholism and
          Substance Abuse Services, Albany, NY; John Keppler,
          clinical director, Commission on Alcohol and Drug Abuse,
          Austin, TX; Kenneth Stark, director, Division of Alcohol
          and Substance Abuse, Olympia, WA; and Dr. Martin Iguchi,
          co-director, Drug Policy Research Center, RAND Corp........    48
        Nance, Jerry, executive director, Teen Challenge
          International, Florida; Dr. Charlotte Giuliani, director of
          substance abuse treatment, Seminole Community Mental Health
          Center; and JoAnne Murwin, Seminole County Resident........    20
    Letters, statements, etc., submitted for the record by:
        Chavez, Nelba R., Administrator, Substance Abuse and Mental
          Health Services Administration, Department of Health and
          Human Services, prepared statement of......................   132
        Giuliani, Dr. Charlotte, director of substance abuse
          treatment, Seminole Community Mental Health Center,
          prepared statement of......................................    34
        Heinrich, Janet, Associate Director, Health Finance and
          Public Health Issues, U.S. General Accounting Office,
          prepared statement of......................................    50
        Iguchi, Dr. Martin, co-director, Drug Policy Research Center,
          RAND Corp., prepared statement of..........................    87
        Keppler, John, clinical director, Commission on Alcohol and
          Drug Abuse, Austin, TX, prepared statement of..............    80
        Leshner, Dr. Alan I., Director, National Institute on Drug
          Abuse, Department of Health and Human Services, prepared
          statement of...............................................   150
        Mica, Hon. John L., a Representative in Congress from the
          State of Florida, prepared statements of.................. 6, 113
        Mink, Hon. Patsy T., a Representative in Congress from the
          State of Hawaii:
            Followup questions and responses.........................   125
            Prepared statements of................................. 15, 121
        Murwin, JoAnne, Seminole County Resident, prepared statement
          of.........................................................    37
        Nance, Jerry, executive director, Teen Challenge
          International, Florida, prepared statement of..............    23
        Puccio, Paul, executive deputy commissioner, Alcoholism and
          Substance Abuse Services, Albany, NY, prepared statement of    64
        Towns, Hon. Edolphus, a Representative in Congress from the
          State of New York, prepared statement of...................   116

          HHS DRUG TREATMENT SUPPORT: IS SAMHSA OPTIMIZING RESOURCES?

                                  ----------

                          THURSDAY, FEBRUARY 17, 2000

                      House of Representatives,
    Subcommittee on Criminal Justice, Drug Policy, and
                                       Human Resources,
                                Committee on Government Reform,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:13 a.m., in
    room 2154, Rayburn House Office Building, Hon. John L. Mica
    (chairman of the subcommittee) presiding.
        Present: Representatives Mica, Souder, Mink, Cummings, and
    Kucinich.
        Staff present: Sharon Pinkerton, staff director and chief
    counsel; Don Deering, congressional fellow; Mason Alinger and
    Frank Edrington, professional staff members; Lisa Wandler,
    clerk; Cherri Branson, minority counsel; and Jean Gosa,
    minority assistant clerk.
        Mr. Mica. Good morning. I would like to call this hearing
    of the Subcommittee on Criminal Justice, Drug Policy, and Human
    Resources to order.
        I apologize for the delay. Several other Members are
    involved in other committee business.
        This morning we are conducting a hearing entitled, ``HHS
    Drug Treatment Support: Is SAMHSA Optimizing Resources?''
        I will open first with my opening statement and recognize
    other Members, and then we will hear from our witnesses. I
    think we have three panels today.
        Our subcommittee is conducting this oversight hearing today
    as a part of a series of hearings to examine programs and
    agency operations within the Department of Health and Human
    Services. This subcommittee is particularly interested in
    agencies with critical responsibilities in implementing our
    national drug control strategy.
        The Substance Abuse and Mental Health Services [SAMHSA], as
    we refer to the agency, is the Federal agency before us today,
    and its support for drug treatment is the focus of our hearing.
        National estimates of Americans in need of drug treatment
    range from 4.4 to 8.9 million, yet less than 2 million people
    reportedly receive treatment. This gap of course must be
    addressed since drug treatment needs today, unfortunately, are
    predicted to grow, not diminish.
        SAMHSA's block grant program is a key element to reducing
    the gap as States and communities provide direct services and
    each block grant dollar spent on treatment generates $1.50 in
    additional State or local treatment spending.
        SAMHSA claims to be contributing to the first three goals
    of our national strategy, which I will paraphrase. The first
    goal is educating and enabling youth to reject illegal drugs
    and tobacco. The second goal is reducing drug-related crime and
    violence. And the third goal is reducing the cost of drug
    abuse.
        To achieve these goals, SAMHSA must optimize its resources.
    It must also provide the most efficient and effective support
    possible for State and community drug treatment efforts. Today,
    we will investigate whether this is happening and what should
    be done if, in fact, it is not.
        As we will hear, States and communities are making progress
    in their drug treatment efforts but continue to have pressing
    needs. Every drug treatment dollar received by those on the
    front line is extremely vital.
        We will learn that the Federal Government should allocate
    resources to support more successful treatment programs that
    will serve more clients, and that is one of my major concerns
    is that we reach out and serve more people, but with more
    successful programs. We will also learn that SAMHSA has an
    inordinate administrative cost in overhead, and somehow we must
    reduce the red tape and bureaucratic obstacles that hinder
    service to the States and also these local communities programs
    that are so effective. In doing so, SAMHSA can better achieve
    the goals of our national drug control strategy.
        Our first panel today represents local treatment efforts on
    the front line of the drug epidemic. We will hear testimony
    from local treatment providers both public and private
    indicating that every treatment dollar makes a difference.
        One witness is concerned that Federal funds are not
    available to help establish a needed local treatment facility.
    As a result, clients must travel significant distances outside
    their community.
        We will also hear from a client how effective drug
    treatment enabled her to overcome addiction and to reclaim her
    life. Another treatment provider represented here today is
    faith-based. Some of our most successful programs, in fact, are
    faith-based. This provider's counseling and work elements
    apparently did not match traditional public treatment facility
    licensing criteria, thus preventing the program from qualifying
    for Federal support.
        Worse yet, Federal food stamp assistance for its clients
    has been cutoff, even though clients would continue to receive
    food stamps had they remained on the street abusing drugs.
    There is something dramatically wrong with this picture.
        Should Federal assistance not reach deserving clients and
    programs that work even though the program uses religious or
    faith-based counseling and work as treatment elements?
        Our second panel will address the State perspective, where
    most drug treatment is actually funded and administered. We
    will hear from the General Accounting Office. GAO has provided
    descriptive data on what SAMHSA is doing with its resources.
    This data provides a basis for further questions regarding how
    agency efficiencies and effectiveness can be improved, a topic
    we will explore in this hearing.
        GAO data indicates that about 80 percent of SAMHSA's
    substance abuse grant funds flow to the States through block
    grants managed by about 11 percent of the agency's staff. The
    remaining 89 percent of SAMHSA's staff is engaged in
    Washington-based discretionary grants or other agency
    activities. To me, this represents some sort of a misallocation
    of personell and resources based upon the mistaken belief that
    Washington knows best. I think our experience has shown us just
    the opposite.
        We have witnesses from several State programs that are
    successful in breaking the train and chain of drug addiction,
    restoring families, and creating productive citizens and saving
    lives really needs to be the goal of all of these programs and
    some of them are successful, some of them are not.
        The States that have some successful programs are New York,
    and we visited one of those programs. I do not think the
    members that are here today got to go with us but the DTAP
    program was extremely successful in Texas and Washington. GAO
    has commended these States for their successes in a number of
    drug treatment areas.
        We look forward to learning more about what works in these
    and other States and hearing about their successes and how we
    can pattern them.
        We also have a witness who will address the topic of
    evaluation. We need to understand how drug treatment works and
    what, in fact, works best. Still, we do not need to reinvent
    the wheel or spend hundreds of millions, sometimes billions of
    dollars, on interesting but unnecessary Washington based
    research at the expense of precious treatment dollars.
        Last week, the SAMHSA administrator, Dr. Chavez, testified
    on the effectiveness of current drug treatment programs. She
    stated,

        An evaluation of treatment programs funded by the Center
    for Substance Abuse found a 50 percent reduction in drug abuse
    among their clients in 1 year after treatment. Our services
    research outcome study produced similar findings 5 years
    following treatment. We have achieved success that can parallel
    or exceed the results of patients receiving treatment for other
    chronic illnesses like diabetes, hypertension, and asthma.

        Citing a 48 community study that found significant
    reductions in drug and alcohol abuse among males, Dr. Chavez
    concluded, ``We know what works in prevention and treatment.''
    That is important for us to also know as a subcommittee in
    Congress that funds these programs.
        While I agree that we must continue to evaluate drug
    treatment programs, I do not agree that the States like New
    York, Texas, or Washington must rely on advice and mandates
    from all from Washington, DC.
        These States have fine universities that are quite capable
    of conducting rigorous research and evaluation. States can
    easily find talent in Washington, DC, or other locales when
    needed, but States remain the true laboratories of democracy
    where most innovation does, in fact, occur.
        Furthermore, States are quite willing to share data and
    results with others and the Internet also is a new mechanism to
    provide an efficient way to carry that out.
        Our final panel today will include an official from
    SAMHSA's Center for Substance Abuse Treatment. It is my hope
    that she and other SAMHSA officials will provide this
    subcommittee with the answers to questions that we have
    relating to agency activities and operations.
        Among the questions which we need to obtain the answers for
    some of the following: Why our States forced to undergo so much
    bureaucratic red tape to receive their block grants? I
    understand that some States invest more than 400 man-hours just
    completing the applications. If the IRS can accept an
    electronic tax return and immediately send a refund, other
    Federal agencies should be just as efficient.
        Why does SAMHSA choose to award such a large percentage of
    its moneys through discretionary grants called knowledge
    development and application [KDA], and targeted capacity
    expansion [TCE], grants? Why are these grants not coordinated
    with the States, which may be forced to pick up their funding
    later?
        Does SAMHSA really have superior knowledge and are States
    clamoring for more Federal guidance? I think not.
        The National Governors Association and the National
    Association of State and Alcohol and Drug Abuse Directors favor
    more consolidated block grants, more State flexibility, and
    less red tape. I remain very concerned with the allocation of
    SAMHSA's staff and resources.
        While 59 staff are dedicated to all State block grant
    activities, including mental health, prevention and treatment
    combined, the Office of SAMHSA Director alone has 73 staff,
    furthermore, 139 staff in the agency's three centers are
    assigned just to KDA discretionary grants.
        I am concerned that SAMHSA's enormous administrative costs
    in the GAO reports in 1999 fiscal year, SAMHSA's administrative
    costs were more than $150 million. Now, if we could just divide
    that by 50 States and add $3 million to each State rather than
    support this huge Washington bureaucracy, how many people could
    be treated for that amount?
        It is also unclear to me why SAMHSA is spending tens of
    millions each year for research when the National Institute on
    Drug Abuse was established as the primary research agency. Is
    NIDA not conducting practical research applicable to treatment
    evaluation and delivery? If not, why not?
        Finally, SAMHSA has a problem for which a statutory cure
    may be needed in order to protect State treatment funds. The
    problem is that SAMHSA's enforcement of the Synar provision
    within the Substance Abuse Prevention and Treatment block
    grant. The provision, established in 1992, requires States to
    reduce smoking. It provides a 40-percent reduction in block
    grants for State inaction.
        In recent years, SAMHSA has moved to impose unreasonable
    requirements on States, including State-specific annual target
    rates. As a consequence, in fiscal year 2000, seven States and
    the District of Columbia stood to lose millions of drug
    prevention and treatment dollars, but Congress provided them a
    1-year conditional reprieve.
        I understand that SAMHSA has rescinded its guidance to
    these States and still has not issued new guidance. Why the
    delay? Other States, in fact, are at risk of losing funds, much
    needed funds, in the future. Does it make sense to deny
    desperately needed State treatment funds because progress
    regarding youth smoking does not satisfy SAMHSA? That is a
    question I think we are also going to have to ask today. The
    Nation's drug czar, the States, and others think not. This
    needs to be fixed, and SAMHSA should act now.
        [The prepared statement of Hon. John L. Mica follows:]
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        Mr. Mica. I wish to thank all of the witnesses who are
    appearing before us today. I also wish to thank the ranking
    member of the subcommittee whose primary interest has been to
    ensure that we have good, adequate, accessible, and effective
    treatment. I am pleased to recognize her for an opening
    statement at this time.
        Mrs. Mink.
        Mrs. Mink. Thank you very much, Mr. Chairman. I would ask
    that my prepared statement be included in the record at this
    time.
        [The prepared statement of Hon. Patsy T. Mink follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.009

        [GRAPHIC] [TIFF OMITTED] T7551.010

        Mr. Mica. Without objection, so ordered.
        Mrs. Mink. I would just like to make a few responses at
    this point to the chairman's observations.
        I think that we all are very much concerned about how
    Federal funds are spent. We are constantly reminding our
    Federal officials that they must march to the heavy drumbeat of
    accountability to make sure that the statutory guidelines and
    requirements that have been laid out by Congress are fully
    adhered to and that, as Federal officials, they will be held
    accountable for this performance.
        So given those requirements by statute and by appropriation
    riders and so forth, the Federal agencies are compelled to
    adhere to these requirements and restrictions. So I think we
    ought not to criticize the agencies for those actions and steps
    that they have taken because of congressional mandates.
        I believe very strongly, as the chairman has indicated,
    that the primary responsibility for drug prevention and
    treatment lies in the local and State communities. I serve on
    the education committee and we are constantly reminded of those
    who come to the Congress that the primary responsibility in
    education is local and supplemented by State funding, and that
    the Federal responsibility is very minute. In the case of
    education, it borders around 7 or 8 percent only of the funding
    for the total educational requirements from K-12.
        So, similarly, it seems to me that Congress has to abide by
    the idea that drug prevention and treatment programs are
    basically responsibilities of the local and State governments.
    It is an enormous responsibility admitted by the fact that
    Congress has taken steps to include vast sums of money to
    supplement the State and local efforts.
        In doing so, I believe it is very critical that the
    Congress set forth guidelines on how these funds are to be
    spent. We cannot simply be saying that there is a formula based
    upon population or based upon some other criteria of need that
    funds are going to be allocated without some fairly stringent
    requirements. And yet these are the requirements that have come
    under fire.
        I think it is important to look at the overhead criticisms
    that the chairman has made with regard to the Federal agencies
    and to make sure that they are not excessive, and that the bulk
    of the moneys are being distributed to the local and State
    agencies. But I cannot quarrel with the requirement that the
    agency places upon the allocation of these funds by making sure
    that they are going for the specific purposes and needs as
    indicated by the State and local agencies's applications.
        So I would strongly urge that we not remove the agency's
    responsibilities to make sure that the allocations conform to
    the basic outlines of needs as established by the Congress and
    established by themselves. If they set up criteria as the basis
    for their application for block grants or other kinds of
    grants, then they ought to demonstrate that those needs are
    being met by the Federal funds that are being allocated.
        Treatment is an enormously expensive program but I continue
    to feel that that is probably one of our greatest needs and
    deficits currently in our drug policy program, when we are told
    that only 50 percent of those that come for treatment are
    actually able to be serviced, we know that we have not really
    begun to meet that requirement. Think of the others that are
    not even coming for treatment requirements and are out there
    and have not been reached; 80 percent of the addicts have no
    treatment program. And so rather than diminish the
    responsibility of the Federal Government in this area of
    treatment, I think that Congress has a responsibility to look
    at it more critically.
        We need to find out what programs are working. That, I
    think, is a responsibility of the SAMHSA agency. We have the
    research capability at NIH and they need to find research areas
    that are better than what are being performed out there in the
    field today, but SAMHSA's responsibility is to tell us what
    works and what ways that the Federal Government can intercede
    to make those programs that do work more extensively utilized
    by other State and local agencies.
        Prevention is a whole other part of this enormous triangle.
    If we could prevent addiction, then we do not need to be as
    concerned about treatment. But if we cannot prevent through all
    the intervention requirements that we have in our educational
    system, then we need to pay attention to treatment.
        And so, as a member of the subcommittee, as the chairman
    has indicated, I have been very concerned about this treatment
    deficit and have tried to do what I could to put my inquiries
    in this area because I feel that this Nation deserves better.
    We cannot relegate these addicts to a life of despair,
    hopelessness and total support by the taxpayers because of
    their addiction. We need to find ways to treat them so that
    they can be restored to active participants in our society
    rather than deficits.
        The reports that have been issued by GAO indicate that the
    drain upon our economy and our society is somewhere around $67
    billion. I have however seen reports where that figure has been
    quadrupled to $200 billion as a drain and cost of productivity
    and because of the provision of extra services and other
    things.
        So the cost to this Nation is enormous and the intervention
    by the Congress and the Federal Government is essential. We may
    be able to perfect it, direct it better, but its intervention
    is critical, notwithstanding the fact that I personally believe
    that this is essentially a State and local responsibility.
        Thank you, Mr. Chairman.
        Mr. Mica. I thank the gentlewoman.
        I recognize the gentleman from Indiana, Mr. Souder. No
    opening statement.
        I am pleased to recognize the gentleman from Maryland, Mr.
    Cummings.
        Mr. Cummings. Thank you very much, Mr. Chairman.
        I want to thank you and our ranking member for requesting
    the GAO report and calling for this hearing.
        I want to associate myself with the words of our ranking
    member, Mrs. Mink. I want to add to that that one of my
    concerns, in a city that has the problems that Baltimore has
    with regard to drug addiction, is quality of treatment.
        One of the things that we have recently talked about with
    our new mayor and with a group of former addicts, recovering
    addicts now, is that a lot of time, I mean, these people really
    believe that some of the treatment programs are not doing what
    they claim they are supposed to be doing. And I hope that some
    of your comments will go to it. It is one thing to have the
    treatment slots, it is another thing to have--for those
    organizations that provide treatment to be effective.
        I think that if they are not effective or there are no
    standards, then I think we are just playing a game on
    ourselves. Drug addiction, as Mrs. Mink has stated so well, has
    an effect on so many parts of our society.
        Just the other day, I took my daughter to the emergency
    room at one of our local hospitals and I was sitting there for
    about an hour and I watched the ambulances come and go and I
    asked one of the attendants, I said, you guys are kind of busy.
    And he just shared with me that 85 percent of all their
    ambulance runs in Baltimore city are drug-related. That is
    astounding. And so, you could imagine we could probably save a
    lot of money in Baltimore if we did not have the kind of
    problems we have.
        But my point is that, you know, I just want to make sure
    that whatever money is being spent, that it is being spent
    effectively and efficiently, effectively and efficiently.
        I note from some documents that we have up here that during
    1999 your administrative costs were 6 percent. I mean, I do not
    think that is bad at all. But it would be interesting for us to
    know what kind of followup there is and, with regard to these
    dollars being spent, are we really getting people off of drugs,
    and if we are not, then what could we do from this level.
        While it is, as Mrs. Mink said, a local kind of situation,
    if Federal dollars are being spent and there are taxpayers'
    dollars, we want to make sure that they are spent in a way that
    achieves the goals that we have set out.
        So I look forward to the hearing today and I want to thank
    all of our witnesses for being with us.
        Mr. Mica. I thank the members of the panel for their
    opening statements.
        We will now turn to our first panel of witnesses. We have
    today, as a little of the chairman's prerogative, witnesses who
    are all from central Florida. I want to say that, in fairness
    now, on the 27th I will be in Baltimore with Mr. Cummings, and
    we are going to do a hearing in Baltimore, so I will travel
    there, which is not a big deal. It is not that far but it is an
    important hearing.
        Mr. Cummings, I hope we can have the mayor and the police
    chief there. I was thinking about this this morning. In fact, I
    want the mayor and the police chief there, and I want to hear
    what their plans are. You have a new mayor, I think, and a new
    police chief. I am going to invite them. If they do not
    respond, I may consider requiring their attendance. I think it
    is so important.
        Mr. Cummings represents an area that he has, he estimates,
    some 60,000 drug addicts. Crime is still high and it is our
    responsibility to see that the programs work and that the
    situation in Baltimore comes under some control. That is surely
    our responsibility. But I will be there the 27th. I invite
    Members to be there.
        Then I will travel to Honolulu, which I prefer more than
    Baltimore, on the 20th with Mrs. Mink, and invite the other
    members of the panel. I am sorry I have to go and just fly
    back, because I would love to stay. But we will hear from her
    constituents her problems relating to Southeast Asia drug
    trafficking and treatment and other things in that community.
        Then on March 6th, for the information of this
    subcommittee, we will be in Sacramento. Mr. Ose may be joining
    us. He was with me earlier in Sacramento. He has requested a
    field hearing in his community about the problem.
        Finally, on the 7th, in San Diego we will deal with the
    southwest border and our oversight responsibility, at the
    request of Member Mr. Bilbray.
        So while the chairman takes a little liberty in inviting
    these folks from sunny Florida into the cold cockles of
    Washington, I am pleased to welcome them, and we will
    accommodate the other members accordingly.
        On our panel, we have Mr. Jerry Nance, who is the executive
    director of Teen Challenge International, which is located in
    central Florida; we have Dr. Charlotte Giuliani, director of
    substance abuse treatment, Seminole Community Mental Health
    Center; and Ms. JoAnne Murwin, who is a Seminole County
    resident from central Florida who is recovering and who has had
    difficulty, she will describe, with drug addiction.
        I am pleased to welcome all three of you. I appreciate your
    being with us this morning.
        We are an investigations and oversight subcommittee of
    Congress. In that regard, we do swear in our witnesses. If you
    would please stand.
        [Witnesses sworn.]
        Mr. Mica. The witnesses answered in the affirmative.
        I am pleased to have you join us again today. What we also
    do is, if you go over 5 minutes today, she is going to put a
    little red light on, and I will ask you to conclude. You can
    submit lengthy statements for the record just upon request and
    I will do that. Then we will have an opportunity for a few
    questions from members of the subcommittee.
        So, with that, let me introduce and welcome Jerry Nance,
    executive director of Teen Challenge.

     STATEMENTS OF JERRY NANCE, EXECUTIVE DIRECTOR, TEEN CHALLENGE
      INTERNATIONAL, FLORIDA; DR. CHARLOTTE GIULIANI, DIRECTOR OF
      SUBSTANCE ABUSE TREATMENT, SEMINOLE COMMUNITY MENTAL HEALTH
          CENTER; AND JOANNE MURWIN, SEMINOLE COUNTY RESIDENT

        Mr. Nance. I am Jerry Nance. I want to introduce to you one
    of the best kept secrets, I believe, in the world; and I
    believe that is Teen Challenge.
        Teen Challenge was founded by David Wilkerson in Brooklyn,
    NY, in 1958. And this year we celebrate 41 years of service,
    with 140 Teen Challenge centers in the United States and an
    additional 250-plus centers in more than 67 countries of the
    world. The majority of these centers operate 1-year faith-based
    residential programs.
        Independent studies have shown that Teen Challenge programs
    have consistently documented 87 percent success rates. Let me
    just highlight some of the results of a June 1999 research that
    was done by Northwestern University study, just a couple of
    remarks.
        Their research said that one of the most powerful features
    of Teen Challenge is the work, training, and the strict
    discipline. The research compared Teen Challenge to other drug
    programs and of the other group only 41 percent were employed 1
    to 2 years after they completed the program while 90 percent of
    the Teen Challenge graduates were employed 1 to 2 years later.
        The Teen Challenge program costs an average of $1,000 a
    month, in comparison to other programs which cost between
    $10,000 and $30,000 a month.
        They found that students in the program have an attitude
    of, ``it's a privilege to be here'' and they were very thankful
    that they had a chance to participate in the Teen Challenge
    program.
        My responsibilities are that I oversee the Teen Challenge
    centers in Florida and now in Georgia. Currently, we operate
    nine centers in the State of Florida, three in Georgia, with
    350 beds for boys, girls, men, and women.
        Our budget last year was $3.6 million, and of that we only
    received $15,000 from a block grant in Volusia County to do
    prevention work. According to the National Teen Challenge
    headquarters office in Springfield, MO, of the 140 Teen
    Challenge centers in America, less than 10 percent were State
    licensed. This is because of the difficulties many times in
    negotiating contracts and/or relationships between the faith-
    based program that exists in Teen Challenge.
        Some key issues today that I would like to bring to this
    hearing's attention is, and I am not here today to ask you to
    fund all faith-based programs, on the contrary, I am here to
    say that we are happy to fund what we did as far as our
    program, but I have three distinct issues that I believe need
    to be addressed and need the attention of this committee.
        No. 1 is food stamps. At our Sanford, FL, men's facility,
    we house 140 men, ages 18 years old and older. Last year our
    students lost the ability to file for food stamps. The Food and
    Drug Administration made a decision to not allow students in
    programs that were not State licensed to receive food stamps.
    This decision cost Teen Challenge in excess of a $100,000.
        This decision not only affected Teen Challenge students,
    but also students and other humanitarian organizations, like
    Salvation Armies and inner-city missions. My question is does
    this make any sense? An individual can live in the streets, he
    can use drugs, he can rob people and steal and get their food
    stamps, but if they come to a faith-based, non-State licensed
    facility like Teen Challenge, they lose their food stamps. It
    does not make sense to me.
        The second area of concern I believe that needs attention
    is the issue of faith-based programs and State licensure. In
    1998, Teen Challenge of Florida attempted to secure State
    licensure with children and family services at the time that we
    had lost our food stamps. But due to the conflict with program
    requirements, we withdrew our efforts.
        In addition, we reviewed the Department of Juvenile Justice
    service provider contracts and the Department of Corrections
    requirements, and in each case we found key conflicts with the
    program requirements in relationship to the faith-based issues
    that we feel are important to our program.
        Examples: All Teen Challenge's programs require mandatory
    chapel attendance, and that is almost without regard to the
    main problem that we have in licensure. Adults in Florida State
    license programs were required to have 20 hours of group
    counseling each week. The Teen Challenge's curriculum, although
    proven successful, was reviewed and found not to be acceptable
    to the State of Florida standards. Therefore, to adhere to
    State licensure, Teen Challenge would have to restructure the
    entire program and rewrite or restructure the entire
    curriculum, and we are not willing to do that to alter our
    curriculum or risk jeopardizing the 86 percent success rate for
    money.
        The problem is faith-based programs cannot realistically
    fit into the current guidelines used to certify programs. These
    guidelines are based on the medical model, which it works for
    some and others maybe they need the faith-based programs. And
    the truly faith-based programs like Teen Challenge are based on
    faith in God as well as Biblical principles and, thus, we have
    a model that we believe works.
        The current guidelines make no allowances for the
    differences between the two systems of helping. Though we do
    have National accreditation standards for Teen Challenge, they
    differ greatly from State standards in regards to program. I
    have a few copies available if anyone is interested in looking
    at those.
        To the best of my knowledge, I do not know of one effort
    being made to bring the faith-based residential programs and
    the State guidelines together. I would like to suggest a study
    of how a successful faith-based program can work in cooperation
    with State guidelines without violating the separation of
    church and State. And I now find that often is the issue.
        The third issue I believe needs attention is the medical
    care for students in faith-based programs. Individuals who come
    to Teen Challenge with addiction problems are usually desperate
    and destitute. They often do not have family or any other means
    of support, financial or otherwise, often emergency medical
    expenses must be absorbed by Teen Challenge.
        The services of Teen Challenge are offered free of charge
    to adults who can pay the intake fees. Less than 5 percent of
    our income comes from adult students with financial
    contributions.
        Currently, 20 percent of our student population are court-
    ordered. We work closely with the judges and public defenders,
    States attorneys, and they refer many, many people to Teen
    Challenge.
        Let me just underscore, in closing, I am not asking for you
    to support the program cost of Teen Challenge. But we do need
    to evaluate the food stamp issue, the guidelines for licensing
    of faith-based programs, and the reviewing of medical coverage
    for residents of Teen Challenge and other faith-based programs.
        I would offer my services, as well as the services of the
    National Teen Challenge director, to participate on a committee
    to address those issues.
        Mr. Mica. Thank you for your testimony. We will suspend
    questions until we have heard from all the witnesses.
        [The prepared statement of Mr. Nance follows:]
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        Mr. Mica. The next witness is Dr. Charlotte Giuliani. She
    is director of the Substance Abuse Treatment Center in Seminole
    Community Mental Health Center.
        Welcome. You are recognized.
        Dr. Giuliani. I am director of Substance Abuse Treatment
    Services in Seminole County.
        Seminole County, as you well know, is a county of 330,000
    approximately residents. And at this point there is only seven
    funded beds in that county.
        It is estimated that over 722,000 adults and 247,000
    children are in need of treatment in the State of Florida.
    Florida's State-administered adult treatment capacity is only
    6,933 beds, and 3,000 of those beds are available in State-
    funded programs such as mine and the balance in the Department
    of Corrections. The average waiting period for these beds is in
    excess of 3 months. At this time it is estimated that at least
    700 adults are on these waiting lists.
        So, as you can see, getting help can often be a confusing
    or frustrating ordeal that appears to create barriers for those
    wanting help with their addiction. Many alcoholics or addicts
    are lost when treatment is not readily available or accessible.
        The use of drugs and alcohol among our children is
    staggering. Most children first try alcohol or drugs at the
    ripe old age of 9. The increase in the number of children that
    abuse alcohol or drugs has tripled since 1992 and a juvenile
    justice program struggles to deal with the huge number of
    adolescents committing crimes.
        47 percent of 13-year-olds say that their parents never
    discuss the dangers of drug use. This is credited in part to
    the fact that a large percent of those parents are abusing
    drugs themselves. Addiction is a family disease and has to be
    treated as a family disease.
        I realize that because of the daily consequences we as a
    society experience, this is not a very popular, nor is it a
    very tolerated disease. The total economic cost of drug abuse
    in our Nation is estimated at $246 billion.
        That is $965 for every man, woman, and child in the State
    of Florida. The cost of substance abuse is incurred by
    emergency rooms, hospitals, increased instances of HIV and
    other substance abuse related illnesses, rising criminal
    activity, and a staggering decline in productivity that affects
    all businesses.
        For every $1 spent on treatment, $7 is saved. So treatment
    is a bargain.
        Treatment, without a doubt, works. Studies done over the
    last 20 years indicate that treatment returns people to
    productive lives, promotes responsibility, and accountability,
    reduces criminal behavior and violence.
        I want you to hold me accountable for the services I
    provide and the way I spend our money. I only ask that you
    allow me the resources to provide services to the large number
    of people needing treatment. The drug issue is about all the
    things that we value the most, family, children, businesses,
    churches, communities, and treatment, education and prevention.
        I could tell you some wonderful success stories, but I am
    here before you on behalf of the ones whose faces I have looked
    at that are no longer with us or no longer alive because of
    drugs or alcohol. This constitutes my own personal war on drugs
    because too many have been lost. It will require the
    partnership of you, our Federal Government, our State
    governments and our communities to stop drug abuse.
        I thank you.
        [The prepared statement of Dr. Guiliani follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.020

        Mr. Mica. Thank you for your testimony.
        I will now recognize JoAnne Murwin, who is a resident of
    the Seminole community. Welcome. You are recognized.
        Ms. Murwin. Thank you, Mr. Chairman. Good morning. I am a
    little nervous.
        Does treatment work? This is a long way from the streets of
    Seminole County for me. My name is JoAnne Murwin and I have a
    story to tell you.
        I am a recovering alcoholic and drug addict who is here
    before you today by the grace of God and a good foundation from
    the treatment center that I went through. I won't go into all
    the war stories, as all you have to do is turn on the news or
    pick up a newspaper and my story of abuse is there.
        What I would like to say is that, although I think
    education plays an important part of recovery, it doesn't do
    much for the prevention of this disease. You can educate anyone
    all you want on the facts of diabetes, but it will not keep
    them from getting it.
        My mother started the recovery process in our family by
    going to Al-Anon. My father is an alcoholic and this is why I
    inherited my disease. Addiction is a disease, and the minute I
    put that first drug into my body my disease started to
    progress. My sisters and I went to Al-Teen for years, and we
    would discuss what was going on with my father and in the
    family. We would swear we were never going to be like him, and
    then we would leave the meeting and smoke pot on the way home.
        Well, we were right to some degree. We weren't like him, we
    were worse, because we added the drugs to the alcohol.
        I started using drugs when I was 13 in 1972. I went to
    treatment when I was 32 in 1992. I used it for 20 years. So
    believe me when I tell you that I am an expert on the subject.
        By the time I went into treatment, the only worldly
    possessions I had were some clothes and pictures I had managed
    to hang on to. I was being evicted, had just gotten fired
    again, had no car, no money, no self-esteem, and nowhere to go.
    If you want the youth today to not start, teach them about
    self-esteem in school. Don't tell them that they are wrong or
    different. They get enough of that in their own homes. It does
    no good to educate children on the dangers of drugs if they
    live with them at home. It is all they know and it is in their
    blood already.
        Funny how the disease of addiction, and I quote from the
    Orlando Sentinel, is still being addressed as ``willful
    misconduct.'' Do you honestly think that I, as a little girl
    growing up, I said to myself, I think I will use drugs and ruin
    my life just to be bad? Give me a break. I used so I wouldn't
    have that feeling of not being good enough, which came from the
    shame of having an alcoholic father.
        I also find it rather interesting that our government
    insurance, Champus, does not cover treatment for this disease.
    Do you know how most people get into treatment? They have to
    hit rock bottom and be threatening to kill themselves to anyone
    who listens.
        I have worked in a number of treatment centers since I got
    sober, and we used to tell people to threaten suicide so they
    could get help. This is an outrage. All I know is that, without
    the treatment I received, I would probably be dead right now or
    in jail, as my habit was becoming increasingly hard to support
    and it wouldn't have been much longer before I was on the
    streets doing whatever it took to be able to get my next fix.
        Today I am proud to say that I am a productive member of
    society. I own my own business, am a registered voter, have a
    valid driver's license and insurance. These are the kinds of
    things a drug addict never even thinks about. I play softball 2
    nights a week. I take care of my 91-year-old grandmother, who
    is unable to care for herself. I am a member of the American
    Business Woman's Association. And I continue to sponsor and
    help other addicts seeking recovery.
        You cannot start just by educating the children. You have
    to stop this vicious cycle by treating everyone in the family
    so that it does not continue to be passed down to future
    generations.
        Working together on this, we might be able to really help a
    lot of future alcoholics and addicts. I beg you to continue
    your support and do all that you can to help us, that never
    knew what hit us.
        Does treatment work? I have stayed clean through my
    grandfather's death, the hurt of a broken heart, and the savage
    rape by a stranger who broke into my house one night wearing a
    stocking mask on his head. I then had to endure the re-
    victimization of the system, and I continue to struggle with
    this issue today.
        Did I want to have a drink to calm my nerves that night or
    dull the pain from the beating I took? You bet I did. But I
    didn't do it, and I owe it all to the treatment center that
    taught me how not to use drugs and my God.
        Thank you for listening and helping people like me who went
    to treatment using one of your funded beds.
        [The prepared statement of Ms. Murwin follows:]
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        Mr. Mica. I thank all of our witnesses. And we will start
    questioning.
        I am going to yield first to Mr. Souder. Mr. Souder, you
    are recognized.
        Mr. Souder. I thank the chairman. I have a plane to catch
    and I appreciate your generosity.
        First let me say, Ms. Murwin, I heard years ago from a
    State Senator friend of Richard Worman in Indiana that many
    legislators either turn to God or booze with our problems. They
    are nothing compared to your problems. And I really uphold you
    and praise you for being able to struggle and confront many of
    the worst things that could possibly hit an individual, as
    coming from a child to the rape and everything else, and being
    willing to stand as an example for others and hold your
    commitment to God and your commitment to staying clean. And I
    think you will continue to be as successful as you are. And I
    thank you for your willingness to speak up.
        Congressman Ramstad has a bill to try to make sure that in
    insurance we can get drug and alcohol treatment covered, and we
    will continue to try to do that. It is a slow process because
    it is very expensive and health insurance costs have been going
    through the roof. And some of the programs, quite frankly, have
    been fairly marginal in their returns and there is a big
    difference in types of programs. But we are doing the best we
    can. I thank you.
        I wanted to pursue with Mr. Nance a couple of questions,
    because for the last few days I have been immersed with this
    whole charitable choice question because we have been dealing
    with over in the Education Committee Even Start, and I have
    read either the summaries or every court case dealing with
    faith-based organizations right now, and particularly as it
    relates to a number of these things.
        First, I want to ask you a technical question. Were you
    receiving the food stamps or were individuals in your program?
        Mr. Nance. The individuals in the programs.
        Mr. Souder. And then they would turn them over to you?
        Mr. Nance. And then they would turn them over to us.
        Mr. Souder. Is the Federal requirement that it has to be
    State licensed, or is this a State decision?
        Mr. Nance. We understood it from the State agency that the
    Food and Drug Administration had set down these laws and the
    States were mandated to follow them, as I recall.
        Mr. Souder. We will attempt to get this clarified, and I
    also would raise this with Governor Bush, because it may be a
    State application that relates to that.
        Mr. Nance. I have raised it with Governor Bush.
        Mr. Souder. What was his answer?
        Mr. Nance. Through Jim McDonough with the drug czar, he
    said he turned it over to a staff person and we have not been
    able to resolve it.
        Mr. Souder. Also, you had in your testimony that you would
    like to see a study of faith-based programs and how they can
    work in cooperation with State guidelines without violating
    separation of church and State.
        This is a quagmire. And let me suggest a couple of basic
    principles. First off, be very wary. I am familiar with the
    cross and a switchblade and it has impacted many people's lives
    with success of Teen Challenge and the Victory Life Temples in
    Texas with Freddie Garcia and Juan Rivera and others. But you
    need to be very careful about getting the Government's hands on
    any program that is successful because it is amazing how they
    can make them less successful. We may be tolerant of faith-
    based organizations as long as the faith does not get too much.
    We are a little nervous about that.
        As I understand the court decisions, which are evolving
    every day and which are not clear, is that you cannot, while
    receiving any direct Federal funds, ever require mandatory
    chapel time as a condition for entering a program, and that is
    not likely to change, which is right at the heart of many of
    these programs. It is unlikely because proselytization clearly
    cuts multiple directions. As somebody who represents and I am a
    baptist, we usually lose in any type of State religion. And we
    are not too hot on it, either, and you need to be careful about
    funding it.
        At the same time, we have made progress on staffing
    requirements, because there is nothing that says that religious
    people cannot administer programs that help people if you are
    not teaching religion with government funds. So there can be
    separation of programs, but if you had somebody come in that
    did not participate in that, now, that is different. In other
    words, you probably will not be eligible for any program that
    is a direct grant program as long as that is a key component,
    and I believe probably the most critical component of your
    program.
        Mr. Nance. It is.
        Mr. Souder. But vouchers for food stamps do not make sense
    because vouchers are viewed differently as direct grants.
    Vouchers should be the individual's decision where they go.
        You posed the ridiculous question which one possible
    solution would be, put a bunch of men in cars in an empty lot
    and then they could get the food stamps and come over to your
    program. It does not even make any sense.
        Mr. Nance. Well, that's what we said to them: What if we
    brought the 140 men and put them on your parking lot and they
    went one at a time into your office and filled it out? They
    said, well, if they put your address down, they are not going
    to get them.
        Mr. Souder. We should be able to look at this question. It
    looks like an overzealous person coming after Salvation Army
    and rescue missions, your program and others. Because, quite
    frankly, we give vouchers for multiple programs that are faith-
    based, and even education, which is the most controversial. For
    IDEA, we do it for buses and materials for religious-based
    schools.
        When it is something that an individual makes a decision,
    there is a different standard than when it is a grant coming
    from alcohol and mental health and antidrug funds.
        I had one other question, and that is, and I just wanted to
    clarify this. You get 20 percent of court ordered--could you
    explain again. When you say, ``medical care,'' you are not
    getting any dollars for the court ordered students, on the
    other hand, that is because you view this as a mission?
        Mr. Nance. Absolutely. We accept, and based on our approval
    of that person coming into the program, we will do an interview
    with them. Before they come into the program, the courts or the
    public defender or prosecuting attorney will call us and ask us
    to do an interview with this person, and then we'll work with
    them, and the judge sentences them to Teen Challenge for a
    year.
        Mr. Souder. You would have to have, and I gave you some of
    the guidelines with that, is that if you were in those court
    structures programs, able to delineate certain things, like bus
    services or things where there is not proselytization with
    government funds, you might be able to recoup some costs. But
    as long as they are going to the substance of the program that
    ultimately is dependent on individuals committing their lives
    to Christ or changing through some court commitment, we are not
    likely to ever clear that, for reasons to protect Teen
    Challenge as well as the government.
        I thank you for testifying today and also thank you for
    your work in central Florida. I wish I could hear the next
    panels. I went through your written testimony. And will
    continue to work on the treatment.
        Mr. Mica. Thank you, Mr. Souder.
        I am pleased to recognize the ranking member of our
    subcommittee, Mrs. Mink, at this time.
        Mrs. Mink. Thank you very much, Mr. Chairman.
        I would like to join my colleague, Mr. Souder, in
    expressing our profound respect for your mission, Jo-Anne
    Murwin, for your uplifting testimony and for your recitation of
    your enormous personal struggle, which you have translated to a
    social dimension, and by doing so, emphasize the importance of
    our treatment and prevention programs.
        So we cannot lose sight of that essential ingredient, in
    whatever we do regarding drug policy, it is important to look
    at the worldwide production and interdiction by law enforcement
    programs. But our primary goal must be helping and finding a
    way to rescue all the people in our society who are troubled by
    drug abuse and drug addiction. So I commend you for the steps
    that you have taken, your determination and you are certainly
    an example and role model for the program and for all the
    people that we are trying to get help, you are certainly a
    shining example. So I want to commend you personally for what
    you have done.
        Mrs. Mink. Dr. Giuliani, I am interested in the State
    funded programs that you mentioned in Florida, that the State
    has only 6,933 beds?
        Dr. Giuliani. Yes.
        Mrs. Mink. Is that with only State funds?
        Dr. Giuliani. That is Federal and State funded.
        Mrs. Mink. What is the estimated total need for the State
    of Florida?
        Dr. Giuliani. I would estimate there is probably a need for
    about 12,000 beds.
        Mrs. Mink. 12,000 beds, even though you say there are
    722,000 adults that are in need of treatment in Florida?
        Dr. Giuliani. Not all of these people are seeking treatment
    at the same time. As you can see, there are only 700 on the
    waiting list right now. That means that those people are the
    only ones desirous of help and seeking treatment at the time.
        Mrs. Mink. To what extent is residential treatment
    necessary for treatment of addiction? Can you have an
    outpatient kind of program that is going to work as well?
        Dr. Giuliani. I won't say that outpatient does not work,
    because it does work in some instances. The people I personally
    see, and the clients I have, normally have lost everything. So
    you are looking at--they have nowhere else to be. It is
    difficult to come into an outpatient session for 2 hours a day
    and then go back to the community or stand on the corner where
    everybody is using and selling drugs.
        So being an inpatient, it brings them out of that
    environment and makes them feel safe and protected. It also
    gives them a chance not to have the contact, to be able to
    change themselves and see that there are other people and other
    ways to change.
        Mrs. Mink. What is the total cost of the Florida treatment
    program? How much is the State spending?
        Dr. Giuliani. I can't answer that right now. I can tell you
    how much I get from----
        Mrs. Mink. I am sure that the chairman can provide those
    figures.
        Mr. Nance, I am concerned also, as Mr. Souder indicated,
    about how within the constitutional requirements of the
    separation of church and State we can provide such basic things
    as food and health care while not transgressing the
    requirements of the law to keep religion and State separate. So
    I am curious about the fact that 20 percent of your cases are
    court ordered. If they are court ordered, then there is a
    compulsory conjunction of a State service with your agency.
        How do they justify that then if they are not going to
    justify your licensing?
        Mr. Nance. I think basically they are looking for beds to
    place people that have addiction problems; and the court
    system, I think 80 percent of the inmates in the State of
    Florida are drug-related inmates. Because of that, they don't
    have beds and they are looking for programs that will help
    people; and when a public defender or a prosecuting attorney
    offers this as an option to a judge, it gives a judge an
    opportunity to do something. They know that they are not going
    to pay us for our services, but it is basically, as Mr. Souder
    mentioned, that is our mission to help people.
        We interview the student and let them know that it is a
    faith-based program, and if they are in agreement with what we
    are doing and how they will be treated in the program, we will
    accept them, based on that. And whether they choose Christ or
    not, they are still accepted in the Teen Challenge. That is
    part of the program. We are not going to cut the chapel out.
        Because of that, every time we look at a relationship with
    the Department of Corrections, there is always the required
    chapel that we will not compromise because we feel that the
    faith in God is an absolute, key part. We accept them and that
    is a good place to put some of the individuals coming before
    the judges that are seeking help.
        Mrs. Mink. Has there been any inquiry with respect to the
    constitutional compliance of the courts ordering residential
    care in your youth challenge?
        Mr. Nance. We have not done any.
        Mrs. Mink. There has not been any constitutional question?
        Mr. Nance. Not to my knowledge.
        Mrs. Mink. The State doesn't pay you at all for housing
    these youth offenders so that there is no expenditure of State
    funds?
        Mr. Nance. That is correct.
        Mrs. Mink. So you can't use the court order as a basis for
    qualifying for food stamps and anything else?
        Mr. Nance. Not so far, because we are not State licensed.
    In our adult programs, we are licensed.
        Mrs. Mink. How does the court get away with commissioning
    the courts to an unlicensed facility?
        Mr. Nance. Our juvenile programs are licensed under the
    Florida Christian Child Care Agency. I don't know how they
    figure that all out.
        Mrs. Mink. Thank you very much.
        Mr. Mica. Mr. Cummings.
        Mr. Cummings. Thank you very much, Mr. Chairman.
        Ms. Murwin, I would like to congratulate you on your
    accomplishments. As I was listening to you, I couldn't help but
    think about the neighborhood that I live in where there are so
    many people who have not been able to overcome the challenges
    that you have, and they are in so much pain that they don't
    even know that they are in pain. And I want to thank you for
    your example, because I think your example is one that will say
    to other people that they can do it too. So I really do
    appreciate what you have done.
        I appreciate the fact that you have come here and divulged
    information that all of us would consider personal, but through
    your example, I think you will touch and continue to touch
    other people.
        I guess, as I was listening to our witnesses today, I am
    just curious, Mrs. Mink asked the question about whether in-
    house treatment was more effective. What do you all see as
    working? What works? I am convinced as I said a little earlier
    that there are folks when they see the almighty dollar, and our
    Federal dollars, when they see that dollar they will come up
    with facilities to do a job. And that is not to take away from
    those organizations that I know are doing a good job, but when
    it does when they are not doing what they are supposed to do,
    it causes Congress to say, why are we spending this money?
        I am one who is really protreatment, but I also know that
    is what I have heard over and over again ever since I have been
    here, are we wasting our dollars? Are we really affecting
    anybody or are we affecting the people that we think that we
    are?
        What do you all see from your experiences that works? I
    know it is not going to work for everybody and I understand
    that. But to get maximum effectiveness, I guess that is what I
    am trying to get to.
        Mr. Nance. I can only speak for Teen Challenge, but I know
    that a crack addict who is addicted to crack cocaine is not
    going to make it in an outpatient program. It is not going to
    happen. If you find one, it will be a very rare person that can
    stay off crack cocaine; or someone that is mainlining heroin,
    they are going to have a very difficult time.
        Mr. Cummings. Why is that?
        Mr. Nance. It is the nature of the drug. It consumes every
    emotion. Every thought of the day is consumed with that
    addiction. They wake up in the morning asking the question,
    where am I going to get the money for the crack? They know
    where they are going to get it; the question is, what am I
    going to steal today? How am I going to get that money? That is
    what they are thinking; they are not thinking about, how can I
    get treatment? It is because the nature of crack cocaine does
    that to their person.
        Long-term treatment is the success of Teen Challenge. Of
    course, we believe in the faith-based component of the program,
    but also it is the time. We are a 1-year residential program
    for adult men and women and even longer for some of the
    juveniles. Because of the length of stay--and when you say you
    are going to get a crack addict off of drugs in 18 to 28 days,
    I am going to tell you, good luck. Even though there are some
    very good 28 day programs, most crack addicts need longer care
    than 28 days to get free from drugs.
        I think there are individuals that can get help in
    outpatient kinds of programs. We have some of those, but by and
    large, if they are in a community where there are drugs
    available, they find it very, very difficult not to use.
        Mr. Cummings. What is done once they are in treatment to
    get them where you are trying to get them to?
        Mr. Nance. I can only speak for Teen Challenge.
        It is discipline. It is healing their relationships with
    themselves and with their families because they have got a lot
    of burned bridges. We work with them to heal that. Then we try
    to help them accept themselves, that they are not losers and
    forever damned to addiction. We teach them job skills and job
    training so when they graduate Teen Challenge they will have a
    career that won't pay minimum wage, and can have a career in
    computers or whatever, that they can make a living beyond.
        Because it is just like the prostitute in the street, you
    tell her that I will put you on minimum wage and they make $300
    in a week, they can make that in a night or an hour. It is real
    hard to survive on $300 a week in America.
        We have to meet that need while they are in treatment of
    giving them life skills that they can make, and that is why the
    values training, the biblical training of honesty and trust and
    not manipulating, those are the principles; and a lot of the
    State programs teach the same principles of dealing with your
    anger and the issues of life, you have kids growing up--we have
    a kid at 7 years, his father put a rubber strap on him and
    stuck the first shot of heroin in his arm and laughed at him as
    he fell around the room. We have other guys with cigarette
    burns on their skin. These kids are angry and they are mad as
    heck at the world. They want drugs to just deal with the pain.
        Mr. Cummings. Mr. Nance, what kind of area do the young
    people that you work with come from? Is it a rural area?
        Mr. Nance. It is everything. It is costs--there are inner
    city kids and country boys. There are kids and young adults
    coming from all walks of life. We have people flying in
    Learjets, dropping their kids off, and people sleeping behind
    trash cans. Take your pick.
        Mr. Cummings. How long have you been doing this?
        Mr. Nance. Eighteen years.
        Mr. Cummings. We get all of these reports from the drug
    czar from everybody. We get report after report telling us teen
    usage is down. Teen usage is up; we get a whole lot of data.
        In your 18 years, can you kind of tell us--and this will be
    my last question--what you have seen? The differences in who
    you see, what kind of people you see, was there one time, for
    example, just about the only people you saw were African
    Americans or Hispanics, and now do you see a change? Has it
    been constant? Was there a point in time when you saw things
    sort of explode? Can you answer that for us?
        Mr. Nance. Yes, there are a lot of questions there. There
    are all different races that come. Fifty percent of our student
    population are black, 40 percent are white and the other 10
    percent are Hispanic in Florida and Georgia. Across the Nation,
    that range will differ.
        There have been changes. We are seeing more and more heroin
    addicts coming to Teen Challenge for help, but the last 10
    years it was crack cocaine, 90 percent of the students coming
    to Teen Challenge for help; and these would be predominantly 18
    years old and above, were coming because of crack cocaine.
        We had an executive with Winn Dixie Corp. that came to Teen
    Challenge for help. He had gone through several short-term
    programs and had gotten fired and kicked out because of drugs,
    because of short-term programs. But now we are seeing more and
    more heroin.
        We don't see as many addicted--the juveniles didn't used to
    be addicted, but we are seeing more and more juveniles addicted
    coming to us than we used to see. The ones that started playing
    around at 9, 10, 11 years. They tend to do that during the
    experimentation stage, and by the time they are 17 and 18, they
    are addicted. We are seeing 14- and 15-year-old kids addicted
    to drugs. They don't care about anything in the world but
    getting drugs. They will stab you, sell their body, whatever
    they need to get drugs. And the youth are more violent today
    than ever before.
        Mr. Cummings. Thank you, Mr. Chairman.
        Mr. Mica. Dr. Giuliani, do you receive State or Federal
    assistance?
        Dr. Giuliani. Yes.
        Mr. Mica. Both?
        Dr. Giuliani. We have Federal block grants, and then we
    receive Department of Children and Families funding.
        Mr. Mica. Have you ever gotten a discretionary grant?
        Dr. Giuliani. No.
        Mr. Mica. Let me ask you a question. How much do your
    expenditures in your program total?
        Dr. Giuliani. About $255,000.
        Mr. Mica. For the year?
        Dr. Giuliani. Yes.
        Mr. Mica. How much is your program, Mr. Nance?
        Mr. Nance. For 12 facilities and 350 beds it is $3.6
    million.
        Mr. Mica. Ms. Murwin, did you go through both public and
    private treatment programs, or just public?
        Ms. Murwin. Public.
        Mr. Mica. How many?
        Ms. Murwin. Just one.
        Mr. Mica. Was that one successful the first time around or
    did you ever have repetitive experiences?
        Ms. Murwin. No, it was successful the first time, but I did
    end up staying there for 6 months. It was supposed to be a 30-
    day treatment, and after 30 days I knew that I was not ready to
    go out into the world so I stayed there 5 more months.
        Mr. Mica. Did you have to wait for treatment?
        Ms. Murwin. Yes. I had to go home and wait, and I continued
    to use drugs. The only reason that I ever ended up in treatment
    was because my sister was already clean. She had gone through a
    couple of treatment centers herself, and she grabbed a hold of
    me and kept me. She, like, baby-sat me until I got into
    treatment.
        Mr. Mica. So long-term treatment, once you got it, was
    successful?
        Ms. Murwin. Yes, sir.
        Mr. Mica. Are you familiar with others who participated in
    these programs?
        Ms. Murwin. Yes, sir.
        Mr. Mica. And similar success?
        Ms. Murwin. Yes, sir.
        Mr. Mica. Thank you.
        One of the frustrations we have is we have almost doubled
    the amount of money in treatment in the last 7 years, and I
    think, in the last 5 years, have had substantial increases, I
    think somewhere in the neighborhood of 26 percent trying to get
    the money to the programs.
        Your $255,000 and your program--in my opening statement I
    showed the way the dollars are spent in Washington. What do you
    think of 73 people in the administrators office of the national
    program, what do you think about 11 percent of the staff being
    used to administer 80 percent of the funds in the program, and
    then 89 percent of the staff--now, this is not peanuts; this is
    $155 million in administrative costs.
        $155 million in administrative costs going to Washington. I
    was absolutely stunned at the cottage industry that is built up
    around the Beltway. That is just the administrative costs. If
    we adjust the amount of money in some of these evaluation
    programs which, in my estimation, may be duplicative of NIDA's
    efforts and some other efforts, you have $64 million or 64
    percent of the contracts specifically identified for technical
    assistance and evaluation for the grants. We are up to a
    quarter of a billion dollars in overhead.
        What do you think?
        Dr. Giuliani. Sir, it is way too much. I know that when----
        Mr. Mica. Doesn't that warm the cockles of your heart to go
    back and know that your Congress is increasing the money, and
    we have created an incredible bureaucracy? These people are
    feeding off of--I could name the firms here in contracts to
    help even prepare the forms to give to the bureaucrats to
    review.
        Dr. Giuliani. For every dollar I receive, and speaking to
    Mr. Nance, if I spend 1 hour with a client, I am spending 45
    minutes doing paperwork on that client.
        Mr. Mica. I'm sorry, would you repeat that for the record?
        Dr. Giuliani. For every 1 hour I spend with a client, I am
    spending 45 minutes on paperwork for outcome measures,
    reporting to the State, reporting to the District and reporting
    to the Federal Government. And it is not uniform.
        Mr. Mica. What is absolutely incredible to me for the
    benefit of the ranking member, who is with me, and the record,
    I attended the drug summit we held at the State level and asked
    the department, Florida Department of Children and Family
    Services, to list--to give me a list of the programs; and there
    are 22 State grant programs awarded to Florida, 19 received by
    organizations that already either receive block grants or State
    funds for providing substance abuse services.
        So we are spending all of that money and all of that
    administration to do basically the same thing over again. It is
    absolutely mind-boggling.
        I am going to put the subcommittee and the House on notice
    that when their appropriation comes up, I will do everything,
    including stopping the proceedings of the House, by calling for
    successive motions to adjourn until we take the money from this
    overhead and put it into these treatment programs.
        So everybody is on warning here. We are going to find a way
    to get that money out of these bureaucracies and these blood-
    sucking Beltway bandits into the programs.
        I thank you for coming. You won't get anything out of this,
    Mr. Nance, because you don't even participate, nor do you get
    the opportunity to fill out those forms. That is a blessing.
    But we will see what we can do to try to make your programs
    eligible for some of the requests that you have made that sound
    reasonable.
        I appreciate your coming here and helping us do a better
    job to serve those who need service and particularly thank you,
    Ms. Murwin, for your testimony today.
        Mr. Nance. Thank you.
        Ms. Murwin. Thank you.
        Mr. Mica. We will excuse this panel.
        I would like to call the second panel.
        Ms. Janet Heinrich, U.S. Health Finance and Public Health
    issues with the GAO; Mr. Paul Puccio, executive deputy
    commissioner of Alcoholism and Substance Abuse Services,
    Albany, NY; Dr. John Keppler, clinical director of the
    Commission on Alcohol and Drug Abuse, Austin, TX; Dr. Kenneth
    Stark, director of the Division of Alcohol and Substance Abuse
    of Olympia, WA; and Dr. Martin Iguchi, co-director, Drug Policy
    Research Center, RAND Corp.
        Mrs. Mink, I am going to excuse the third panel today, Dr.
    Camille Barry, and ask them to come back; and if necessary, I
    am going to also subpoena the Director of the office, Mrs.
    Chavez, who is the administrator and who we invited today and
    is not coming today. So I am excusing at this point--with your
    permission, we will have her back, and Camille Barry, to
    respond to both of us and also have a full opportunity to
    respond to what has been brought up here today.
        So this will be our final panel.
        Mrs. Mink. I agree with that, Mr. Chairman.
        Mr. Mica. Thank you.
        At this time, as I mentioned to the previous panel, if you
    didn't hear me, this is an investigations and oversight panel.
    I would like you to all rise, please, and be sworn.
        [Witnesses sworn.]
        Mr. Mica. As I informed the previous panel, if you have
    lengthy statements or documents you would like entered into the
    record, upon request, we will grant that accommodation. I think
    we have everybody seated now.
        I would like to start with the General Accounting Office,
    Ms. Janet Heinrich. You are Associate Director of Health
    Finance and Public Health Issues. Welcome, and you are
    recognized.

       STATEMENTS OF JANET HEINRICH, ASSOCIATE DIRECTOR, HEALTH
       FINANCE AND PUBLIC HEALTH ISSUES, U.S. GENERAL ACCOUNTING
    OFFICE; PAUL PUCCIO, EXECUTIVE DEPUTY COMMISSIONER, ALCOHOLISM
        AND SUBSTANCE ABUSE SERVICES, ALBANY, NY; JOHN KEPPLER,
       CLINICAL DIRECTOR, COMMISSION ON ALCOHOL AND DRUG ABUSE,
     AUSTIN, TX; KENNETH STARK, DIRECTOR, DIVISION OF ALCOHOL AND
        SUBSTANCE ABUSE, OLYMPIA, WA; AND DR. MARTIN IGUCHI, CO-
           DIRECTOR, DRUG POLICY RESEARCH CENTER, RAND CORP.

        Ms. Heinrich. Thank you, Mr. Chairman and members of the
    subcommittee. I am pleased to have the opportunity to testify
    on the Substance Abuse and Mental Health Services
    Administration's efforts to support an effective drug abuse
    treatment system.
        We are releasing the report to you that you requested on
    SAMHSA's funding for drug abuse treatment-related activities
    and efforts to determine whether funds provided to States
    support effective drug abuse treatment programs. I will
    summarize the key findings of our report in which we described
    the activities supported by SAMHSA for drug abuse treatment,
    both the block grant and the knowledge development and
    application grant programs, SAMHSA and State mechanisms for
    monitoring fund use, and SAMHSA and State efforts to determine
    the effectiveness of drug abuse treatment supported with block
    grant funds.
        The Federal Government has made a considerable investment
    in drug abuse treatment-related activities, about $581 million
    in fiscal year 1996 which is the latest year of complete block
    grant data. Of these funds, more than 80 percent was spent by
    all States for treatment services funded through the block
    grant program.
        To better understand the types of services States provide,
    we surveyed 16 States that received at least $25 million for
    their fiscal year 1996 block grant. The States we surveyed
    support a range of services, primarily in outpatient settings.
    Methadone treatment expenditures ranged from 2 percent to 50
    percent, in part demonstrating the flexibility States have in
    determining the services supported by block grant funds. States
    also use State funds, other Federal funds, such as Medicaid,
    and county funds to support drug abuse treatment services.
        Block grant set-aside dollars, about $25 million were used
    for technical assistance contracts requested by the States and
    program evaluation efforts. Examples of technical assistance
    include redesigning treatment policies and procedures,
    establishing cost-effective treatment models, and training
    seminars. SAMHSA spent the remaining funds, approximately $78
    million, for KDA grants to determine the effectiveness of
    selected treatment practices, expand the availability of
    treatment services for specific locations and populations, and
    promote the adoption of best practices in treatment techniques.
    To help improve the overall quality of substance abuse
    treatment and facilitate the adoption of current knowledge
    about effective interventions, SAMHSA has developed treatment
    protocols by bringing together clinicians, researchers and
    policymakers. This effort is coordinated with the National
    Institute on Drug Abuse.
        SAMHSA monitors grantee use of funds through onsite
    reviews, and reviews of independent financial audit reports and
    grant applications. These mechanisms are used to monitor
    grantees' compliance with program requirements, identify
    grantees' technical assistance needs, and provide grantees
    guidance for improving program operations. The current
    accountability system for the block grant is mostly based on a
    review of State expenditures designed to determine whether
    States comply with statutory requirements.
        SAMHSA does not track States' responses to deficiencies to
    determine if they are resolved, nor does SAMHSA focus on the
    outcomes or effectiveness of States' drug abuse treatment
    programs.
        Several State and SAMHSA efforts are under way to determine
    the effectiveness of drug abuse treatment programs, using
    client outcome measures such as substance use, employment, and
    in criminal activity. Nine of the States we surveyed conducted
    such assessments, but the outcomes measured, the populations
    assessed, methodologies used and availability of results vary
    from State to State, making an overall program evaluation
    impossible.
        SAMHSA is funding a pilot effort with 19 States to develop
    and report on uniform core client outcomes. SAMHSA has also
    asked all States to voluntarily report client outcome data in
    the year 2000 SAPT block grant application. This effort will
    not yield consistent data because some States are not currently
    collecting the outcome data requested.
        SAMHSA has supported two national studies that suggest some
    drug abuse treatment can be effective in improving outcomes,
    such as decreasing substance use and criminal activity.
        In conclusion, there are efforts under way to determine
    program effectiveness. While SAMHSA monitors State expenditures
    to determine whether block grant funds are used in accordance
    with statutory requirements, monitoring is not designed to
    determine the effect State drug abuse programs are having on
    client outcomes. A few States have systems in place from which
    lessons could be learned about measuring the effectiveness of
    treatment, using client outcomes. All of these efforts should
    help to determine what additional actions are needed to obtain
    uniform State reporting on the results of drug abuse treatment.
        Mr. Chairman, this concludes my statement and I will be
    happy to answer any questions that you or other Members may
    have.
        Mr. Mica. Thank you. We will withhold questions until we
    have heard from all of our witnesses.
        [The prepared statement of Ms. Heinrich follows:]
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        Mr. Mica. I recognize Mr. Paul Puccio, executive deputy
    commissioner, Alcoholism and Substance Abuse Services from
    Albany, NY.
        Mr. Puccio. Thank you, Mr. Chairman. It is a pleasure to be
    here. I am going to speak the highlights of my written
    testimony and sort of summarize the basic points we want to
    make.
        First, I want to set a context. The New York State system
    is a large and comprehensive delivery system. It is
    approximately $1.3 billion on an annual basis to pay for
    prevention and treatment services. That is the publicly funded
    system. The block grant approximates about $100 million of that
    amount. There are about 125,000 people on any given day in the
    treatment system; about 250,000 people are treated annually. It
    is a very large and comprehensive system.
        But I want to point out two very important factors. One is
    that the gatekeepers for admission to the system are very
    diverse and multiple in a State like New York. We have judges
    from drug courts to the traffic courts to family court; DAs,
    you mentioned the DTAP program, on the social welfare side,
    employment side, all of them have authority to mandate people
    into treatment. Approximately 40 to 50 percent of all the
    people in the treatment system are there because of some form
    of mandate.
        Also, the system does not exist in isolation of other human
    service systems. Successful alcohol and drug treatment services
    don't arise only out of the treatment system; they arise out of
    a complementary set of services associated with the provision
    of health care, mental health services, housing services, child
    welfare services, and it goes on. Systems operate in some sort
    of synergistic fashion in order to make a difference for the
    lives of people enrolled.
        The other thing to understand is that all of these systems
    that send people to us, all of the gatekeepers are demanding
    expectations of the system. They all are looking for points of
    accountability and for good outcomes of treatment. That is an
    important understanding because it relates directly to the
    reporting requirements that fall to the system. Everyone is
    accountable to multiple gatekeepers and there are multiple
    systems of accountability that are cumbersome and difficult for
    our providers, and for States and county governments, as we
    deal with these demands for accountability.
        I would also point out that one of the things that happens
    in a State like New York is that we, as the single State
    agency, play a very significant role as systems managers. We
    are not only managing our own system of services, which is very
    complex and extensive, but we are also doing it in relation to
    other service delivery systems; and that is an important
    understanding about what we do at the State government level.
        This system did not get built without a long-term
    partnership with the Federal Government. Federal agencies
    working with State agencies, working with county governments
    and providers helped build the system over a long period of
    time. The block grant sustains a portion of that system, and
    KDA local funding was used to incrementally improve the system
    with an infusion of technology, as well as to provide
    additional services which complemented and added to the
    richness of the service delivery system.
        It is also important to know that technical assistance that
    is provided by SAMHSA is a valuable commodity to the States. We
    in New York use technical assistance to provide managed care
    training to our providers as they begin to enter the world of
    managed care. They needed to get up to speed, and that was an
    important element in terms of using those resources to train
    those providers.
        The system is very accountable. We have shared with the
    committee copies of our evaluation studies. We are doing very
    well in terms of demonstrating the effectiveness of our service
    delivery system. That effectiveness is enhanced by the multiple
    points of accountability. Everyone wants the same things in
    terms of outcome, and we are beginning to see significant
    improvement.
        We are beginning to allocate our resources in the State of
    New York based upon provider performance. Not only must you do
    well, but you must be increasing standards and do so in a cost-
    effective, cost-efficient manner. We are pleased with that.
        I would say to you that we have a concern with regard to
    the future of the system, in particular our relationship with
    the Federal Government. We have a very rich and diverse system.
    It is unique to New York; no two States are the same in terms
    of the service delivery system. It is important when moneys
    flow into the State of New York, there is a dialog and
    discourse with the State agency about how things will fit; if
    they don't fit well, there is the potential that there will be
    ineffective use of those resources. It is important that money
    flow through the State in a way that allows us to assure its
    integration into the system.
        We also are very concerned about data reporting, and this
    is a major issue for us. As I mentioned, the multiple systems
    of accountability, we see a lot of that and we cannot have
    multiple systems lying on top of multiple systems.
        We in New York have built a significant information system
    that supports accountability in our State. As we look to the
    future for new reporting requirements that come from the
    Federal level, it has to be integrated carefully with what we
    do, and we need that to occur so there is not an inappropriate
    disinvestment in the already expensive information systems that
    we have in place.
        The bottom line is that we see the need, as we look to the
    future, for increased flexibility in the use of the block grant
    in terms of being able to accommodate the emerging needs and
    the changing needs. We need systems of accountability that
    integrate Federal, State and local and provider concerns and
    are not competitive and result in dislocation and disruption;
    we also need a continuing partnership with the Federal
    Government that basically produces an effective local service
    delivery system such as we believe that we have in the State of
    New York.
        Thank you.
        Mr. Mica. Thank you for your testimony.
        [The prepared statement of Mr. Puccio follows:]
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        Mr. Mica. Dr. John Keppler, clinical director, Commission
    on Alcohol and Drug Abuse from Austin, TX.
        Welcome, and you are recognized, sir.
        Dr. Keppler. Mr. Chairman and members of the committee, I
    thank you for allowing me to be here. At the outset, I am
    submitting this packet of information from Texas for the
    record.
        Mr. Mica. Without objection, that information will be made
    part of the record.
        Dr. Keppler. I will summarize some of my thoughts from my
    little prepared talk today.
        I spent 15 years in the direct delivery of service both in
    private practice at the faculty of a medical school and
    rehabilitation medicine and being a medical director and direct
    service provider to individuals with this problem, both in
    detoxification and active treatment, both inpatient and
    outpatient in the public and private sector. And so in my last
    2\1/2\ years of going into different kind of public service, it
    has been an interesting perspective to see the struggles which
    the country faces.
        Texas, as does the rest of the country, faces an immense
    struggle with what I prefer to call an epidemic of substance
    abuse. The availability of the substance throughout our society
    as an agent that causes many people to fall ill, like any other
    illness that we face. Against the overwhelming need and demand
    for these services are rising health care costs and costs
    shifting from private to public sector, where the public-sector
    dollar for substance abuse literally becomes one of the few
    places you can obtain what one would refer to as adequate
    substance abuse treatment services.
        Again, the dollars being so precious, the quality of
    outcome and the quality those services provided is very
    important. The substantial portion of total available publicly
    funded substance abuse services outside criminal justice comes
    from the substance abuse prevention and treatment block grant
    in our State.
        We have worked closely with SAMHSA over the years on
    several policy matters, including the difficult issues
    surrounding services to those with both mental health and
    substance abuse problems; and Texas is about to implement the
    children's health insurance program, and is proud of the
    excellent benefits for substance abuse prevention and treatment
    that it contains. It is perhaps one of the largest benefits in
    the country for our children.
        We are grateful for SAMHSA's clear leadership on that and
    very grateful for the collaboration between SAMHSA and NIDA,
    for the excellent technical assistance we have received; and we
    appreciate their publications. That has helped and trained a
    lot of folks in the public sector. They are very readable and
    extremely helpful.
        We served about 40,000 people with the substance abuse
    prevention and substance abuse block grant, and as you heard
    from the doctor who was here before, you can quintuple that
    number who actually need and want services. There is more than
    just need, but as we define want, you can quintuple that number
    to around 250,000.
        We have some concerns. We are concerned about the KDA
    projects. They are well intentioned, but SAMHSA's involvement
    is time limited. When SAMHSA is out, it is up to the State to
    continue the program, a program that may not fit into our
    service plan. In Texas, SAMHSA has helped us develop a strong
    data collection system, and that system coupled with our
    knowledge and need surveys puts our State in the unique
    position to make the best and most efficient use of funding
    currently being awarded through Federal KDA grants.
        We are excited, though, about the 19 States participating
    in the treatment outcome and performance pilot studies, and we
    believe this project has a great potential to develop
    standardized methods to measure the effectiveness of our
    programs, particularly in the area of looking at outcomes from
    the aspects of case mix adjustment, which I believe we need to
    do in our field very strongly. We have collected outcome data,
    performance outcome data since 1985 and get outcome data on 70
    percent of our clients, which I have included in this packet.
    We know it works in Texas. We also know where the problems are.
        With the support of SAMHSA, we utilize a great deal of
    epidemiological data to help us monitor the drug trends in our
    State. I believe our emerging epidemiologic studies are very
    important.
        I would like to say how much we appreciate SAMHSA's
    national leadership. Certainly that leadership has helped Texas
    strengthen and develop our data collection tools. Now we would
    like to use these tools to be able to make all of the relevant
    funding decisions in the State.
        Giving the States control over the money currently set
    aside for KDA will preserve the best parts of this program. The
    money will meet the needs of the most vulnerable populations
    and develop innovative services. That is what we are already
    doing at the State level. We need the added flexibility to
    ensure that the money devoted to these projects are pursuant to
    our State delivery plan. This change would help us better meet
    the unique needs of Texans struggling with addiction, and that
    is a mission that I share with the Federal.
        Thank you for an opportunity to testify today. On a
    personal and professional level, I have struggled with this
    issue in the private and public sectors. I relate extremely
    strongly to the previous panel members, who are out there on
    the front lines, and respect their work. Thank you.
        Mr. Mica. Thank you.
        [The prepared statement of Dr. Keppler follows:]
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        Mr. Mica. Now I recognize Kenneth Stark, director, Division
    of Alcohol and Substance Abuse from Olympia, WA.
        Mr. Stark. Thank you. I will try to be as brief as
    possible. I would like to take a few minutes to respond to some
    of the questions that came up during the previous panel. When I
    speak about those issues, I will touch on them relative to
    Washington State because, as has already been stated by Paul
    from New York, each State is somewhat different. There are
    different needs and resources and different systems that have
    been built, although they all try to focus on serving the best
    practice possible, given the demands for those resources.
        Let me first mention that our division is the single State
    agency responsible for managing block grant resources. In the
    State of Washington, we get about $30 million a year for the
    block grant, out of a total of $110 million per year budget for
    prevention, treatment and related support services. So you can
    see that the block grant is a part of our budget but not by any
    way, shape or form the largest part. We have a fairly
    substantial State investment in services.
        One of the things I heard earlier is that treatment is
    expensive, and part of the context of that is, compared to
    what? When you look at alcohol, drug problems, and particularly
    when you get to issues of chronic addictions, we know at least
    in Washington State, and I am sure that these numbers are not
    that different nationally that more than 50 percent of all
    emergency room visits that are related to trauma are alcohol-
    or drug-related. We know that a good 82 percent of the kids
    locked up in our State juvenile correctional facilities have a
    substance abuse disorder. Seventy percent of the people in
    jails and prisons have a major problem.
        We know that when we provide treatment, those numbers are
    substantially impacted. People get better. So the question is:
    Is alcohol/drug treatment expensive? Well, in the context of
    spending nothing else, maybe it is, but in the context of
    spending money on the consequences of not funding alcohol/drug
    treatment, alcohol/drug treatment is cheap.
        In the State of Washington, in the public sector, the
    average cost of alcohol-drug treatment per client is about
    $2,500. That includes our so-called failures and our so-called
    successes; it is not that expensive. We know from a lot of data
    collection and a lot of research that we have done--and this is
    not just self-reported data, but this is verifying data from
    other records, including criminal records, vital statistics,
    birth records, medical records--that when you provide alcohol/
    drug treatment compared to a population that needed that
    treatment that is comparable and didn't get it, there are
    significant cost savings. Even after accounting for the cost of
    the alcohol and drug treatment, it more than pays for itself.
    And in Washington we have been fortunate to have major support
    from the Governor and major support from our State legislature
    and some of the other program areas that have seen our data and
    know that when you fund alcohol/drug treatment, you are funding
    health promotion/crime prevention. It is a key issue.
        Treatment standards were mentioned earlier. It is important
    to have treatment standards. I can't tell you a thing about
    programs that are out there in the State of Washington that are
    not certified and accredited by us because we don't monitor and
    regulate them, and so we don't research them; so I can't tell
    you about those. I can only tell you about the ones that we
    fund, we regulate and we accredit.
        Faith-based services, we do fund faith-based services, but
    there is that issue, and it is a Federal one, about you cannot
    force somebody to go to chapel or go to church. So we have got
    faith-based organizations who are accredited by us and are
    funded by us, but the faith-based part of the program for the
    clients that we fund has to be optional.
        Six percent SAMHSA administration, is that good or bad? I
    couldn't tell you by looking at that chart. I can tell you that
    the administration in our division is 6 percent, and I don't
    see that as expensive, assuming that you know what the other
    services are that get funded with that. In our division, 6
    percent covers budgeting, contracting, contract monitoring,
    evaluation, training, technical assistance.
        So is 6 percent expensive? In our division, no. As a
    general number, I would say no. In this case, on that chart, I
    can't tell you; I would have to look at all of the details.
        What are some of the issues? SAMHSA positive stuff. I am
    moving faster now. Clearly technical assistance is helpful.
    Clearly the studies on evaluation are helpful. The State needs
    assessment grants that SAMHSA has funded are very helpful. What
    is problematic, the block grant is not a block grant, it is
    ``blockegorical.'' It has so many set-asides and requirements
    it is incredibly cumbersome to manage.
        Then the second bullet in my written testimony talks about
    the block grant application. You, Mr. Chairman, have talked
    about 400 hours to fill it out. Part of the reason is because
    the block grant itself, the congressional requirements are so
    categorical. SAMHSA has to require us to report on a number of
    different things, so they can get some relief by that.
        There is also a big push that I would like to make relative
    to a comprehensive research strategy and outcome-performance-
    based strategy. We lack one. There are a lot of activities
    going on, but we lack a comprehensive strategy within SAMHSA,
    as well as across the Federal agencies working in partnership
    with the States, to truly look at how we can best measure
    outcomes utilizing resources available. One of the problems is
    the institute funding for research, although it does a lot of
    good research it has very little relationship to the SAMHSA
    block-grant-funded programs. Why is that? The red light is on.
    I will close and answer questions later.
        Mr. Mica. You can finish. We give a little bit of breathing
    time.
        Mr. Stark. On the KDAs, good news and bad news. They have
    funded a number of good programs. The challenge with the KDAs
    is that there needs to be a stronger relationship between
    SAMHSA and the States relative to developing the priorities for
    funding with the KDAs, as well as the reporting protocols, and
    how it fits into a comprehensive strategy. So we think we could
    use some increased partnering there.
        I already talked about the NIDA stuff. There needs to be a
    closer link between the Federal institutes research and the
    block-grant-funded prevention and treatment programs.
        The national household survey, while it is a great tool for
    a national macro picture of the alcohol-drug use patterns and
    the problems, even with the new proposed State sort of
    monitoring processes, it will not be useful for States. Again,
    the number of people that will be included from the individual
    States are so small to render them useless for counties to be
    able to look at individual county-level needs. So there is a
    problem there.
        And the national household survey is not what I would
    consider low cost. It is a fairly expensive study, and it seems
    to me maybe we could look at how that could be made more
    efficient, and some money could continue in the SAMHSA budget
    to fund State needs assessment projects where you can get
    lower-level, county-level needs which at the local level you
    need.
        And then finally, my last point in the written testimony,
    how do we get more State representation in policy development
    relative to SAMHSA's activities? One of the ways to do that is
    on committees, including the current SAMHSA advisory
    committees, and having been on one of those committees, I can
    tell you, although they do good work and I appreciated being on
    it, there is minimal participation from States on those
    advisory committees. But there is significant grantee
    participation on those committees, and I think there needs to
    be more balance, since States are the predominant receiver of
    SAMHSA funding.
        With that, I will close.
        Mr. Mica. Thank you.
        Now I would like to recognize Dr. Martin Iguchi, co-
    director of the Drug Policy Research Center of the RAND Corp.
        You are recognized, sir.
        Dr. Iguchi. Thank you, Mr. Chairman, and thank you for this
    opportunity to testify. I ask that my written statement be
    entered into the record.
        Mr. Mica. Without objection, so ordered.
        Dr. Iguchi. As a member of CSAT's National Advisory
    Council, as a NIDA treatment researcher, as a psychologist and
    former drug treatment program administrator, and as co-director
    of the Drug Policy Research Center at RAND, I have spent
    considerable time thinking about SAMHSA's role as it relates to
    the provision of drug treatment in America.
        I am going to focus on one question: Is SAMHSA helping
    local and State communities to make the best use of their
    scarce drug and alcohol treatment resources? My discussion on
    this question involves three areas of SAMHSA activity in
    support of the community decisionmaking: one, helping
    communities to identify treatment costs, treatment utilization,
    and treatment outcomes; two, are they helping communities to
    determine where treatment is most needed; and three, are they
    helping communities to identify best treatment practices?
    SAMHSA plays a vital role in these areas, and as I will
    discuss, they continue to face many challenges.
        In the first area, communities need information to assess
    what treatment resources are in place, the cost of those
    resources and how those resources are performing. This is a
    very complicated process, as a single individual may utilize
    services from a variety of systems. For example, a single
    person may be enrolled in drug treatment, they may be getting
    treatment for depression at a community mental health center,
    they may be on Medicaid, and they could be involved with a
    criminal justice diversion program. Each system contacted by
    that individual keeps its own records in its own separate data
    base. In order to understand the coordinated cost of services
    utilized by a given individual requires a single data base
    integrating information from multiple systems.
        Recently in partnership with the States of Oklahoma,
    Washington and Delaware, SAMHSA developed a data base system
    capable of merging cost and utilization information from
    Medicaid, mental health and substance abuse systems. This
    integrated data base system represents an important step
    forward in that it overcomes significant technical obstacles
    and recognizes the multitude of agencies and resources that
    must be coordinated to evaluate service delivery.
        Although it would be ideal for all health delivery programs
    to monitor outcomes as a matter of routine, doing so can be an
    expensive and complicated proposition. This is particularly
    true for substance abuse treatment because followup is
    complicated by a distinct lack of resources in existing
    agencies to collect this information, by the illegal nature of
    the problem, by the low socioeconomic status of many in
    treatment, and by the multiple life dimensions positively
    influenced by treatment that need to be measured to fully
    reflect the effect of treatment.
        For example, treatment may reduce substance use, it may
    diminish criminal activity, it may diminish violent behavior,
    it may improve mental health, it may increase the likelihood of
    employment, or it may prevent the birth of a drug-exposed
    child.
        Recognizing the complications and expense of ongoing
    outcomes monitoring in community settings, SAMHSA has
    commissioned a working group specifically to address this
    issue, and they have entered into numerous partnerships with
    States to develop performance measures for a variety of
    treatment interventions. Quite appropriately, these groups have
    focused, to date, on a number of drug treatment process
    measures that may be used by communities as predictors of
    outcome. These intermediate measures might include, for
    example, the amount of substance use reduction, treatment
    retention, treatment engagement, patient satisfaction, or
    quality-of-life improvement.
        While significant progress has been made in the development
    of tools for assessing cost and performance, much work remains
    to be done in integrating cost and effectiveness measures.
    While this is not an issue for SAMHSA alone, the lack of
    consensus among economists regarding the best means for
    conducting economic evaluations of drug treatment programs
    means that the comparisons across different evaluations are
    compromised by a lack of reporting standards. This leads to
    decisionmaking guided by cost considerations alone--without
    adequate attention to effectiveness.
        On my second point of helping communities to determine
    where treatment is most needed, in 1998, the U.S. GAO reported
    serious deficiencies in States' abilities to develop estimates
    of treatment need. This problem continues. States still do not
    have capacity for assessing treatment need. SAMHSA's recent
    expansion of the National Household Survey on Drug Abuse to
    allow for State-level analyses represents a potential
    improvement in the availability of epidemiological data for
    communities. However, in order for this information to be
    useful to States, several problems must also be addressed.
        First, SAMHSA needs to place considerably more emphasis on
    releasing the data as quickly as possible to State analysts in
    a form that allows for analysis of regional need.
        Second, States require more technical assistance to develop
    systems for monitoring treatment need. SAMHSA needs to provide
    leadership in the development of analytic models that will
    allow States to make use of their own data. At this point,
    there is very little capacity.
        On the third point of helping communities to identify best
    treatment practices, SAMHSA has done an excellent job in the
    promotion of evidence-based practices. The addiction technology
    transfer centers and the treatment improvement protocols all
    play an important role in the dissemination of ``best
    practices'' guidelines.
        Another mechanism for promoting treatment quality is
    through accreditation. In the treatment of chronic opiate
    abusers, SAMHSA's new role in accrediting methadone treatment
    providers, formerly an FDA function, represents a tremendous
    move forward for the field and holds significant promise for
    the promotion of evidence-based practice.
        In addition to dissemination, SAMHSA appears to recognize
    that many community treatment programs already provide
    excellent care. SAMHSA has several projects that document and
    evaluate these model programs. SAMHSA also has a number of
    treatment projects that take empirically validated treatments
    and apply them in multiple community settings. These studies
    are important as they help to identify barriers to
    implementation, they demonstrate the real-world utility of
    interventions known only to researchers, they provide important
    information regarding cost cultural relevance, and they serve
    as models for policymakers and other treatment providers to
    consider.
        In summary, SAMHSA has clearly played a vital role in
    helping communities to make good decisions about their
    allocation of scarce treatment resources. However, and as might
    be surmised from my brief review, SAMHSA has several challenges
    ahead. In particular, SAMHSA has a great deal more work to do
    in helping communities to identify treatment gaps. In order for
    the expanded National Household Survey on Drug Abuse to be
    useful, a system must be put into place that will get the data
    to States in a form that they can use.
        Further, there is a tremendous need to upgrade the analytic
    capability of States and to provide them with technical
    assistance to make use of the data. This challenge must be met
    if communities are to make optimal use of their resources, and
    if we are to have full participation as a Nation in achieving
    the goals established in healthy people 2010.
        Thank you.
        [The prepared statement of Dr. Iguchi follows:]
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        Mr. Mica. I thank each of the witnesses for their
    testimony. Unfortunately, some of the other Members are not
    here. They canceled the floor proceedings, and there are other
    hearings, so we don't have the normal participation of all of
    the Members.
        For that reason, also, I have concurred with the minority
    in asking the final witness, Dr. Camille Barry, and also the
    administrator, Dr. Chavez, to appear at a later date so that
    will be a continuation of this hearing. We suggested also to
    staff that we may ask Dr. Leshner, the head of NIDA, to also
    participate in that, since we may need to look at the
    cooperative effort of NIDA and SAMHSA.
        With those comments, let me, if I may, ask some questions.
        First, for GAO. I notice on the GAO report table, for the
    27 of the 29 contracts, over $1 million are awarded to
    Washington, DC area contractors.
        Does this practice raise an issue of limiting business and
    range of knowledge to a particular area? Did you all look at
    that at all?
        Ms. Heinrich. We did not evaluate the contracting practices
    at your request. We simply obtained from SAMHSA the listing of
    the contracts that they do support. And as you state, I think
    almost 99 percent of them are in the Washington, DC area.
        Mr. Mica. How might GAO ascertain the level of satisfaction
    of the States with SAMHSA's involvement and contributions to
    their efforts?
        Ms. Heinrich. Well, we certainly could go out to the States
    and ask those types of questions. And certainly you have some
    wonderful representatives here that will be able to give you
    information on that, as well, I am sure.
        Mr. Mica. Could a comparison be made of States' support for
    increased block grant assistance versus discretionary funding?
        Ms. Heinrich. Yes, a comparison could be done.
        Mr. Mica. Now, I looked through the report, Mrs. Mink did
    too, and we may want to re-craft additional requests for GAO's
    study. It provides us some preliminary information, but I think
    not in the depth or scope that we would like to obtain. But I
    appreciate your cooperation with this subcommittee.
        I heard, New York and Texas and Washington, a little bit
    about your programs. Now, if you could recall for us on the
    committee the dollars that come from block grant and Federal
    sources versus State.
        Mr. Puccio of New York.
        Mr. Puccio. Our total system is about $1.3 billion. Half of
    that is Medicaid. About $100 million is the block grant and it
    is about $270 million in general fund tax dollars.
        Mr. Mica. $100 million is block grant?
        Mr. Puccio. Right. And about $700 million is Medicaid
    program.
        Mr. Mica. And the balance is State?
        Mr. Puccio. State, local tax levy, and miscellaneous
    receipts from public assistance funds and a variety of mixed
    revenues.
        Mr. Mica. How about you, Dr. Keppler?
        Mr. Keppler. I prefer--I can get you the information on
    Medicaid because that is administered by the Health and Human
    Services Commission, which is our umbrella agency. So our
    agency does not control the Medicaid substance abuse dollars,
    nor the dollars our legislature dedicates for the in-prison
    treatment, our criminal justice system.
        It is $122 million of the Federal substance abuse block
    grant, and I believe $27.5 general revenue for the programs we
    fund, publicly community-based projects outside Medicaid.
        Mr. Mica. Mr. Stark, for Washington?
        Mr. Stark. In Washington State, it is $110 million total
    budget. $30 million of that is Federal block grant funding. A
    little over $50 million are several sources of State funding,
    and the remainder is a blend of Medicaid and direct Federal
    grants.
        Mr. Mica. In looking at the regulations that pour out and
    the constraints that are put on these programs, it appears that
    many of the programs are driven by Federal regulation
    requirements. Is that correct, Mr. Puccio?
        Mr. Puccio. It is more driven in New York by our regulatory
    structure. Every treatment program is licensed and regulated
    and monitored by us. Whether it is faith-based or not, if they
    provide treatment in the State of New York, they are going to
    be subject to one of our licensing requirements.
        Mr. Mica. How does that overlap with Federal regulations?
    Are State regulations pretty much a mirror of Federal?
        Mr. Puccio. State regulations pretty much govern the
    service delivery side of things. Where the problem arises is
    that the set-asides and the other requirements that are
    inherent in the block grant basically put in place requirements
    and restrictions in terms of how it is that we use money. Any
    money that goes into the treatment system has to follow our
    regulations, but some of it has to be targeted at HIV, at
    people who are IV drug users, pregnant women. It goes on and on
    like that.
        With all the different set-aside requirements, depending
    upon the locality, they may or may not have demand or service
    requirements that fit that mix; and it's the mismatch of the
    requirements against the local need that sometimes causes the
    problem.
        Mr. Mica. So all of you three agree we need, first of all,
    more flexibility in the block grant program? All right.
        What about in discretionary grants? How do they work? Mr.
    Keppler, how does that work for you in Texas?
        Mr. Keppler. Well, as I tried to explain, I think it's
    somewhat problematic for us. In fact, we are oftentimes loathe
    to apply because it even limits our flexibility more. If we
    decide to go after something that has been decided upon that
    seems to fit what we might need, at some point in time it may
    go away and then we have to figure out how to shift things to
    pick that up and then catch the next one. So our desire to go
    after a significant sum of money which we would just prefer it
    go through the formula of the block grant and be distributed
    for us to plan, it is very hard to pick it up.
        Mr. Mica. Now, in your States, I asked Florida to provide
    me with a list of all the programs that receive grants and then
    see how many they were already funding. Would the pattern be
    similar that most of the discretionary grant money goes to
    programs that you already are supporting?
        Mr. Puccio. Absolutely. That is absolutely correct.
        Sometimes what happens is that the KDA may actually add an
    element of service that is missing from the service delivery
    system, especially in certain geographic areas. So we may have
    a need for specialized women's beds that serve women and their
    children in a particular area, and a KDA might fit that
    particular requirement, and then it does complement with what
    takes place in that geographic area, even though we may already
    have substance funding with that provider. It fills a gap.
        Mr. Mica. So in New York, in most instances, there is
    already going to be a program that is supported by the State?
        Mr. Puccio. Yes.
        Mr. Mica. Texas?
        Mr. Keppler. Again, I want to emphasize, some of the
    clinical ideas have been extremely helpful, they have been
    extremely helpful ideas, ideas about how to put processes in.
        Mr. Mica. If we had the cash, I think you could probably
    come up with some pretty good programs.
        Mr. Keppler. I wouldn't argue with that.
        Mr. Mica. Now, Mr. Stark, are most of the discretionary
    programs funded by the Federal Government that receive money in
    your State already funded also by the State?
        Mr. Stark. I would say probably around 60 to 70 percent.
    And sometimes within that 60 to 70 percent, what you end up
    going through the KDA is helping us expand capacity.
        One of the problems that results, though, is that expanded
    capacity is generally reimbursed at a rate higher than we
    usually pay; and then the other difficulty is, within the 30
    percent that are not tied to our system, without there being a
    connection when the Federal money runs out, they come to us and
    want to continue and, of course, they are not part of the
    existing system.
        Mr. Mica. So they may not be a part at the beginning, but
    you get them in the end?
        Mr. Stark. Well, in the end the pressure, once the Federal
    money goes away.
        Mr. Mica. Once it starts, someone is going to have to pick
    up the slack or the program. Not that these programs are not
    all worthwhile, but the astounding figure to me is the
    bureaucracy that is required, $155 million in overhead, the
    pure number of administrators to administer a smaller program.
        Now, I guess, Dr. Keppler, you gave quite an encouraging
    statement to fund these programs, and without these programs
    what a disaster we would have. That is not really the question
    before us. I have some pretty conservative members on the
    panel, and I have some pretty liberal members on the panel. I
    think to a man and woman on the panel, they will spend whatever
    is necessary no matter how conservative. Now, the liberals, it
    is easier for them to do just philosophically. But that is not
    the question here. The question is, the money that we are
    spending, is it being spent as efficiently as possible?
        I also could spend the rest of the afternoon talking about
    the bureaucracy to support the bureaucracy that we have
    created. I mean, I would imagine that many of the things that
    your folks in New York or Austin or Olympia, I would imagine we
    have forced you to employ administrators and evaluators. Maybe
    they are not spending 45 minutes filling out forms for an hour
    of treatment, as you heard, but I know that there is
    duplication in this.
        Then the other thing, too, I think everyone would agree we
    need some evaluation or measures of performance. We have got to
    have some accountability. About how many levels of this?
        Then, the thing that is astounding to us, too, is the lack
    of possible coordination between NIDA and SAMHSA in, say,
    research is important, some of the other things that are going
    on. So I think that maybe as a result of this hearing we might
    bring NIDA into the mix and see if anything can be
    consolidated.
        Again, the intent of the hearing is to see how we can get
    the money to the programs that are most successful, retain some
    accountability, provide the maximum amount of flexibility. And
    it sounds like most of the programs you are overseeing on a
    day-to-day basis, New York sounds like they have a pretty
    awesome control on these programs. And then there are probably
    areas, and maybe you could summarize these for me, there are
    some areas that only the Federal Government can provide
    assistance, and resources where it cannot be done effectively
    by the States or the local programs?
        Mr. Puccio, I will put you on the spot. Dr. Keppler is
    second. Mr. Stark, tell me what would be the best things we
    could do at the Federal level that would fill a gap and provide
    assistance, things that should be done at our level?
        Mr. Puccio. Two things, one of which is to focus on
    research and target it at the needs that are arising in the
    States. Good basic research is fine, but it also has to fit the
    needs that are arising out of the populations that are using
    drugs and out of the needs of the treatment providers.
        Mr. Mica. How is that filtered to SAMHSA or NIDA?
        Mr. Puccio. I think they have a variety of mechanisms,
    advisory committees and so forth, to surface that.
        Mr. Mica. One of the criticisms that I think Mr. Stark made
    is that we do not have a balanced representation. Would you
    agree with that?
        Mr. Puccio. I think that's fair. I'll also give you an
    example of sort of what I'll call an inventive approach to
    things. NIDA has been working to develop clinical trial
    networks which deal with the fusion of technology arising out
    of their research.
        There is an effort to look at research practice
    collaboratives, which we have used in the State of New York to
    build a relationship between our treatment providers and the
    State agency. We had discussions internally about how to fit
    these two things together in order to expedite the process of
    technology transfer and the rapid deployment of new technology
    that we hope will be there on the pharmacological side into the
    treatment system, and that has always been a concern of ours.
    And we think that by building partnerships that allow research
    to move State systems into the provider community in a much
    more rapid fashion is something that could be done.
        It is not easy. Each agency at the Federal level and
    sometimes at the State level has its own interest and
    jurisdiction. But if we could figure out ways, like we are
    attempting to in New York, to build those linkages to go
    rapidly deploy technology, we may be able to make some
    significant gains.
        Mr. Keppler. I would be loathe to say that the universities
    and the brain research and things and practical clinical
    research in Texas wasn't the equal of any other States or any
    other domain. I would be loathe to say that.
        At the same time, some of the directed work on developing
    best practices, and I sometimes wish they would be a little
    more forthcoming in what they think they might be, but I think
    it is deeply tied to the outcome study.
        I hopefully have some faith in TOPS too in that, even
    though it sounds like bureaucratic jargon, that mixed case
    adjustment work they are trying to do where they find out where
    under each kind of addict which treatment works for them. Well,
    all addicts are not the same. Alcoholics are different within
    those subgroups, which goes to your question, sir, before
    regarding how do we know what works.
        Well, we've got to know what works for different subtypes
    of those people. Then you can say what works. I think that
    needs to go on and it needs to be organized.
        That being said, our State agency itself was mandated by
    our legislature, develop best practices within Texas and we're
    working on that. And the brain research and biochemical and
    biological research at NIDA is invaluable, I think, in
    medications; and I salute that highly. This is a unique
    specialty that they are doing there.
        Mr. Mica. Mr. Stark, did you want to comment?
        Mr. Stark. Sure. You know, I'm sitting here thinking about
    what I was going to say and I realize that there is only one
    way to say what you're thinking, and that's say it and not try
    to tone anything down or cover anything up.
        Mr. Mica. I do that all the time. It gets me in trouble.
        Mr. Stark. Yeah, it does me too.
        When I really look at the whole issue of does treatment
    work, which has come up today at the table, and you look at the
    block grant and we've been criticized in some of our publicly
    funded treatment programs about a mixed bag of program that may
    work or those that don't work, the question comes to my mind
    of, why is it that we do not know, every one of us,
    definitively that these programs work? Why don't we know that?
        We've been funding block grant programs for quite a while.
    We've been funding research for a long time. Why don't we know
    the answer, and why isn't it consistent from one person to the
    other? And it gets back to what I said earlier, that there has
    been a disconnect between the research money and the publicly
    funded block grant programs.
        And I don't mean that as a negative slam on any of the
    agencies, it is simply a matter of there's been a disconnect.
    The research money has gone predominantly over history to
    university researchers. Although most of it goes to biomedical,
    and I agree that we really need to look at that, some of it has
    gone to services research and applied research, but much of
    that services research and applied research has been funded
    toward theoretical models, always looking for that magic
    bullet, looking for some new thing.
        Well, why are we looking for a new thing if we haven't
    answered the question about whether what we're doing right now
    works or doesn't work? Why would I want to run off and find
    something new if I believe what I'm doing now works?
        So we need to do some research on what's being funded today
    and verify does it work or does it not work. If it does not
    work, then, by all means, change it. If it works, then expand
    it.
        Mr. Mica. Mr. Iguchi, did you want to say something?
        Mr. Iguchi. Yes, I would very much like to say something.
        I think there are such a multitude of agencies and a
    multitude of levels of government involved here that all are
    requiring information and answers and, in fact, requests for
    information and answers have multiplied remarkably with many
    recent changes of government asking for much more
    accountability with real numbers.
        We have the general over at ONDCP now putting together a
    wonderful plan with performance measures, the PME plan, and you
    have all these different plans and goals and different
    guidelines being put together and being mandated by very, very
    many people; and, so, everybody is trying to respond at once
    with their best possible answer. But, with all these different
    voices, all that you're hearing right now from every level is
    chaos.
        And I think the role of the Federal Government is to help
    cut through that and help find some simpler answers and simpler
    ways of doing things. But to do that you have to bring all
    these different voices together, and you actually have to sift
    through a lot of that chaos. I think that to a great extent,
    from what I can see, SAMHSA's efforts of trying to put together
    evaluation instruments and to model things that are being done
    well and in the States that are doing them well and bring them
    to the attention of other States, that that actually has been
    an effective way for disseminating information. And they are
    getting a lot better at it.
        So I think that from where I sit as an evaluator, I
    actually have been very pleased that there have been States,
    like the State of Texas, that are doing this really very well,
    but they have no way of getting out and telling other States
    how they are doing it.
        Most of the different treatment programs that I've come to
    know as being excellent treatment programs in the community I
    knew nothing about until they were brought to my attention by
    different technology transfer mechanisms at SAMHSA.
        And so for researchers and others to find out about what is
    going on right in the field and try to figure out what they are
    doing, for all these different pieces of information to come
    together, I think there is a role for the Federal Government,
    and I think it's actually that it is actually taking place at
    SAMHSA right now.
        Mr. Mica. Are you on the advisory committee at SAMHSA?
        Mr. Iguchi. Yes, I am.
        Mr. Mica. You're an evaluator?
        Mr. Iguchi. I am an evaluator, yes.
        Mr. Mica. Well, there is no question there is chaos. And
    Congress has helped create the chaos, and it has magnified.
        Mr. Puccio, did you say we have multiple systems on
    multiple systems and we have multiple evaluation systems, we
    are creating more and we are creating a huge bureaucracy?
        I mean, they are well-meaning folks and they are mandated
    either by law or regulation, but what I am hoping to achieve
    this year is to figure out some way to bring order to the chaos
    so that we simplify the system.
        I am going to ask one last question, and then see if Mr.
    Cummings wanted to ask questions.
        If we went to, like, a 90-10, 90 percent of all this money
    went to block grants, and we included flexibility, a little bit
    of accountability, now we have got to have a little bit of
    accountability in there, but flexibility, and then, granted,
    there are some things that we said that the Federal Government
    could do best, research, there are other areas, providing data
    and things that would be beneficial to all, could you support
    that?
        Mr. Puccio.
        Mr. Puccio. Generally, yes.
        Mr. Mica. Mr. Keppler.
        Mr. Keppler. Generally, yes.
        Mr. Mica. Mr. Stark.
        Mr. Stark. [Witness nods head in the affirmative.]
        Mr. Mica. I do not want to ask you. You are an evaluator.
    Well, what do you think? Go ahead.
        Mr. Iguchi. I require, I guess----
        Mr. Mica. My goal is to put you out of business, you
    understand.
        Mr. Iguchi. And that would be impossible to do, as you
    know, because better numbers just means we get better analysis.
        Mr. Mica. Not all of you, just we want enough and at the
    right level.
        Mr. Iguchi. And in fact, I think that many States are doing
    very good treatment. But the issue isn't so much are they doing
    good treatment. Can they do it better is the issue, and more
    effectively.
        Mr. Mica. Well, we are studying the hell out of this.
    Again, Mr. Stark, how many times and over and over and year
    after year in study. We do not want to put money in programs
    that do not work. We want to fund those that are most
    successful. But at some point, how many times do you reinvent
    the wheel?
        Mr. Iguchi. I think that there are emerging problems that
    one of the things about the drug abuse problem is that it is
    constantly evolving, and that there are always new challenges
    that we have to face. And actually, as far as science being
    brought to the world of drug abuse treatment, it is a fairly
    new phenomenon. So that there is a long way to go yet before we
    can say we're there and we are providing the most effective
    service. We can do this a lot better. And so, there is a huge
    role here for continued research and for a better evaluation.
        Mr. Mica. I think everyone agreed that there are some
    things that have to be done at that overall level, and even at
    subsequent levels.
        Mr. Iguchi. But they are very different. I mean, each of
    these States has a position that, yes, they can spend their
    money most effectively and they do know what's best. The
    problem is that there are a lot of issues that come up that
    cross a lot of different borders that they are not able to
    solve by themselves and that there is a role for Federal
    leadership in. There are also a lot of very small
    subpopulations whose voices are not heard even in their own
    States.
        Mr. Mica. Most people have said that most of what they get
    that is helpful is from NIDA.
        Mr. Iguchi. I'm not sure that that's what you heard.
        Mr. Mica. Well, a little bit. They said they got some
    things, but they also said there is duplication.
        Mr. Iguchi. I think one of the things that SAMHSA has done
    very well in terms of improving treatment and bringing good
    treatment to the attention of other States is going out in the
    community and highlighting the problems.
        Mr. Mica. I think we want to do that and that should be one
    of that 10 percent responsibilities.
        Mr. Cummings.
        Mr. Cummings. Thank you very much, Mr. Chairman. I had to
    run to another meeting, but I am sorry that you dismissed the
    SAMHSA people because that is why I am here. I wanted to hear
    from them.
        Mr. Mica. I did that at the request of Mrs. Mink.
        Mr. Cummings. Mr. Chairman, that doesn't matter to me.
        Mr. Mica. We wanted to give them full opportunity. She
    cannot be here, so we will have them back and we will have a
    full panel. We also do not have the administrator today, which
    we requested. So we are going to request the administrator, the
    individual that was assigned today in a full hearing, and
    possibly Dr. Leschner, if the minority would agree.
        Mr. Cummings. I understand, and I thank you for clarifying
    that. I just wanted to make sure.
        You know, I guess from where I come from, you know, when
    you have accusations flying, I would like to be able to have
    the person who is being accused to be able to defend
    themselves. Because in my neighborhood I have seen so many
    people accused of things and were not able to defend
    themselves. So I just wanted to make sure that we are clear on
    that and that we will have that opportunity. And I want to
    thank you, Mr. Chairman, for that. I understand, and I
    appreciate it.
        One of the things I think that concerns me as I listen to
    this discussion is that, you know, if you were to go to my
    neighborhood and if you were to talk to the people on the
    corners and you were to talk to them about drug treatment, what
    they would say is that there are a lot of people making a lot
    of money, but we are not getting much better. A lot of people
    making a lot of money, a lot of people being experts on this,
    experts on that.
        We can send people to the moon, we could send a ship to
    Mars, we can do all kinds of things; and you cannot convince me
    that we cannot figure out what works and what does not work and
    cannot get that information out. It is incredible to me.
        And I have got to tell you that I do not think that it
    takes--and I do not know that much about it--but I do not think
    it takes a rocket scientist to figure this thing out, in other
    words, what works for certain populations dealing with certain
    drugs.
        And again, I think that what happens, and I think the thing
    that worries me, Mr. Chairman, is that, if we have situations
    where the tools that we have are not properly evaluating, and
    even if they are and if that information is not getting out,
    then what happens, and I am telling you I have seen it over and
    over again in this Congress, what happens is people, say, let
    us not spend the money on it, let us not do it because it is
    not working. And I think that is so unfair to some people like
    the lady who sat up here, Ms. Murwin, the lady who sat up here
    a few moments ago and talked about her overcoming.
        So I want to ask a few questions so we can kind of get
    through this a little bit so I can be clear. Some you all
    apparently feel that treatment works. Is that true? Treatment
    works.
        There was a recent study and I cannot even remember, I
    think 60 Minutes did it, I know it was in the Washington Post,
    where they talked about how the research is done a lot of times
    on projects like this and the research apparently is oftentimes
    put on a shelf and never used. And even things that work a lot
    of times may not be refunded, they may not get their proper
    due, or things that do not work do not get put to the side
    because nobody uses them.
        Again, it goes back to what the guys in my neighborhood are
    saying, people are getting rich off of us, but are those
    dollars really getting to the people that they need to get to?
        Let me tell you, the biggest problem with all of this is
    that if there is not integrity within the system, then what is
    going to happen is that we are not going to stand still, but we
    are going to go backward because you are going to have all
    these people saying, I have got treatment, I have got
    treatment, I have got treatment and the addicts are going to
    get sicker and sicker; and then we are going to move from
    generation to generation to generation, as I see in my
    neighborhood of addicts.
        And so, to the GAO people, did your report issue
    recommendations on how SAMHSA could improve oversight in
    monitoring the block grants?
        Ms. Heinrich. No, sir, we did not have any recommendations.
    What we did was describe the programs as they currently exist
    in terms of the block grant and the KDA grant programs. And we
    also were asked to determine how SAMHSA and the States were
    actually monitoring their programs from a perspective of
    accountability. And the systems that we have currently in place
    really do seem to focus more on assuring that the States are
    complying with the statutory requirements. We were also asked
    to describe SAMHSA and the States' efforts to determine the
    effectiveness of drug abuse treatment supported with block
    grant funds. And what we found there is that there are
    activities going on at SAMHSA level, and there have been at
    least two large SAMHSA-funded national studies and then several
    States have really exemplary programs in terms of evaluating
    program effectiveness, patient outcomes. And three of the
    States that are doing the most are here today.
        Clearly, there are many other States that are not doing
    nearly as much in terms of determining program effectiveness.
        Mr. Cummings. How do you determine, since you just gave
    those wonderful compliments to these States, what is the
    standard for saying that my program works and works well? I
    mean, is it like, we treated 10 people and, after 5 years, 6 of
    them are still off of drugs? I mean, how do you measure that?
        Mr. Cummings. How does somebody go around saying what you
    just said, they have got the greatest programs in the country?
        I need to know that. And the reason I need to know it is
    because, if you have got something that is working, and
    assuming that you have a reasonable kind of measuring tool,
    then what you said, Mr. Stark, is what we ought to be doing,
    using the best practices of things that work.
        Let me just give you a little example that upsets me. In my
    school system in Baltimore, they go around asking everybody all
    over the world, how can we educate poor kids, when we have got
    schools with kids from the very kinds of neighborhoods that
    these kids come from there are not doing well, who are doing
    well.
        It seems to me, and maybe I am missing something, that
    somebody would say, well, if we have got school X 2 miles away
    in the same kind of neighborhood, children with the same kinds
    of backgrounds in the same city, that we might just want to
    make a phone call over to school X and say, now, X, we are
    having problems over here with Y; what are you doing that we
    are not doing?
        And yet, still we are spending thousands and thousands of
    dollars exporting experts from everywhere, and going back to
    what you said, Mr. Stark, maybe, maybe we have the answer of
    what works. Maybe we have the measuring tools of what works.
        And so, I want to know how do you measure, to say, how does
    somebody come to the conclusion that was just stated, that you
    all are some of the best programs, and how do you measure
    yourselves? Or do you measure yourselves?
        Mr. Stark. In the State of Washington, we very much do
    measure ourselves. Just to give you an example, although we do
    some of the rigorous scientific studies that would be funded by
    NIDA, working with researchers from the University of
    Washington and Washington State University and some private
    researchers, although we do some of those very expensive
    studies that actually do track the client population and
    interview them pre and post and have comparison groups. That
    data, although good and whatnot, is still self-report data and
    clients are simply answering, are they still using drugs? Are
    they getting in trouble with the law? Are they participating in
    work? Are they using health care services at the rate that they
    used to be or not? Are they living now in a shelter versus a
    house versus whatever?
        Although those questions get asked, we continue to get
    challenged even by our State legislature, even on those
    rigorous scientific studies, yeah, but that's self reports.
    What's the real impact? Did it really cost us, the people of
    the State of Washington, less money for those individuals that
    you treated compared to those that needed treatment that were
    similar and didn't get it?
        So, about 10 years ago, we began to look at tracking and
    integrating multiple data bases. We said, what are the
    consequences of addictions? And you've already described a
    number of those. There is crime and there is health problems
    and there is violence and there is poverty and there is a whole
    lot of consequences related to true addictions.
        So if those, in fact, are the consequences, we ought to be
    able to measure those. And if alcohol and drug treatment has an
    impact in improving in those areas, we ought to be able to
    measure that.
        So we began taking clients who received assessments but no
    treatment and then those that received different types of
    treatments, residential treatment followed by outpatient, or
    residential treatment only, or outpatient only, and then
    compared treatment completers to treatment non-completers, then
    looked at subpopulations, pregnant women versus kids versus
    chronic SSI, supplemental security income clients, and we began
    to look at those outcomes. Prior to them coming into treatment,
    what did they cost the State of Washington? Post treatment,
    what did they cost the State of Washington. In some of the
    studies, we only looked at 6 months post treatment. Some we
    went as far as 5 years out.
        And in virtually every case, every study we did showed
    significant positive outcomes with the aggregate. Now, that
    isn't to say that some of those clients didn't fail. Some of
    them did. But through the aggregate, taking the failures and
    the successes together, those treatment programs had major
    reductions in real health care expenditures, real reductions in
    crime and jail and prison time, real improvements in employment
    and earnings, and I could go on and on.
        So we measure it a variety of different ways. We do use
    SAMHSA funding, and we very much appreciate it. SAMHSA has done
    a good job working with us in helping us build this
    infrastructure. And we also use NIDA, National Institute of
    Drug Abuse, dollars by partnering with researchers and going
    after that money to do this research.
        Part of the question is, if you are going to evaluate and
    evaluate effectively, there is no free outcome; it costs money
    to collect data, analyze data, and put out reports.
        The other question, Chairman Mica, was about why do so many
    of these things end up on the shelf? Well, part of it is that
    there is lot of the expensive research that has been done, and
    in some cases it answered questions that nobody else was
    interested in quite frankly. In some cases, it answered
    questions everybody else might be interested in, but it was
    written academically, not from a policy perspective. And when
    it got done, they met their need for publish or perish, if you
    are in higher-ed you know what that is all about, and then it
    got shelved.
        We need to have a national strategic plan and some
    coordinating committee that comes together and looks at
    maximizing those research results and look at how do we move
    from research to policy and to practice. And there are some
    activities going on now, but they need to be coordinated.
        Mr. Puccio. If I can, I am going to draw a distinction
    between outcome measure and impact measure and give you an
    example of those two things.
        A drug court judge is going to be interested in whether or
    not a treatment program is effective in terms of reducing
    criminal behavior. So we actually do measure whether or not our
    programs produce reductions in criminal behavior along with
    gains in employment and a variety of other measures.
        We then take those measures and we deploy them in rank
    order and compare one program to another. So you may have in a
    community three or four or five providers that are providing
    similar kinds of services. The question then arises that are
    the outcomes of provider A better than B and then, if so, why;
    and then how do we work that through?
        One of the things we have done is use the peer review
    requirement that is under the block grant and use that to have
    providers work with providers on sharing their technologies to
    make sure they are, in fact, improving. That is very different
    than looking at what I will call impact.
        I am a school board member and I know what it is like to
    live in a community where you struggle with trying to
    understand what is happening in terms of the overall impact of
    drug prevention and treatment services in your community.
        In the State of New York, we have begun to take, and I know
    Ken has done this in Washington, take surrogate data, we have
    looked at PINS petitions, we look at drug arrests, we look at
    emergency room visits, we look at a whole variety of different
    indices that get at this impact measure, aggregate it at the
    county level, and then rank order counties to be able to
    compare and contrast those counties that are suffering more or
    less from the consequence of outcome drugs and then begin to
    talk about prevention strategies on the level that make a
    difference in terms of achieving better outcomes and match that
    up on a State-wide basis.
        The problem you run into is that, at the subcounty level,
    the collection of that data is extraordinarily difficult. So
    with my school district, with 1,000 kids in it, the collection
    of PINS information at the county-wide information, which is
    children that are in protective service under probation, this
    is a very difficult thing to go have available. We have it at
    the county level but we don't have it broken down into smaller
    jurisdictions.
        We are trying in New York City, for example, to break it
    down into the zip code level. But even then, that is a very
    large aggregation of a community.
        It is a very difficult thing. It is time consuming. It is
    expensive. But I think we are all working hard at building the
    data systems that allow us to say yes, it works, and then to
    compare and contrast providers so that we can begin to get at
    the components of what are the treatment differences that make
    for better outcomes beyond what we have right now.
        Mr. Cummings. If you had a situation where you took your
    criteria, your measuring tool, and discovered that drug
    treatment center A, had according to your measuring tool a 10-
    percent success rate; and B, had a 75-percent success rate; and
    C, had a 70-percent success rate, what happens to the guy with
    the 10 percent?
        Do you follow what I am saying? I mean, does somebody say,
    look, you are not even close? And let us assume that you have
    got some complaints going along with it. I mean, does that
    person get kicked out or are you all trying to help them, too?
    Because the thing that I am worried about is that if we do not
    begin to look at those kinds of things, all of you are going to
    be out of a job. I am serious, not because of me, but because
    the Congress will say, wait a minute, it is not working.
        And you all provided some wonderful testimony today that
    really I am sure helps Mr. Mica, and I know he feels a lot
    better than he has in a long time because you all have said
    some very positive things about treatment. But I can tell you
    that if that word gets around and everybody begins to feel up
    here that treatment is not working and folks are operating on a
    10 percent level with a few 70 and 65 percents, you have got a
    problem, because there are some people who have the opinion
    that once on drugs, never off.
        Do you understand the question? Is there a mechanism in
    your States to kick somebody to say, look, you are not doing
    it. It is not getting done. We are spending a lot of money on
    you. We are wasting taxpayers' dollars. We have had people that
    have come into your program, they thought they were being
    treated, they weren't being treated, they came out of the
    program, they are still on drugs, and they are worse off than
    they were before, because now they go around saying, see,
    treatment does not work. Why should I be bothered?
        Mr. Keppler. I agree with that. And I certainly will say
    this, yes, we do monitor them. We go out and look at them. We
    have a compliance visitor if they are not doing it. That kind
    of outlier would very likely be defunded, with one proviso,
    sir. Unless that program was 10 percent, if I went there and I
    saw they were taking care of the sickest, most chronic people
    that had been treated before on multiple occasions, and as a
    choice at the State level we said we still have to have some
    commitments, we aren't ready to let them die yet, as opposed to
    another program that were first-time, younger people, who
    perhaps were just substance abusers and not yet fully dependent
    for a year, for 10 years, for 15 years, I'd look at that a
    little differently. In other words, what kind of cases are they
    treating?
        That being said, if they are treating the same kind in each
    one, look the same, no difference in their history, I would
    certainly go after the 10 percenter. They would be done. They
    would have to move on.
        One more thing, and this will leave me Dr. Clark and Dr.
    Leschner, who I both deeply respect, this is a complex
    neurobiological disorder. I'm sure you have heard that. We
    don't fall under necessarily the criticism we have for some
    other terminal brain diseases which have taken years and years
    to cure and treat. We are just coming into the place of
    learning new ways to treat stroke, new advances in Parkinson's
    disease, new advances in multi-infarct dimension, new advances
    in schizophrenia, all these types of complex neurobiological
    disorders of which substance dependence disorders are just one,
    so we are on that same playing field.
        Mr. Cummings. Is it State law that will allow you to kick
    them out?
        Mr. Keppler. It would be our State auditors, probably akin
    to who would look at what we are doing in our legislature that
    makes us do this performance-based contracting with progressive
    sanctions.
        Mr. Cummings. Do you think most States have those kinds of
    mechanisms? I mean, do you?
        Mr. Stark. Washington State does.
        Now, there are two levels in Washington State. There is
    both the issue of contracts. There is also the issue of
    accreditation. We accredit both publicly funded as well as
    private-pay treatment programs through our division in the
    State of Washington. So, with the 10 percent issue, if it were
    the first time we had done an evaluation of that program and
    discovered only 10 percent, we would probably start with some
    training, technical assistance. But if it was clear that there
    was only 10 percent success and they were satisfied with 10
    percent success and it wasn't changing, then if it was a
    contracting agency, we would be looking at getting rid of the
    contract. And if the program continued and it was quality of
    care issues, we would be looking at the issue of accreditation.
        But I want to point out another thing that is different.
    There are times, many times, when somebody who needs maybe a
    year of treatment starting off in maybe short-term residential
    treatment followed by continuing outpatient treatment, they
    need that multi-level care, high intensity, then low intensity.
    And they get into the high intensity program and when they
    finish that level, they can't get into the next level because
    it's full, there are no open slots.
        Mr. Cummings. Like after-care.
        Mr. Stark. It is continuing care. It can be fairly
    intensive outpatient. So the question becomes one of, can you
    punish treatment program, No. 1, because the rest of the
    treatment that that individual needed wasn't available? So
    that's another issue you have to consider in this when you are
    comparing one treatment program to another. It is not only the
    issue of case mix adjustment and are you, in fact, comparing
    the same client across different systems, but it is what else
    did that individual need and did they or did they not get it?
        It then becomes incumbent upon every level of treatment
    program to be working very, very diligently to identify the
    additional needs of the client they are serving beyond just the
    alcohol drug treatment need, whether that that be housing,
    food, shelter. I mean, you know as well as I do, we put people
    in prison and we let them out of prison and they have major
    drug and alcohol problems and family problems and poverty
    problems, and we let them out on the street and they walk out
    on the street with no job and no place to stay and we wonder
    why they got in trouble again.
        Now, I don't know what you think about that, but clearly
    we're doing the wrong thing if we know that we are all going to
    strive to find a place to sleep and eat to get our basic needs,
    and if they are not met through some mechanism, we have a job,
    we have training to get a job, we have a place to stay that is
    a safe place, then we will figure out a way to get that,
    whether that's through medicating ourselves with drugs to
    forget about our problems or committing crimes to get the money
    to pay for the basic needs.
        Mr. Cummings. Before I came to Congress a few years ago, a
    group of men in my community volunteered to do an after-care
    program for people coming out of the boot camp system. And one
    of the reasons why I have asked the chairman to make sure that
    when they come to Baltimore that we bring the New York program
    up, the one that the State's attorney up in New York started,
    and I am hoping we will be able to do that, Mr. Chairman, is
    because, one of the things that we noticed for recidivism, and
    I think in dealing with their drug problems, if we could get
    somebody a job, a job, and get them sort of reoriented toward
    their family, as opposed to the corner, toward their kids and
    get into sort of a self-help kind of discussion kind of thing,
    what we discovered is that those guys who we could keep off the
    corner, get jobs, and get more oriented toward their family
    were more apt to really pursue treatment and were more apt to
    do well. And this was basically--I mean, it just worked.
        Apparently there is a New York program which is basically
    an alternative to a prison program that works, I guess, you're
    familiar with. And one of the things, we had testimony from the
    folk up in New York, I was sitting there and I kept hearing the
    success rates and I said there has got to be more than just
    getting them into treatment. And finally, at the end of the
    testimony, the guy says, jobs, jobs, jobs, jobs.
        And I said, that is it. I mean, not that that is the total
    cure, but when you think about it, one of you all said people
    get up in the morning, and what they are doing is they are
    going out and looking for their fix. They are basically going
    out trying to figure out how to kill themselves, to be frank
    with you, because that is what it is, is a slow death.
        So if you could find things to occupy their time, give them
    a sense of value, give them a sense of whatever. But it is a
    complicated process. I understand that. If anyone wants to
    comment on that, you may. But I want to thank you all for your
    testimony. And would you all agree that there should be
    measuring tools?
        Mr. Keppler. Yes.
        Mr. Iguchi. Yes.
        Mr. Puccio. Yes.
        Mr. Stark. Absolutely.
        Mr. Mica. I thank the gentleman from Maryland. I want to
    associate myself with his remarks that we do need to find some
    way to better coordinate all of the efforts and the things that
    are required to make these programs successful, mental health,
    job training, social services, health care.
        I did visit the DTAP program, and that is a totally
    integrated program. It is expensive, but the alternative is far
    more expensive. And many of these people, their lives are a
    total disaster, not only their lives, the lives of their
    families.
        I could go on, Mr. Cummings, and tell you about some of the
    people I met. One guy spent half of his life in jail. He was 38
    and in and out. The social cost. Another one, his wife had died
    of a heroin overdose. He was a heroin addict.
        But we have got to figure out a way to make this all come
    together. We have got to figure out a way to try to eliminate
    some of the bureaucracy we have created. We want these programs
    evaluated, but we do not want paralyses by analysis. And we
    have got to figure out a way to make this whole thing function.
        As I said, I do not know if you heard me, there are some
    conservative members and some liberal members, but I think they
    all want to see that everyone who needs treatment has treatment
    and that it is effective and that we hold the programs properly
    accountable.
        The good news is that we will have a continuation of this
    hearing. In fact, I will leave the record open. And I would
    also like a copy of all of this hearing transcribed, if
    possible, on an expedited basis so that the administrator can
    see the comments from this hearing and then respond to them.
        I want the administrator here, not only the deputy that was
    supposed to be here. And we can also invite Dr. Leschner to see
    if there are some things we can do more effectively in a
    cooperative effort.
        So, with those comments, I do want to thank each and every
    one of our witnesses today, thank GAO for their report. And
    also, for the record, I think we need to ask some additional
    questions of GAO and, hopefully, get some more answers so we
    can do our job more effectively in an oversight capacity.
        There being no further business to come before the
    subcommittee at this time, again, I thank our witnesses, they
    are excused, and this hearing is adjourned.
        [Whereupon, at 1:04 p.m., the subcommittee was adjourned.]

          HHS DRUG TREATMENT SUPPORT: IS SAMHSA OPTIMIZING RESOURCES?

                                  ----------

                            TUESDAY, MARCH 14, 2000

                      House of Representatives,
    Subcommittee on Criminal Justice, Drug Policy, and
                                       Human Resources,
                                Committee on Government Reform,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10:15 a.m., in
    room 2154, Rayburn House Office Building, Hon. John L. Mica
    (chairman of the subcommittee) presiding.
        Present: Representatives Mica, Mink, Cummings, and Tierney.
        Staff present: Sharon Pinkerton, staff director, chief
    counsel; Steve Dillingham, special counsel; Don Deering and
    Frank Edrington, professional staff members; Lisa Wandler,
    clerk; Cherri Branson, minority counsel; and Jean Gosa,
    minority assistant clerk.
        Mr. Mica. Good morning. I'd like to call this hearing of
    the Subcommittee on Criminal Justice, Drug Policy, and Human
    Resources to order. I apologize for being late.
        Mrs. Mink, as you know, we have many folks from our
    districts in town, and while I love people with the various
    agencies in Washington, I have a certain appreciation of the
    people back home.
        Mrs. Mink. Apology is noted and accepted.
        Mr. Mica. Thank you. For that, we'll begin our hearing
    today. This hearing is actually a continuation of the February
    17 hearing, and the hearing is entitled, ``HHS Drug Treatment
    Support: Is SAMHSA Optimizing Resources?''
        I will have a brief opening statement, and then yield to
    our ranking member, Mrs. Mink, for her statement. Then we'll
    hear from our witnesses.
        Today, our subcommittee is resuming its oversight hearing
    on programs and operations of the substance abuse and mental
    health services administration, also referred to as SAMHSA,
    which is located within the Department of Health and Human
    Services.
        We began this hearing on February 17, but both the majority
    and minority agreed to adjourn the hearing and continue at a
    later date, so we could obtain a more detailed response to some
    of the issues that were raised, and also to hear directly from
    the administrator of SAMHSA, Dr. Nelba Chavez. Since we'll
    discuss the topic of agency-sponsored research on drug abuse
    and treatment, we also decided to invite the Director of the
    National Institute of Drug Abuse, also known as NIDA, Dr. Alan
    Leshner. NIDA funds drug abuse research, and it's important
    that we have him for this discussion while we also have the
    administrator of SAMHSA.
        A startling statistic that we discussed in our last hearing
    was that the national estimates of Americans in need of drug
    treatment range from 4.4 to 8.9 million people, yet less than 2
    million people reportedly receive treatment services. We're
    most concerned about this gap in treatment services and how to
    address it. In that regard, I noted that SAMHSA's block grants
    are key to reducing the treatment gaps, as each grant block
    dollar spent on treatment generates $1.5 in additional State
    and local treatment spending. We heard from State and local
    providers the successful drug treatment programs are now in
    place, and every drug treatment dollar is so vital to our
    efforts.
        I was concerned to learn that participants in a successful
    faith-based treatment program lost their eligibility for food
    stamps. We must do everything possible to prevent such absurd
    results and also to fund more successful drug treatment
    programs that, in fact, serve more clients. We learned that
    SAMHSA has huge administrative and contractual operational
    costs, and that oftentimes the agency also imposes unnecessary
    burdens and red tape on States and providers.
        We also heard from the General Accounting Office [GAO],
    which reported on what SAMHSA is doing with its resources. This
    data raises questions regarding agency efficiencies and
    effectiveness. The data indicates that 80 percent of SAMHSA's
    substance abuse grant funds flow to the States through block
    grants, and they are managed by 11 percent of that agency's
    staff. The remaining 89 percent of SAMHSA's staff are engaged
    in something else, and those activities include research and
    technical assistance, which seem to be inordinately based in
    Washington, DC.
        To me, this raises a red flag and many questions. Do we
    have reason to believe that only Washington area consultants
    know what works best for our States? Driving in from the
    airport yesterday, I was looking at some of the massive
    buildings and so-called Beltway bandit operations that have
    grown up around the Capital. It seems nice to have those high-
    paying activities in the shadow of our Nation's Capital. But
    are they providing the treatment and funds to those programs
    and individuals out there beyond the Beltway?
        I'm aware that fine public and private universities train
    drug treatment professionals and researchers. I believe they
    are quite capable of assisting programs in that regard.
    Witnesses have testified from various States with programs that
    are successful in breaking the chains of drug addiction,
    restoring families, rebuilding job skills, and saving lives.
    The States included Florida, New York, Texas, and Washington.
    GAO commended these States for their successes in a number of
    drug treatment areas. Today, we have as a witness the
    Administrator of SAMHSA, which I said, Dr. Nelba Chavez. Dr.
    Chavez has testified that CSAT-funded treatment programs are
    working resulting in a 50 percent reduction in drug abuse among
    their clients 1 year after treatment. She further concluded and
    stated, ``we know what works in prevention and treatment.''
        Despite the success and others that she will mention, I
    think that Dr. Chavez will agree with me that we cannot be
    complacent in our efforts or satisfied with a status quo.
    Significant challenges lie ahead, and our future successes
    depend on how efficiently and how effectively we allocate our
    resources to accomplish shared goals in preventing and treating
    drug abuse.
        Let me outline some of the issues that I hope we'll address
    at this hearing today. If we can't cover them today, we can
    followup with another hearing after today. With regard to
    SAMHSA's operation, my concerns include: agency administrative
    costs, organizational staffing, contracting practices, how our
    research and evaluation dollars are expended, and are we
    getting good results, discretionary spending practices, grant
    application, the whole process, and processing award
    efficiencies.
        With administrative costs of over $150 million annually, we
    must ask what is being accomplished and at what price. Again,
    if you go back and look at 89 percent of the expenditures and
    grants being administered by 11 percent and the other 11
    percent of the funds consuming a tremendous administrative
    overhead costs, something is wrong. What concerns me also is
    that many of the projects that we and GAO reviewed and are
    already funded by either State government or other Federal
    block grant programs for which we're incurring this huge
    administrative overhead.
        Something is wrong. I just learned from SAMHSA that GAO
    staffing figures do not include dozens of contract employees
    who augment SAMHSA's staff. SAMHSA now employs almost 600
    people. I'm concerned about reported staff reductions and
    turnover in the agency's three centers, and whether this
    contributes to low staff morale.
        Also, I'd like to ask the staff to conduct a review and
    investigation of how many of the former staff are now some of
    these contract officials. I found, while investigating other
    agencies, that some of the former employment of the agency
    personnel turns into cottage industry on a contract basis.
        We also need to examine what value SAMHSA has received from
    its hundreds of millions of dollars in research and
    evaluations. I'm a strong supporter of research and studies,
    particularly scientific studies that will lead us to do a
    better job and more effective, and I don't think we could ever
    spend enough to make certain that we've explored every research
    avenue, but we also must see that if we are duplicating
    activities, that we eliminate that duplication, and most cost
    effectively, expend these hard earned taxpayer dollars on
    effective research.
        I think the administrator will share some highlights with
    us today. I have with me a copy of the ``Handbook for
    Evaluating Drug and Alcohol Prevention Programs, Staff/Team
    Evaluation of Prevention Programs.'' It's called STEPP, I think
    is its acronym, published in 1987 by SAMHSA's predecessor
    agency ADAMHA. It looks like it would be very helpful to
    evaluate activities. I'm told that it was distributed and sold
    through the Government Printing Office for many years. Is this
    evaluation guide no longer useful? If not, why not? Should
    similar handy guidance be prepared and made available to
    treatment professionals? Is this an illustration of my concern
    that the agency may unnecessarily be reinventing the wheel?
        Let me mention another area that I'm most interested in
    that remains a drug treatment priority. That area is the
    nonviolent offenders who are eligible, motivated, and in need
    of treatment. It's my understanding that SAMHSA's discretionary
    grant programs provide some limited support for treating
    offenders who are not incarcerated. I'm very aware of the need
    for offering treatment to deserving nonviolent offenders who
    have a need and desire to break the chains of addiction, and
    who also hope to obtain productive employment and engage in
    law-abiding behavior.
        In this regard, I have a copy of the report of the National
    Task Force on Correctional Substance Abuse Strategies entitled,
    ``Intervening With Substance Abuse Offenders: A Framework for
    Action,'' published in 1991 by the Department of Justice. This
    national task force with participants from ONDCP, the Office of
    National Drug Control Policy, Justice, HHS, including ADAMHA,
    State treatment and correctional agencies, probation and parole
    organizations, and experts from institutions, such as Yale,
    outline promising correctional treatment strategies. This is
    back in 1991.
        This project and its publication received extensive praise
    from treatment professionals, yet it only cost $100,000 to
    complete. Are we getting that return on our investment today?
    Has anyone paid any attention to this report? I ask SAMHSA to
    convincingly answer the question and to ask its expensive
    contractor ``Where's the beef?''
        Finally, we also need answers to the question of how well
    SAMHSA coordinates with NIDA. NIDA, as we know, is the primary
    agency with a responsibility for conducting drug abuse
    research, and we use NIDA in research in assisting States and
    local programs. Is NIDA research relevant and does it
    demonstrate its value to the States? If not, why not? How is
    SAMHSA documenting and expanding this contribution? I've raised
    a number of questions, a number of questions were raised in the
    hearing that we conducted previous to today's meeting, and I
    hope that we can hear from Dr. Chavez and Dr. Leshner on these
    and other issues today as we explore ways to improve our
    delivery of an effective and efficient drug prevention and
    treatment program and policy for our whole Nation.
        [The prepared statement of Hon. John L. Mica follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.057

        [GRAPHIC] [TIFF OMITTED] T7551.058

        Mr. Mica. With those opening comments and remarks, I'm
    pleased to yield now to the gentlelady from Hawaii, our ranking
    member, Mrs. Mink.
        Mrs. Mink. Thank you, Mr. Chairman. First, I'd like to ask
    unanimous consent that a statement by our colleague, the
    Honorable Ed Towns of New York, be submitted for the record.
        Mr. Mica. Without objection, so ordered.
        [The prepared statement of Hon. Edolphus Towns follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.059

        [GRAPHIC] [TIFF OMITTED] T7551.060

        [GRAPHIC] [TIFF OMITTED] T7551.061

        [GRAPHIC] [TIFF OMITTED] T7551.062

        Mrs. Mink. Mr. Chairman, it is of course the responsibility
    of this oversight committee as a subcommittee of the Government
    Reform Committee to pay attention to the ways in which the
    various agencies and departments of government function and
    whether they carry out the mission of their responsibilities as
    delineated by Congress. We have to be, I think, absolutely
    sure, in whatever criticisms we level against an agency, that
    we compare their functions and activities with what this
    Congress has charged them to do. The criticisms of their
    conduct would not be fair in my estimation. It did not take
    into contact the myriad of riders and charges and other kinds
    of mandates that they have been given either by authorizing
    legislation or through appropriation riders.
        Having said that, I think it's also important to understand
    that in this particular agency of SAMHSA, our charge is drug
    treatment, but SAMHSA has responsibilities in mental health, so
    although its budget is $2.5 billion, about $400 million of that
    amount is spent in the mental health area, of which we are not
    making any specific inquiries today.
        In addition, there is another area known as knowledge
    development and application, which is allocated $329 million,
    both of which are under considerable scrutiny by the Congress
    through its appropriation process.
        The area that you have called attention to in this
    particular continuation hearing is the block grants and the
    outside contracts that have been awarded to ascertain whether
    the moneys are being well spent and doing research and a
    variety of other things. The block grants constitute $1.6
    billion of the agency's funding, and as I understand it, these
    funds are distributed to the various State agencies based upon
    formula, based upon criteria elaborated by the Congress. And
    that the SAMHSA agency is the Administrator pursuant to those
    instructions laid down by the Congress.
        The GAO report indicates that the administrative cost,
    which this agency has reported roughly at 6 percent, does not
    constitute an excessive administrative overhead. You have
    raised the question that perhaps the true cost of the manpower
    is the number of individuals that are assigned to specific
    tasks within the agency. In that context, you have raised the
    question as to whether the true criticism should be with the
    allocation of personnel, and you have outlined that perhaps 11
    percent of the personnel is spent on the administration of the
    block grants.
        So we have much to hear from the agency, and I appreciate
    the presence of Dr. Nelba Chavez at these hearings. I'm
    confident that she will adequately explain the various issues
    that you have raised, and I look forward to Dr. Chavez's
    testimony. Thank you.
        [The prepared statement of Hon. Patsy T. Mink follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.063

        [GRAPHIC] [TIFF OMITTED] T7551.064

        [GRAPHIC] [TIFF OMITTED] T7551.065

        Mr. Mica. I thank the gentlelady. Now I'm pleased----
        Mrs. Mink. Just one more comment. Following the hearing we
    had on February 17, I sent to GAO a series of questions which
    arose from the testimony that we received, and I would like to
    have the responses and my questions inserted in the record at
    this point.
        Mr. Mica. Without objection, the responses from GAO will be
    made part of the record.
        Mrs. Mink. Thank you.
        [The information referred to follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.066

        [GRAPHIC] [TIFF OMITTED] T7551.067

        [GRAPHIC] [TIFF OMITTED] T7551.068

        [GRAPHIC] [TIFF OMITTED] T7551.069

        Mr. Mica. Thank you. I would like to now recognize the
    gentleman from Massachusetts, Mr. Tierney, for the purpose of
    an opening statement.
        Mr. Tierney. Thank you, Mr. Chairman. I'll just associate
    my remarks with those of the ranking member, and I look forward
    to the testimony of the witnesses and thank them for being here
    today. Thank you.
        Mr. Mica. Thank you so much, Mr. Tierney. Welcome back, Dr.
    Leshner. I think you know the procedures. This is an
    investigations and oversight subcommittee of Congress. We do
    swear in our witnesses. If the witnesses will please stand and
    be sworn. I'm sorry, I don't know this gentleman's name. Could
    you identify yourself for the record and let's get a name
    plate.
        Mr. White. I'm Timothy White from the General Counsel's
    Office from the Department of Health and Human Services.
        [Witnesses sworn.]
        Mr. Mica. The witnesses have answered in the affirmative.
        I would like to welcome the witnesses this morning. I
    understand we just have two opening statements. First, Dr.
    Nelba R. Chavez, and she is the Administrator of the Substance
    Abuse and Mental Health Services Administration with the
    Department of Health and Human Services. The second witness
    will be Dr. Alan I. Leshner, and he is the Director of NIDA,
    the National Institute on Drug Abuse, also under the Department
    of Health and Human Services. We'll recognize first Dr. Chavez.
    We won't run the clock on her since we only have two Members.

     STATEMENTS OF NELBA R. CHAVEZ, ADMINISTRATOR, SUBSTANCE ABUSE
    AND MENTAL HEALTH SERVICES ADMINISTRATION, DEPARTMENT OF HEALTH
        AND HUMAN SERVICES, ACCOMPANIED BY JOSEPH AUTRY, DEPUTY
     ADMINISTRATOR FOR SAMHSA; AND DR. ALAN I. LESHNER, DIRECTOR,
      NATIONAL INSTITUTE ON DRUG ABUSE, DEPARTMENT OF HEALTH AND
                             HUMAN SERVICES

        Dr. Chavez. Thank you very much, Mr. Chairman, good morning
    to you and members of the subcommittee. I do want to thank you
    for the opportunity to testify and provide the subcommittee
    with information on the operation and effectiveness of SAMHSA's
    programs. Before I proceed, however, I would like to enter our
    written testimony for the record.
        Mr. Mica. Without objection, the entire statement of the
    witness will be made part of the record.
        Dr. Chavez. Thank you, Mr. Chairman. Also testifying with
    me today is Dr. Joseph Autry, who is our Deputy Administrator
    for SAMHSA. I want to thank you for the meeting and also it is
    indeed a pleasure and honor to be here with Dr. Alan Leshner.
        There are some people that I would very quickly like to
    just recognize for the wonderful work that they do throughout
    the United States for individuals and families and children who
    are in need of substance abuse services. First, I'd like to
    recognize General Arthur Dean from the Community Antidrug
    Coalitions of America; Sue Thau from the Community Antidrug
    Coalitions of America; Tom McDaniels from the Legal Action
    Center; Dr. Linda Wolf-Jones from the Therapeutic Communities
    of America; Jennifer Pike from the National League of Cities;
    and Mr. Jack Gustafson from the National Association of State
    alcohol and Drug Abuse Directors. Also Crystal Swann, who is
    with the U.S. Conference of Mayors; and finally, Dr. Westley
    Clark, who is SAMHSA's Director for the Center for Substance
    Abuse Treatment. He is in the audience as well.
        Thank you, Mr. Chairman. It is an exciting time for the
    fields of substance abuse and mental health. We have
    established SAMHSA over the past 7 years as a critical
    component of our Federal health and human service system. We
    have improved prevention and treatment services across the
    country and, at the same time, streamlined our management. For
    example, we reduced the number of administrative offices from
    20 to 7 through consolidation. We were able to reassign 44 FTEs
    and transferred to the centers for program support. Never
    before has the potential been so great and pride in our efforts
    so strong. The data attest to the fact that our strategy is
    reaping dividends. Recent studies show that drug use among
    teens is no longer on the rise. It may, in fact, be declining
    and without exception, our treatment programs, across the
    board, are helping people triumph over addiction and are
    leading to recovery. We have accomplished a lot for a small and
    lean organization. Most of our budget is distributed by formula
    set by Congress that limits flexibility to target funds based
    on need. However, with the tools and the limited discretionary
    resources available, we are clearly and capably carrying out
    our mission with success.
        Despite the Nation's recent success in preventing and
    treating substance abuse, we are far from declaring victory.
    Unfortunately, the stigma of substance abuse and mental
    disorders persists. Lack of health insurance parity combined
    with limited government resources prevent people in need from
    receiving treatment services, and we still have much to do to
    improve service system performance and quality because of past
    emphasis.
        Much of the work done to date is focused on male hard-core
    addicts. The demographics of substance abuse are changing. We
    often think of substance abuse as the province of adolescent
    and early childhood, of boys and not girls. Well, the girls
    have caught up with the boys and as the youth of the 1960's
    grow older, the number of older persons who abuse illicit drugs
    and alcohol may increase simply because the rates of substance
    abuse for this age group are higher than they were for previous
    generations.
        Our systems are not prepared for an aging group of drug
    abusers, and at the same time, treatment for teenagers, male or
    female, is far from its potential. Our predictions, combined
    with the potential cost to society, argue strongly for an
    approach to prevention and treatment that balances the need to
    fund services with the need to improve the services available
    and to ensure services are targeted and relevant to the
    populations in need.
        To help address the needs, we are working to give States
    increased flexibility with their block grants. As you may know,
    SAMHSA has a reauthorization proposal on the table. The Senate
    has already acted and approved the measure. I hope the House
    will act soon.
        SAMHSA's role is clear. The findings from KDA grants offer
    service providers and purchasers of prevention and treatment
    services including Federal, State, and local government, access
    to improved, more efficient, and more effective prevention and
    treatment models. Targeted capacity expansion offers a way to
    target prevention and treatment services to the areas of
    greatest need. Block grants provide a way to help support
    States and maintain their prevention and treatment delivery
    systems. And data collection and evaluation provides
    accountability for the Federal resources entrusted to SAMHSA.
    This four-part strategy is the balanced approach that we need
    to continue if we are to make progress.
        Again, Mr. Chairman, and members of the subcommittee, thank
    you for the opportunity to appear today. I'll be pleased to
    answer any questions you may have. Thank you.
        Mr. Mica. Thank you for your testimony and remarks.
        [The prepared statement of Dr. Chavez follows:]
        [GRAPHIC] [TIFF OMITTED] T7551.070

        [GRAPHIC] [TIFF OMITTED] T7551.071

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        Mr. Mica. Rather than start with questions, we'll first
    hear from Dr. Alan Leshner, Director of NIDA. Thank you and
    you're recognized, sir.
        Dr. Leshner. Thank you very much, Mr. Chairman, and members
    of the subcommittee. I'm very pleased to be here today to tell
    you about NIDA's diverse research portfolio and how research
    findings are being used to better understand and prevent and
    treat drug abuse and addiction. I provided a detailed analysis
    in my written testimony, but I'd like to make just a few points
    if I may here.
        NIDA is one of the scientific institutes of the National
    Institutes of Health, the world's leading biomedical research
    institution. NIDA supports over 85 percent of the world's
    research on the health aspects of drug abuse and addiction. Our
    comprehensive portfolio addresses the most fundamental and
    essential questions ranging all the way from the causes of drug
    abuse and addiction to its prevention and treatment. We also
    work hard to ensure the rapid and effective dissemination of
    our research findings into practice.
        Because of our dominant world role in science, NIDA is ever
    mindful that even our most basic research findings must be
    useful beyond just to the scientific community. For example,
    the fact that scientists can now use the most advanced brain
    imaging techniques to see the profound effects that drugs can
    have on the brains of awake, behaving, experiencing individuals
    may not immediately appear to be relevant, but I point out that
    it's precisely these kinds of abilities that are rapidly
    providing us with new insights into how to prevent and treat
    addiction. They are also helping us determine the factors that
    make individuals more or less vulnerable or susceptible to
    becoming drug addicts.
        NIDA supported science is also significantly advancing drug
    abuse treatment in very direct ways. For example, NIDA
    researchers have developed a wide array of behavioral
    treatments and interventions, including cognitive behavioral,
    relapse prevention and new family therapies. They also
    developed the patch, gum, and spray for nicotine addiction and
    LAAM and methadone for heroin addiction. NIDA is also working
    to develop medications to treat cocaine addiction and to
    develop both behavioral and biological treatments for
    methamphetamine and other emerging drug problems. NIDA is
    working very closely with our sibling agency, SAMHSA, to bring
    buprenorphine, yet another effective treatment for heroin
    addiction to the clinical toolbox of physicians and others.
        Moreover, NIDA research has shown not only that drug
    addiction treatment is effective, but also that it reduces the
    spread of HIV, reduces drug use by up to 60 percent, and
    diminishes the public health and safety consequences of
    addiction, including the increasing criminal behavior.
        Research clearly shows that treating drug users while they
    are under criminal justice control dramatically reduces both
    their later drug use and their later recidivism to criminality
    by 50 to 70 percent. It is this combined set of scientific
    findings that is serving as the basis for the new trend that's
    gaining momentum throughout this country of blending criminal
    justice and public health approaches.
        NIDA is also taking a proactive role to be sure that the
    science is used to improve the quality of drug addiction
    treatment throughout the United States. As is the case for
    other chronic disorders, effective treatments for addiction do
    exist. However, as is also the case for other disorders, we can
    do better. Moreover, few of the new treatments are being
    applied on a wide-scale basis in real-life treatment settings.
    In response, NIDA has expanded on a model pioneered by other
    NIH institutes, the National Cancer Institute, the National
    Heart, Lung, and Blood Institute, the National Institute of
    Allergy and Infectious Diseases, and we have established the
    National Drug Abuse Treatment Clinical Trials Network. We call
    it the CTN for short. The CTN will provide a much-needed,
    national research and dissemination infrastructure to both test
    new pharmacological and behavioral treatments and to
    systematically research how to correctly incorporate these
    interventions into real life settings.
        We've already established the first six nodes and have
    brought 42 community treatment providers into this
    infrastructure. We'll bring another six nodes including another
    40 treatment providers into the network this year.
        Our ultimate goal is to include as many universities and
    community treatment providers in the network as possible and,
    of course, to be truly effective, the network must blanket the
    entire country.
        The National Drug Abuse Treatment Clinical Trials Network
    epitomizes NIDA's role as a supporter and conveyor of reliable
    science-based information. However, to truly optimize its
    dissemination of new findings to frontline providers, we work
    closely with colleagues and many other Federal agencies,
    particularly SAMHSA. A prime example is SAMHSA's addiction
    technology transfer centers, which are working closely with the
    nodes of our Clinical Trial Network to help ensure that
    rigorously tested and effective treatment programs are
    disseminated to communities across the country.
        To conclude my introductory remarks, because addiction is
    such a complex and pervasive health issue, we must include in
    our overall strategies a comprehensive public health approach,
    one that includes extensive research, education, prevention,
    and treatment. We're very pleased about the tremendous progress
    in drug addiction research and how these scientific advances
    are offering us the tools and practical solutions to reduce the
    devastating problems caused by drug abuse and addiction for all
    Americans.
        Thank you very much. I'll be pleased to answer questions.
        [The prepared statement of Dr. Leshner follows:]
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        Mr. Mica. Thank you. Let me start with a few questions, if
    I may, for Dr. Chavez. One of the concerns that was raised as a
    result of the GAO report that we requested was the distribution
    of personnel. You testified in your opening statement about
    some changes reducing the administrative offices. Did you say
    20 to 7?
        Dr. Chavez. Yes, sir.
        Mr. Mica. And moving FTEs to centers. I wasn't quite sure
    what that was. Could you elaborate on the movement of those
    personnel?
        Dr. Chavez. In 1996, the House Appropriation Committee
    requested that we review our organization, and one of the
    things that they were looking at was the duplication. For
    example, we had many duplicative services in all three centers
    at SAMHSA. Their recommendation was that we centralize many of
    these administrative services. In addition, they also
    recommended that we look at some areas that needed to be
    strengthened.
        Mr. Mica. Where did these 44 people come from and where did
    they go? 44 FTEs, are they just slots?
        Dr. Chavez. These were FTEs and these were slots.
        Mr. Mica. Eventually, people moved from one point to
    another point. Where did they go?
        Dr. Chavez. They went to the three centers, to the Center
    for Mental Health Services, to the Center for Substance Abuse
    Treatment, and the Center for Substance Abuse Prevention.
        Mr. Mica. So we have the same number of people. They've
    just been moved to other responsibilities?
        Dr. Chavez. That is right. Some of those individuals--some
    of those positions were vacant, so those positions were also
    transferred to the centers.
        Mr. Mica. One of the other things that caught my eye was
    the number of personnel in the administrator's office, which
    GAO reported at least 73, and I think you said there were 7.
    Can you account for this discrepancy? Where are the other folks
    working?
        Dr. Chavez. The reason that the Office of the Administrator
    appears to be large is that numerous essential operational and
    coordinating functions are grouped with the Office of the
    Administrator, the umbrella organization. For example, in my
    immediate office, there are seven individuals, a total of seven
    that are directly in that office, including Dr. Joseph Autry,
    who is the Deputy Administrator. There are five others that are
    detailed. One is detailed to the Department of Health and Human
    Services. Another person is detailed to HCFA. And the other to
    the Executive Secretary. In my office, I have a Deputy, an
    Assistant, and a Secretary. Dr. Autry has a Secretary and an
    Assistant. So in the immediate office there are seven
    individuals. Those other individuals which are listed are in
    various offices and provide agency-wide roles. For example,
    contract and review, which was one of the groups that the House
    Appropriation Committee recommended be centralized. They are
    responsible for managing legally required reviews for the
    centers. We also have program coordination and policy
    activities and offices that are responsible for coordinating
    many of these activities. Some of these offices are in statute.
    For example, we have an office for AIDS. We have an office for
    women. We have an office for alcohol. We also have legislative
    services as well as Equal Employment Opportunity, Civil Rights,
    and Executive Secretary functions.
        Mr. Mica. There are 73 people total assigned to your staff,
    and then you have each of the different activities. Mental
    health has 113, substance abuse prevention 118, and Center for
    Substance Abuse Treatment 115. So most of what you have in
    these other activities would be a duplicate at your full
    administrative office. For example, you have 12 in
    communications, public communications. In mental health for
    that entire agency there are 13 substance abuse, and
    communications has 22. And 26--I'm sorry, 7 in substance abuse
    treatment. So you have duplicates in the Administrator's Office
    of which we have those activities, and each of the individual
    activities, one being just for citing--the numbers would be as
    I cited with public communications; is that correct?
        Dr. Chavez. Let me----
        Mr. Mica. Those numbers are correct. I'm just looking at
    one function, which is communications or PR, and you have 12 in
    your office.
        Mr. Autry. Mr. Chairman, may I respond to that, please. If
    you look at the fact that SAMHSA is an operating division
    within the Department of Health and Human Services, that means
    that we have functions that we have to carry out, including
    clearance of testimony, clearance of reports, doing special
    reports to the Congress, reports to the Secretary, et cetera.
    Those are functions that are carried out within the Office of
    the Administrator. The functions that are carried out in the
    centers are primarily those related to synthesizing knowledge
    information, disseminating that to the field around specific
    issues like substance abuse treatment, substance abuse
    prevention, mental health services, so there is not duplication
    in that area. Also, Dr. Chavez noted, we did centralize a
    number of the functions so that all of the peer review
    mechanisms are now centralized in OA. That did result in a
    savings of FTEs. Grants management contracts management, and a
    number of offices that run administrative services were also
    centralized in the OA as well as legislation and policy staff.
    So those are not duplicated in the Centers.
        Mr. Mica. One of the major concerns, if they put the chart
    back up, on the block grant, the SAMHSA funding and staff
    allocations was--I'm sure you've seen it--State block grants,
    which accounts for 80 percent of the funds, which you give,
    that would be non-mental health or just in substance abuse
    prevention treatment? Can you put that chart up?
        Again, what has raised some questions about the expenditure
    funds is--and 6 percent may be a good figure for overall for
    administering $3 billion at whatever total amount of funds
    you're administering, but with the bulk of the money, 80
    percent of the money is given out in State block grants, 11
    percent of the personnel are used. To give out the
    discretionary grants or other activities, 89 percent of the
    administrative funds are used to distribute to 20 percent,
    which has brought many to believe that we should block grant
    just about everything. Then we had people at the last hearing
    noting that there is overlap. They couldn't answer questions
    about research and scientific activity. I know some of your
    responsibility is evaluation, and that's an important activity,
    and also mandated by Congress. But there were questions as to
    why that hasn't been researched, being given to NIDA which has
    that responsibility, to bring down the cost of administration
    and put more of this money out into the treatment programs.
        So we have some serious questions about the amount of money
    that is being expended for a very small portion of the budget.
    Did you want to respond?
        Dr. Chavez. Yes, sir. Thank you. Let me talk a little bit
    about the administrative costs and the excessive overhead that
    seems to be seen. SAMHSA's overhead costs are not excessive----
        Mr. Mica. We've all agreed on that generally. But 11
    percent of the personnel, according to the GAO, we didn't study
    it. We have no prejudice in this. All we're trying to do is
    look at the facts. They say 11 percent of your personnel are
    used to distribute 80 percent of the fund. The 89 percent are
    in the expenditure of 20 percent of the funds, and some of
    those activities are indeed NIDA, who has the lion's share of
    activity, I would imagine.
        Dr. Chavez. You are correct. NIDA is the premier research
    institute.
        Mr. Mica. Should we turn the rest of that over to NIDA, the
    activities you now have in R&D?
        Dr. Chavez. Yes, I would like to answer the block grant
    question if that's OK with you.
        The question that has been raised is that perhaps we're
    either shortchanging the block grants staffing, whether it's
    appropriate and reasonable. The block grants differ from all of
    our SAMHSA programs in that the States decide on which project
    will be funded and then they manage these directly.
        What we have done at SAMHSA is to ensure that the staffing
    for the block grants is in proportion to what we believe is
    critical--in relation to the work that needs to be done. Now,
    the staff members who are assigned direct responsibilities are
    also supported by other staff members to carry out the
    necessary functions. For example, we do a lot of technical
    assistance which is, by the way, requested by the States. We do
    site visits and we do audits. Joe, I don't know if you want to
    add anything else to that.
        Mr. Autry. Mr. Chairman, if I may add a couple of comments.
    One of the things about block grants is that they are, by
    definition, moneys that go through the States with very little
    strings attached to them, if you will. And so there is not the
    degree of review of application, nor the degree of oversight in
    terms of what specific activities that they are funding that is
    necessary in a discretionary grant program. As Dr. Chavez
    indicated, the review of the applications regarding TA, making
    sure we do appropriate audit procedures are the main function
    of the block grant staff. It's not as labor intensive as our
    discretionary grant program. Most of our discretionary grant
    programs are what we call cooperative agreements, which means
    there's a significant Federal oversight role in developing both
    individual project and cross-project, or cross-program
    evaluation, to determine how effective and efficient those
    activities are as they are delivered in the real world.
        Dr. Chavez is quite correct that our program is quite
    different from Dr. Leshner's, and as he noted, his institute
    does, in point of fact, conduct research. They do clinical
    trials work, they look at behavioral therapies, medications
    interventions, et cetera. Once you put that out into the
    community, and I can tell you as a practitioner, many times
    what you develop in the laboratory or very controlled setting
    differs significantly on what really works in the real world.
    And we're very pleased to have an ongoing dialog with Dr.
    Leshner to continue to get his input as we try to improve the
    effectiveness and efficiency out in the real world.
        The acknowledge development activities that we support are
    in service of the block grant and in service of targeted
    capacity expansion trying to find more effective ways to
    intervene, better ways of doing assessments, and more efficient
    ways of using what we know and constantly trying to improve our
    knowledge, including feeding interventions back to NIDA that
    need additional research. So it is more labor intensive than
    the discretionary grant program.
        Mr. Mica. Well, first of all, Dr. Chavez, I never or anyone
    from this panel, accused you of shortchanging in the
    administration and overhead for the block grant program. It
    appears to be fairly cost effective to administer in the scheme
    of things. That's not the problem. The problem is on the other
    side of the equation. I could be a better advocate for your
    department than both of you are because there are many things
    that Congress has mandated. Part of your costs are the
    evaluation system, which we require to be set up, and
    accountability. And that's an important mandate. From the
    testimony we heard from folks, that sounds like we went a
    little bit overboard, and we need to go back and grant a little
    bit more flexibility.
        There was one witness who said she spends 4 hours preparing
    forms. Almost 1 day a week preparing forms and reporting and 4
    days for treatment. That's how bad it's gotten in the reporting
    area. We're here straightening out many of the things and
    States overreact. The other thing we heard was also
    duplication. When you're down at the lower end of the pecking
    order, the States have requirements and Feds have requirements,
    and this poor little person who is trying to treat folks at the
    end of the feeding chain, and sometimes smaller operations, are
    burdened with overhead and spending time on completing forms
    rather than treating people.
        The other thing that we are concerned about technical
    assistance, and we do need to provide that. Sometimes, only the
    larger body can provide that. In this case, hopefully, the
    Federal Government and agency can adequately provide technical
    assistance on a broader base. You didn't say, I think,
    publications. We had testimony that noted some of what you do,
    as far as even publications and bringing information together
    and disseminating, is extremely valuable.
        Our problem is we also heard testimony and have evidence
    that show many of the discretionary grants are given to
    treatment programs that already are getting State money or
    indirect Federal money through State money, so they are going
    through sometimes three levels of evaluation or scrutiny or
    reporting. And it seems like we've created a very expensive
    overhead for some of these KDA activities. So we are wondering
    why we can't shift more money to get out to the treatment
    programs and less money for administering discretionary
    programs.
        I'm sure there are some unique programs that only the
    bureaucrats and only the people in Washington can decide that
    are valuable for national interest, but when you spend $129
    million, and if my plan works, to spend only $29 million and
    give $2 million additional dollars to States for those
    activities--she doesn't like that. OK. We'll redo the figures.
    In any event, we're trying to find a way to have less
    administrative overhead yet more money into the programs,
    eliminate these extra requirements. And the final thing is if
    there's overlap with Dr. Leshner, if we could shift to NIDA
    with some interagency agreement. For them to conduct this, then
    the problem we have is even when we get into some of these
    testing areas. I don't want to take all the time.
        I want to yield, and then we can come back. We get into
    some of these testing areas, and I find that there are further
    delays in testing and evaluations. I just read out a report
    that now we may be looking at 2003 before the earliest standard
    for new drug tests, and technologies-acceptable standards can
    be implemented. So we have research. We have testing. We have
    evaluation. We have different important functions in trying to
    sort out how we can make them all fine-tuned and efficiently
    delivered.
        Dr. Leshner, finally, could you see us combining and
    working in some interagency agreement and shifting all of the
    research activities to your agency?
        Dr. Leshner. Actually, sir, I don't think we have literal
    overlap in what our two agencies do. We conduct research and
    applied research and SAMHSA, and we overlap, at most, just a
    hair at the edges of what we do and in an attempt to provide a
    somewhat seamless transition.
        Mr. Mica. They may not overlap, but I just say there are
    administrative costs. Is there any efficiency of you doing the
    whole enchilada and having some type of cooperative agreement?
        Dr. Leshner. Not that I'm aware of, sir.
        Mr. Mica. Maybe we can ask GAO to look at that question,
    specifically. Sometimes, it's hard for agencies to come up with
    consolidation recommendations and dichotomy of scales.
        Mrs. Mink.
        Mrs. Mink. Thank you, Mr. Chairman.
        Dr. Leshner, your primary research mission, as I understand
    it, is to analyze how drugs impact on behavior, on human
    development, and create a wide variety of mental and physical
    disorders. Is that basically the type of research that you do
    in NIDA?
        Dr. Leshner. That's a portion of the research that we
    support because we represent 85 percent of the world's
    research. Our research portfolio ranges, actually, all the way
    from the very most molecular levels of analysis of
    understanding how drugs of abuse function and produce addiction
    through prevention research, treatment research, and research
    on the organization and financing of services for substance
    abuse. And so we say we do everything from the molecule to
    managed care, or everything from the most molecular level all
    the way out to understanding social systems and how those
    social systems affect and respond to the drug abuse and
    addiction problem.
        Mrs. Mink. The primary function of SAMHSA is to distribute
    block grant moneys for treatment of drug addicted individuals,
    and that's how they distribute their block grants. Is it at all
    feasible to consider a suggestion that NIDA then determine
    whether the treatment programs that are funded by the Federal
    Government are working and to what extent they could be
    improved, or to what extent they could be translated in other
    venues?
        Dr. Leshner. We do, in fact, study the treatment system,
    both public and private and its effectiveness, and again have
    determined it to be highly effective. However, we don't have
    any authority over individual programs or the way in which
    States administer the treatment programs.
        Mrs. Mink. I don't mean to suggest you would have any
    authority but to study whether they are effective or not.
        Dr. Leshner. We do, in fact, not tied to any particular
    funding stream, but, of course, we do analyze the nature of
    this treatment system in this country and the way in which it's
    functioning.
        Mrs. Mink. Is that why they distribute it then to the
    various State agencies?
        Dr. Leshner. I believe it is. Just as one example, we
    recently produced the first science-based guide to drug
    addiction treatment, which has now gone out to over 250,000
    communities in this country, and we've had over 55,000 copies
    downloaded from our Website. Every State is using this guide as
    a part of its own activities, and it's a compilation of
    research and what we've learned from research, so I do believe
    that the information is, in fact, available to the States. The
    States are participating actively in our Clinical Trial
    Network. In fact, the State director from Oregon is a member of
    the CTN oversight board. So that there is a close relationship
    between us.
        Mrs. Mink. So the work that you've just described as part
    of NIDA and the work that is now assigned and taken over by
    SAMHSA, you say there's only a fine line of duplication of
    effort?
        Dr. Leshner. My own view is that there is virtually no
    duplication. There is, however, an attempt to have a seamless
    connection between what we do and what SAMHSA does. An example
    of that I mentioned in my testimony is the Association of the
    Addiction Technology Transfer Centers that SAMHSA supports with
    our clinical trial network. Another example would be, just last
    week I was in Oregon meeting with our northwest node, and
    present in the room were the people from the Center for
    Substance Abuse Treatments Practice Research Consortium, so we
    do, in fact, try to mesh activities as much as we can in order
    to have that translation. My own view is we have virtually no
    overlap.
        Mrs. Mink. I know that it's not particularly appropriate
    for one agency to criticize or make comment about another
    agency's function, but since we are here today to try to
    understand SAMHSA, and if there are any possible ways in which
    their application of the law can be improved, would you be able
    to comment, with respect to this one area that the chairman has
    criticized with the KDA, if there is any room for improvement
    as to how the funds should be allocated there or commissioned
    out by contracts and so forth. Is there anything that you could
    clarify for us?
        Dr. Leshner. I don't know enough about the administration
    of it to make any comments like that. I can say that the KDAs,
    with which I'm most familiar, use science and use the science
    base that we've provided as a foundation for what they do, but
    I really am not qualified to comment on the administrative ends
    of it.
        Mrs. Mink. Are you able to comment on whether SAMHSA has
    need for the delineation of this program for research and for
    evaluation and for dissemination of information?
        Dr. Leshner. I find SAMHSA's programs extremely useful in
    terms of helping to get dissemination and translation into
    actual practice of what we do. I apologize for going on, but
    just give you one example, NIDA research produced something
    called the matrix model as a treatment approach for
    methamphetamine addiction. The subject must be well known to
    you and SAMHSA's Center for Substance Abuse Treatment has now
    done a multisite KDA demonstration of that program in a variety
    of places around the country, and I believe that again is an
    example of the relationship that can exist.
        Mrs. Mink. Thank you. Your responses to my question, I
    think, are very illuminating. While we could probably get the
    same response from SAMHSA, Mr. Chairman, sometimes it's much
    more compelling if you have another agency corroborating what I
    believe the primary witness, Dr. Chavez, has already testified
    to. Frankly, Mr. Chairman, administrative costs are always a
    disturbing factor when you think of the tremendous need out
    there for additional funds and only 50 percent of the people
    that should get treatment do. I think it's relevant to say that
    the Federal Government does not have the entire responsibility
    for drug abuse treatment. We share only a limited participation
    in this area. The main function ought to be State and local
    governments, but in looking at my own situation in my State, I
    find that the Federal Government is supporting more than 50
    percent of what we are spending in my State, and I think that's
    willfully lacking in terms of our own State performance.
        So while I would like to see many more dollars going out
    there to my State for treatment, I do think that the burdens
    that have been placed upon this agency for evaluation and
    research and dissemination of information and so forth require
    this 50-person allocation for administration of these block
    grants. But I think it's worthy to look at it and to study it,
    but I see really no basis for criticism of the agency's use of
    these 50 bodies.
        There's one column in this column which is mental health,
    which is not part of our inquiry, so we're only taking the
    three, and there are 50 bodies that go across the line block
    grant. But I don't think that's only for analyzing who gets the
    grants. It's to make sure that the use of the funds as
    appropriate and in accordance with the law, and I think that
    you and the majority members in particular are always honing in
    to make sure that the funds are properly spent, yet you don't
    want one-size-fits-all, and you don't want the Feds dictating
    how the funds are going to be used.
        So you're kind of in a tough spot, Mr. Chairman, in trying
    to meet all of these criteria. But I think in this instance, I
    personally am satisfied that the agency is doing well, and
    while I would like to have more money and greater freedom in my
    district for how the funds are to be used, I don't see any
    particular discrepancy in the administrative costs allocation
    insofar as the testimony that's been presented so far. Thank
    you, Mr. Chairman.
        Mr. Mica. Thank you. I'll respond in my questions when I
    get time after Mr. Tierney.
        Mr. Tierney. Thank you. Dr. Leshner, let me go a little bit
    astray here on this. You said about 95 percent of your work was
    drug abuse and treatment research. How much of that is
    allocated to alcohol abuse?
        Dr. Leshner. Another NIH Institute, the National Institute
    on Alcohol Abuse and Alcoholism [NIAAA], has primary
    responsibility for alcohol research, because if you have a
    grant from NIDA, you may also be studying alcohol in the course
    of it, since most drug addicts are, in fact, polydrug users, we
    estimate, and this is an estimate that we support, about $40
    million a year, that includes alcohol.
        Mr. Tierney. Most of it goes under another NIH----
        Dr. Leshner. NIAAA.
        Mr. Tierney. You also indicated NIDA was instrumental in
    coming up with a patch, gum and spray for nicotine treatment,
    that your research actually resulted in the development of
    those.
        Dr. Leshner. Yes.
        Mr. Tierney. NIDA is not the one advertising or selling
    those. I am curious to know how they got in the hands of
    private manufacturers and what the deal was underlying that?
        Dr. Leshner. We have our own research laboratories in the
    hospital on the grounds of the Johns Hopkins Bayview campus in
    Baltimore, and one of our researchers, Jack Henningfield, did
    the pioneering work on the addicting qualities of nicotine and
    on techniques for administering nicotine-like substances
    through other vehicles, which goes into the public domain,
    where private companies are, of course, free to pick up the
    technology.
        Mr. Tierney. No proprietary rights on that at all?
        Dr. Leshner. We don't on the nicotine patch. However, now,
    as you may know, we are forming what are called CRADAs,
    cooperative research and development agreements, with
    pharmaceutical companies for the development of antiopium and
    anticocaine medications. We have a number of those and what we
    have there is a share in the developing costs, because the
    Federal Government believes it's so important to develop these
    medications. We don't actually get money back as a result of
    it, but we do, in fact, facilitate treatment, and it keeps the
    costs down tremendously.
        Mr. Tierney. Why is it that you don't get anything back,
    and didn't in particular with Mr. Henningfield's work?
        Dr. Leshner. In the case of Dr. Henningfield's work, it
    was, of course, the work that produced our understanding that
    nicotine is an addicting substance, and he has since gone on to
    great and famous things. But the technology itself was
    developed as a part of the scientific investigation and was not
    at the time developed predominantly to be a marketable product.
    Therefore, when it was published, it went into the public
    domain and just like many other technologies that you now have
    for the application of medicines, the various parts of your
    body, have been in the public domain, that particular
    technology was also. The approach of trying to produce
    sustained nicotine levels as a treatment approach was the
    scientific question that Dr. Henningfield was investigating at
    the time.
        Mr. Tierney. You also made some comments or your remarks
    that few of the new treatments that are being developed are yet
    to be widely used. Am I correct in quoting you there?
        Dr. Leshner. Yes, sir, you are.
        Mr. Tierney. Can you tell me what we're doing about that
    and how we're going to improve that situation?
        Dr. Leshner. There are a variety of things happening. First
    of all, it's important to recognize that many of these
    treatments are treatment components. They are not comprehensive
    programs. They are pieces that you might incorporate into a
    comprehensive program and they have only been developed within
    the course of the last 10 years.
        However, having said that, we are about to mount the first
    three trials in our Clinical Trial Network just 4 months since
    we made the first awards. What will happen is we'll test them
    in real life settings, and then if they work, people will use
    them. In addition to that, what we're doing, and again, to use
    that methamphetamine matrix example or the addiction technology
    transfer centers example, SAMHSA's programs take the results of
    the scientific research, and then help disseminate them to
    community-based providers.
        So we have both a relatively permanent research
    infrastructure, our Clinical Trials Network. That's one
    vehicle. SAMHSA's addiction technology transfer centers and
    their KDAs programs that provide another mechanism to help
    facilitate dissemination of scientific findings. Both of these
    activities are really quite new, and my own view is that they
    are being pretty successful at getting the information out but
    there are many thousands of treatment programs in this country,
    and it's very hard, of course, to change behavior.
        Mr. Tierney. Thank you.
        Dr. Autry and Dr. Chavez, let me ask you, the chairman made
    a comment about block granting everything in your program,
    which I don't think is necessarily going to be the appropriate
    way to proceed, but I'd like your comments on that. Would it at
    all help or hinder your efforts to address the situation for
    which you're formed?
        Dr. Chavez. Mr. Congressman, in 1980-1981, that was
    considered by the Congress--in 1980 and 1981 as well as in
    1986. At that time, in 1980 and 1981, the Congress made a
    decision that, in addition to block grants, we also needed to
    have a national presence through demonstration programs. Then
    in 1996, the same issue was addressed, and at that time, the
    Congress made a decision that we really needed to ensure that
    the knowledge or the science that is being developed by NIDA is
    translated and carried out into community programs, and
    basically that is what our knowledge, development and
    application program is about.
        What I believe, and I think many of us out in the field and
    throughout the community believe, is that in order for us to
    really begin to close the treatment gap and to continue to
    reduce drug use among youth, we need a balanced approach. As
    the Congresswoman said earlier in one of her comments, one size
    does not fit all. Our approach has been with--the block grant
    that the States perform a very, very critical job, and they,
    too, are limited, as we all are, in terms of their resources.
    And in some States the demand is so great that it cannot be met
    for treatment services. That is one component of a balanced
    approach.
        The other component of a balanced approach is KDA and TCE,
    which is our knowledge development and application. Within
    that, we take a lot of the research and we build on what NIDA
    has done and give it life in communities. We're asking ``Does
    it work?,'' especially in diverse communities. The other area
    that is also part of that umbrella is what we call our targeted
    capacity expansion. The targeted capacity expansion was created
    because the Congress of Mayors, Indian tribes, the Black
    Caucus, the Hispanic Caucus, and many groups throughout the
    communities came to us and said that they needed our help in
    ensuring that we were targeting services specifically to their
    community.
        We have looked at the drug problem as a national problem.
    However, it's a regional problem as well and as that map that
    we have over on that side clearly indicates, if you look at
    methamphetamine as one example, we have the same information
    for heroin and many of the other drugs. Methamphetamine, in
    this particular instance is, as you can see, a very regional
    problem. What we have done there is that we have issued
    announcements to communities and to mayors and to counties and
    to Indian tribes. Let them assume the responsibility in terms
    of identifying what the problem is in their community and then
    we will provide short-term dollars to help them resolve these
    problems.
        Now, having said that one size does not fit all, and I do
    not believe because of the nature of its formula, and some of
    the other issues, that the block grant alone is going to be
    able to succeed in terms of solving some of the issues that
    we're having to deal with today.
        Joe, do you want to add anything?
        Mr. Autry. I would just like to add a couple of comments.
    One, as Mrs. Mink noted earlier, there really are insufficient
    funds to fund the block grant, and insufficient funds at the
    State level to entirely close the treatment gap using just a
    block grant mechanism. On the other hand, the block grant
    provides the necessary infrastructure to support treatment
    systems within the States and without that, you would be even
    further behind in closing the treatment gap.
        Looking at the regional distribution of drug use in this
    country, knowing that there are communities who do not receive
    sufficient funds through State coiffeurs, and knowing that many
    times we need to have additional funds come in and sometimes
    people are reluctant to use the same old mechanisms to provide
    funds, we try to tailor programs that meet those emerging
    needs. We try to tailor programs that address distribution of
    drug use, emergence of HIV-AIDS infection and the needs of
    special populations who are not met many times through the
    block State funding.
        So if we don't have a balanced approach, we don't provide
    Federal leadership, work in conjunction with our State
    colleagues, we're not going to be able to have the effective
    programs that we need to address substance abuse in this
    country.
        Mr. Tierney. With respect to the amount of money you
    disseminate through block grants, if you weren't constrained by
    the formula, would your agency think of allocating those funds
    in a different direction? Are there other areas of need or
    other priorities that you would address instead of spreading
    them out by the same formula?
        Mr. Autry. Two comments to that. One is, the formula is, in
    point of fact, a vehicle created by Congress. I think it's
    already taken into account a lot of those varying competition
    needs----
        Mr. Tierney. My question is, do you think it's effectively
    doing that or not?
        Mr. Autry. I think the block grant is a highly effective
    mechanism in providing the necessary treatment and prevention
    infrastructure resources in the State, and I'm pleased to say
    we work with our colleagues at NASMPHD and NASADAD to continue
    to provide oversight to that to develop common core outcome and
    performance measures. We look forward to continuing to do that.
        Mr. Tierney. Thank you all. Thank you, Mr. Chairman.
        Mr. Mica. Let me just followup on a couple of things. You
    said you tailor programs to assist where there is a problem.
    This chart identifies the methamphetamine problem. We just did
    hearings in California. I saw the red part, at least the
    California coast, I should say the Pacific coast, and what's
    going on there. There's a meth epidemic. It's beyond anything.
    I've only been chairman for 14 months, and I had no idea that
    it was that severe. I have a chart here that shows the
    percentage of State money for treatment services by funding
    source that was provided to us by GAO, and it shows State and
    Federal funding.
        Actually, California gets about 25 percent of its funds, if
    we include this other Federal, we might get up to 39 percent.
    One of the lowest in Federal funds and highest in State or
    other funds. It would seem to me that a State that would have
    an epidemic problem should be getting more funds.
        Next to it is Florida, which has an epidemic heroin
    problem. Is there anything that's done to make certain that
    more Federal resources get to where we have these epidemic
    problems?
        Dr. Chavez. Thank you, sir. That's a great question or a
    great comment. First of all, California--in terms of block
    grant distribution--California, if I remember correctly, gets
    more dollars than any other State in their grant block
    distribution. The question that you have raised is an excellent
    one, because that's exactly what is at the heart of our
    treatment capacity expansion.
        This is what I said earlier--when communities, when mayors,
    when county officials, when Indian tribes, when the Black
    Caucus, and when the Hispanic Caucus have said that some of
    these dollars are not reaching our communities. We have, in
    some of our communities, epidemics, and these epidemics range
    from HIV-AIDS and substance abuse to methamphetamine, to
    heroin, to drug overdose by young people, et cetera.
        The idea, in terms of the creation of the targeted capacity
    expansion, was to give local communities the opportunity to sit
    with their political subdivisions and define the problem--in
    ways that were truly getting to the heart of that problem. Then
    they would submit an application to SAMHSA which, like all of
    our applications, is reviewed, as required by statute, by
    peers.
        Mr. Mica. The local communities we talked to, almost every
    one of them, are first submitting to the State, and then they
    are submitting again to SAMHSA under your formula. My question
    would be if we do the chart from last year, and I was out
    Monday in that area, they are hanging on by their own teeth,
    only because they put together patchwork programs with the
    State agencies.
        I'd like to see what we've done last year to increase these
    percentages in some of the target areas. If that's our purpose,
    they are telling me they aren't getting the assistance. They
    are already applying to the State, and then we have the State
    investing over 400 hours preparing its application for block
    grants possibly. They were complaining to us that this
    application process is extensive, burdensome, time-consuming.
    It needs to be shortened, streamlined. New York was here and
    testified. They say they have even higher standards than you, I
    think, had set up, and you run them through a lot of
    unnecessary hoops. Why can't some of this be done
    electronically. We have new technology today, and they said
    SAMHSA is still in the dark ages.
        From what I see out there, when you go see an epidemic, and
    you tell me you set it up so communities can apply to you, and
    these people in Washington decide whether they get it, the
    States and locals are already ahead of you and not getting the
    money and complaining about two and three levels of approval
    and preparation.
        Mr. Autry. Mr. Chairman, let me respond to that. Let me
    start first by congratulating California. The reason that we're
    only 25 percent of the treatment dollars there is because
    they've chosen to make a significant investment of State funds
    in the treatment system. Last year California received $217
    million in block grant funds for substance abuse treatment and
    prevention, and they received an additional $30 million in
    discretionary grants from us, and it's because of the very
    nature of the emerging problems, the severity of the problems,
    the prevalence of the problems, that they were as successful in
    competing for those discretionary funds.
        Applying to the Federal Government does not require
    duplicate methods or duplicate applications with the States. We
    do require that communities are applying----
        Mr. Mica. A local community program has already received
    State approval. They don't need additional approval, then, for
    funding from you or additional evaluation.
        Mr. Autry. They do need to be peer reviewed. That's the
    requirement under our statute and regulations that any
    discretionary grant program must have peer review. What we are
    doing is we are experimenting with the ways to simplify both
    the application process, the duration of time from application
    to review and funding; and second, we're experimenting with new
    ways of doing reviews to expedite the reviews. And that's an
    ongoing commitment on our part to try and expedite how rapidly
    we can get dollars out to the field.
        I might also add that many times in the KDA program, we use
    the existing service dollars there to continue to fund the
    services at the same time that we're putting in, looking at new
    interventions, looking at more effective and efficient
    interventions. So we build on the service dollars that are
    there and add dollars on top of that rather than supplanting
    the service dollars.
        Mr. Mica. As I understand the process, discretionary KDA
    grants awarded by SAMHSA go directly to cities and communities.
    Why isn't this process closely coordinated with the States?
        Mr. Autry. Mr. Chairman, it is indeed closely coordinated
    with the States. We have an agreement with the States that when
    a community, a city or sub-State region submits an application,
    it must be reviewed and signed off by the State.
        The reason we do that is twofold: one, we want to make
    maximum effective use of all the dollars that are at the State
    level. Second, we want to build in State awareness of this
    program, so No. 1, they can learn from the effectiveness of the
    interventions used; and No. 2, there will be sustainability as
    the States can pick up the funds once our discretionary money
    has ended.
        Mr. Mica. Now, I can't recall exactly the testimony, and we
    could get staff to submit this question, but in KDA review
    process, they said that the States are not adequately
    represented? We have some testimony on one of those. Some of
    the review process we had criticism that there wasn't adequate
    dollars in the review. We'll get that to you and maybe you can
    respond.
        Let's go a minute to SAMHSA's contracts in the Washington,
    DC area, which is table 4 of the GAO report. And that raised
    some questions, particularly with Mrs. Mink and, some of the
    minority members from other areas that don't have any of these
    contracts. These are all in Mrs. Morella's and Mr. Wolf's
    district. But 27 of 29 contracts awarded by SAMHSA for over $1
    million, those contracts in that range total $64 million
    awarded to the Washington, DC area. Why can't more of these
    services be contracted across the country? It looks like it
    started into a little cottage industry here for big contracts
    with the Beltway folks. What's the story? All the knowledge is
    in Washington. We know that.
        Dr. Chavez. The contract process that we have at SAMHSA is
    open and it's a competitive process.
        Mr. Mica. It doesn't sound like it's that competitive.
    There were two others. Did either go to Florida or Hawaii?
        Dr. Chavez. They adhere strictly to the Federal Acquisition
    Regulation. They don't favor any contractor over another. They
    are all peer reviewed by panels. They are comprised of experts
    from throughout the United States and all of this is required
    by law. Can I maybe--I think----
        Mr. Mica. Let me tell you, I could probably give a better
    answer than that. Congress has imposed a lot of requirements on
    this agency for evaluation and for reporting, and we do buildup
    cottage industries that do those activities. And they are
    located right next to the seat of powers. We need to go back
    and look at what we've done. I also heard that we created some
    inflexible overreporting. But again, it raises eyebrows when
    you have those kinds of funding being spent in one locale.
        Mr. Autry. Two comments. I certainly agree with you that
    cottage industries tend to grow up at the seat of the money,
    and this is an issue that's faced not only by HHS, but all the
    other Federal agencies as well. There are a couple of things I
    think that we try to do differently than perhaps some other
    Federal agencies. One is we work with our State colleagues to
    identify not only what needs they may have for training or for
    TA, but also to find people outside of the Washington area, be
    it in there State or adjacent States, who can work with them to
    meet those training and TA needs.
        So we try to spread the money around, even with the prime
    contractor maybe here in Washington. Similarly, we work with
    our colleagues at NASADAD. The contract money they have does
    not all get spent for what's done here. That actually goes out
    and helps fund the States to do data collection and whatever
    elements we may be needing for that, but we agree with you, we
    would like to see a higher distribution of the moneys
    throughout the United States.
        Mr. Mica. I have another question relating to target
    populations and activities. One of the reasons to have Federal
    programs is to be able to address the broader picture and then
    target our resources. In some instances, they are not the
    largest portion of funds being expended. Tell me about our
    national programs. There was testimony here how important and
    effective it is to reach the corrections population, both
    people entering into the criminal justice system and hopefully
    giving them an opportunity to find another path and then within
    the prisons we find that we have tremendous recidivism with
    drug abusers, users, popping them into prison and then out of
    prison. Could you give me a dollar amount, or is there a
    program amount? Do we have a target publication that says we
    are doing this? Are prisons eligible to apply for these funds,
    and do you have programs in that area?
        Could you respond, Dr. Chavez?
        Mr. Autry. If you don't mind, Mr. Chairman I would like to
    respond to that. You referenced a 1991 report that HHS, ONDCP
    and Justice had done. We had a symposium--assembly, rather,
    just this last fall in which those same three groups came back
    together to talk about what the current State of knowledge is,
    what the current State of need is, and what we can do together
    to work on this. We have an extensive history of providing both
    TA and training to the criminal justice system, and we work on
    both sides of the black box, if you will, those that can be
    diverted from entering into the criminal justice system or into
    incarceration, and those who are coming out----
        Mr. Mica. What programs specifically? How many dollars of
    all of our drug treatment dollars are going to these? In
    Florida, my former district representative now works with the
    correction system, working with me in Congress and going to the
    Florida corrections system. But he is now working with them
    just as an aside, and if I go to him at this point and say we
    spent millions at the Federal level, and we know that there's a
    good program to divert these people, so I don't have to
    incarcerate them in Florida prisons at $60,000 or whatever it
    costs, and I've talked to Dr. Autry, and he said that SAMHSA
    says this is a good program, what is it and which one have we
    spent money on and what do I tell him?
        Mr. Autry. A couple of things. One, we just agreed with the
    Department of Justice and ONDCP to start a new $10 million
    program covering some of the issues you're concerned about. I
    can get you, for the record, additional moneys that are already
    there. I would also point out that a recent report by the
    Department of Justice pointed out that only 40 percent of their
    prisons have treatment programs for substance addiction.
        Mr. Mica. Are prisons eligible to apply for funds for
    treatment?
        Mr. Autry. Those who are incarcerated get their funds
    through the Department of Justice. Those who are not
    incarcerated work jointly, and many times fund those programs
    themselves.
        Mr. Mica. I've been joined by a gentleman from Maryland,
    Mr. Cummings. Let me recognize him at this point.
        Mr. Cummings. Thank you very much, Mr. Chairman. I want to
    thank our witnesses for being with us today.
        Dr. Chavez, in your testimony you said that the drug use
    among teens is no longer on the rise. It may just be declining.
    When will you know whether it's, in fact, declining and is this
    decline in drug use for all drugs or is this just marijuana?
        Dr. Chavez. Mr. Congressman, it's good to see you. Thank
    you.
        Mr. Cummings. Good to see you also.
        Dr. Chavez. We've seen a slight improvement in terms of
    that decline, but as I said in my testimony, I do not want us
    to be overly optimistic. And what I mean by that, sometimes
    when we see these declines, we have a tendency to become very
    relaxed, until we see the next epidemic. What we are seeing is
    that--we're seeing drug use, especially the increases in the
    drug use that we have seen in the past have been among those
    12- and 13-year-olds, which is an age group that we have become
    very concerned about, and as an age group where we have
    targeted many of our efforts. The other area that is of great
    concern, as I mentioned earlier, is the regional nature of the
    drug.
        For example, in some areas, we have seen an increase in the
    use of heroin, whereas in other areas we've seen an increase in
    the use of methamphetamine, and that is one of the reasons that
    we are really trying to target many of our programs.
        Now, in August of this year, we will have the data on our
    household survey, and we are hoping that with the expansion of
    the Household survey--this is the year it was expanded--we are
    going to have information that will be of help to all of us. It
    gives us specific State-by-State data so that we will have a
    better picture in terms of what is happening in some States.
    Why that becomes more and more important is because of our KDA
    and our treatment capacity expansion in that we'll be able to
    focus those dollars more where we see in some of those States,
    that it's more of a problem than it may be in other States.
        Mr. Cummings. Let me ask you, is there a particular type of
    child or are there certain characteristics--when you think
    about a young child, 12, 13-year-old, that's pretty young, and
    I know that children use drugs even earlier than that. I live
    in a neighborhood where I think that happens, in Baltimore.
    From what you've seen, are there any particular characteristics
    or type of settings? In other words, home life or neighborhood
    or how they are doing in school, parental supervision,
    activities, being involved in activities or lack thereof? Is
    there a typical young person that if you looked at a certain
    set of characteristics, you say based upon what we know, this
    child is, I hate to use those words, ``at risk?'' They just
    bother me, but you get what I'm saying. You understand?
        Mr. Autry. Let me speak to that. One of the things I think
    you know as well as the rest of us is that substance abuse is
    really an equal opportunity disease. It doesn't strike any
    particular ethnic group, doesn't strike any particular
    geographic group or strike any particular socioeconomic group.
    It's across the board. There are, however, both resiliency and
    risk factors that do predict when someone is likely or less
    likely to abuse substances. Children who grow up with high
    family bonds is a case in point. Good role models with respect
    for their parents are less likely to use drugs than those who
    don't.
        Children who grow up with families where there's an
    emphasis on communication, emphasis on education, are less
    likely to grow up using drugs than those who do not get that.
    Kids who are engaged in activities such as good school bonding
    and the performance in school is important to them are less
    likely to engage in drug use than those who do not. Children
    who are engaged in post-school activities or entering programs
    are less likely to grow up to use drugs than those who do not.
    I think as we look at prevention, you've seen a shift in recent
    years from talking so much about risk factors to talking more
    about resiliency factors and the things we need to promote good
    mental health, good physical health and decrease substance
    abuse.
        Mr. Cummings. In Baltimore, we have a situation, where,
    because of budget circumstances, we have had to cut back on
    recreation, and unfortunately, I mean, we're approaching the
    drug problem from a criminal standpoint. But I'm of the opinion
    that you need to do both because I think the recreation keeps
    children busy, and a lot of times recreation centers have
    become almost substitutes, and important substitutes for
    children whose mothers and fathers may be working or may be
    part of a single head of household family where the one person
    just can't be there all the time, particularly the summertime
    when you're out on vacation and things of that nature. That's
    why I was just wondering about that. Did you have something
    that you wanted to add?
        Dr. Chavez. Yes, Mr. Cummings. What you've described is
    what we're really looking in terms of drug problems--drug
    issues as public health issues that involve many, many
    components. We know from the research, we know what works. We
    know what are some of the things that are very, very critical,
    and as Dr. Autry indicated, one of the strongest things that we
    have found in terms of the research that has been done is that
    the family bonding becomes very critical at a very early age.
    Unfortunately, what we see happening in terms of the need for
    prevention services and treatment services is that there are
    not enough services to provide for the need that is out there.
    We have a great need. What we are finding in many communities
    is that parents can't find treatment for their young people,
    for their adolescents.
        Many times what happens is that they do commit a crime and
    they become part of the juvenile or criminal justice system.
    Then there will be some treatment which may have been
    unneccessary if we had more interventions, early interventions,
    prevention and treatment programs targeted specifically to many
    of these communities. But again, it's the parent, it's the
    family, the school, it's the community. It's not one.
        It's the responsibility of all of us, including the clergy,
    to be part of developing systems within communities that work
    for those communities.
        Mr. Cummings. Yesterday, when I was at the Post Office, I
    ran into a fellow who was a former drug addict. He's a
    recovering addict. One of the things he said to me was very
    interesting. You know, he said, ``Cummings, I wish people would
    come to my barbershop. I haven't used drugs in 15 years.'' He
    said, ``But every time they show people on television and they
    talk about drug treatment, they always show people who look
    like they're down and out. I'm doing fine.'' He said, ``I can
    show you thousands, literally, there's a whole community out
    there who are former drug users who, because of treatment, are
    now doing fine, raising their families, supporting,
    contributing to our taxes.''
        That leads me to the question that was one of the things
    that was on my mind at our last SAMHSA hearing. This is a
    continuation. And I asked a question of how do we make sure and
    what does SAMHSA do, and what can we do to assure that the
    treatment that is being rendered, moving on to sort of another
    subject now, is effective treatment.
        I'm one of these people that run around the Congress with a
    flag that says treatment and prevention and begging my
    colleagues to look at treatment. But the thing that we get over
    and over again, and I hear, and in many instances this is a
    legitimate argument, I hear the argument, well, is the
    treatment effective? How do we measure it? Are people just
    setting up shop and going through some motions? To be very
    frank with you, there are people who are recovering addicts
    like the fellow I talked to yesterday who told me, and I've
    heard this in my community over and over again.
        There are some shops that are not effectively addressing
    the drug problem. They set it up, and I think that does a
    disservice, not only to the good programs, but to the addict
    because the addict goes through this process, he or she thinks
    she's supposed to be getting well. It's not legit. When I say
    ``legit,'' I mean it's not being effective.
        I think it's going to be very important for States and for
    this Congress to try to hold programs to some kind of standard,
    because as I see it, and I've just been watching, I just don't
    think we're going to be able to get those treatment dollars
    unless we really can show that these programs are being
    effective, that we need some kind of mechanism that makes
    sense. I think we could probably have a whole lot more of the
    Congress saying hey, we've got to give treatment if they know
    that's real and it's going to be effective. So I leave you with
    that. I ask you, do you have any comments?
        Mr. Autry. First of all, let me applaud you for your
    advocacy. Second, we have over there one of the charts that
    shows, as Dr. Leshner referenced earlier, that treatment does,
    in point of fact, work. It reduces criminal activity, reduces
    illicit drug use and alcohol use. It improves housing
    situations, and most importantly perhaps in the Congress's
    perspective, it also increases employability. We rely very
    heavily on the research that NIDA has done in order to look at
    more effective and efficient treatments. We put these out into
    treatment services. We're working with our colleagues in the
    States to define appropriate performance and outcome measures
    that we use, not only across our discretionary grant programs,
    but also across the block grant programs that they will be
    funding, that they do fund in the States. So we're very
    concerned about the performance and outcomes measures, and it's
    as--one of our highest priorities is to continue to improve the
    effectiveness and efficiency in treatment.
        Alan, you want to add anything to that?
        Dr. Leshner. I think the point is well made. I think the
    problem is, sir, is that just as in any treatment enterprise,
    there are people who deliver well and people who don't deliver
    well. We have the problem that we have no mechanisms by which
    to evaluate every single program and to be able to ensure what
    they provide, but I would say the overall quality of drug abuse
    treatment in this country is extraordinarily high, and
    comparisons that have been done on the effectiveness of drug
    addiction treatment compared to other medical illnesses that
    are similar in nature, drug addiction treatment is as effective
    as the treatment for hypertension, as the treatment for asthma,
    the treatment for other chronic, often relapsing disorders. The
    problem is people don't know it.
        Mr. Cummings. Last question, Mr. Chairman. At the last
    hearing, we had representatives from three States. I can't
    remember which States they were, but I know they earned
    reputations nationally as having good treatment, or very good
    treatment, and when I say very good, I mean effective. And one
    of the things that they all had in common is that they had a
    standard by which they were able to measure, which is very
    interesting. And I asked them, I said, ``Well, does every State
    have these standards?'' They said, ``Well, no, I don't think
    so.''
        I know you share Mr. Mica's concerns and Mrs. Mink's
    concerns, and we want all of our tax dollars to be spent
    efficiently and effectively. I'm just wondering, do States come
    to SAMHSA and say, look, what kind of standards can we use or
    does SAMHSA go to States and say, look, this is something you
    might take into consideration in measuring these programs
    because I'm telling you, I mean this, it just irks me. It would
    really upset me. We are setting up shops that are not being
    effective, but then it bothers me if we don't have any
    standards to even determine what effective is. Those are search
    questions under one question, but I'm finished after this.
        Mr. Autry. Let me try and focus on what I think is the most
    important one, that is, how effective are these treatment
    programs and what do we do to make sure we're using the most
    effective interventions we have, whether it be prevention or
    treatment, but treatment in particular? We worked with the
    States through our TOPS 1 and TOPS 2 program to look at and
    define outcome measures, what sort of performance we expect
    from a treatment provider, what sort of performance we expect
    from a treatment system.
        We've done this now in 19 States. And we're working with
    NASADAD to try and collect data across all the States that
    measure outcome measures in the four domains I mentioned
    earlier: criminal activity, decreased drug and alcohol use,
    housing situation, and employability. Those are the elements
    that say is somebody doing well or not. And working with the
    States, we are trying to implement these across all the States.
    Their instrument is vulnerable in terms of the States to
    provide that information at the present time.
        But that's an ongoing commitment on our part and the part
    of NASADAD to continue to work to upgrade the data
    infrastructure so that all States can provide that kind of
    accountability data. Currently we are doing this on a voluntary
    basis. In the future we will be doing this on a mandatory
    basis. Again, building on what we've done with NASADAD and the
    States to this point in time rather than mandating something on
    high sum.
        Mr. Cummings. How soon do you think it will be mandatory?
        Mr. Autry. We have high hopes this will be 2001.
        Mr. Cummings. So what authority do you have to make it
    mandatory?
        Mr. Autry. We recently have an all radioing from our own
    counsel, Office of General Counsel, and also from the GAO that
    we do have the authority to do that. We will work on that this
    year, and if we can't do it for 2001, we hope to move to
    mandatory by 2002, which will be a year from this October 1.
        Mr. Cummings. What would be the holdup?
        Mr. Autry. The holdup is going to be the States' ability to
    provide the information because of the variability and lack of
    infrastructure support. We're currently in discussions with the
    Office of Management and Budget because we have had some
    disagreement within OMB as to whether or not we have the
    authority. We hope to resolve that very shortly in the next
    month or two.
        Mr. Cummings. Do you anticipate the possibility, not
    probability, that you may need authority there in the Congress?
        Mr. Autry. As Dr. Chavez referenced earlier, we have been
    approved in the Senate for reauthorization, we are certainly
    looking for approval in the House. If that does indeed happen,
    I think we will have all the authority we need, sir.
        Mr. Cummings. Thank you.
        Mr. Mica. Thank you. Just a couple of wrap-up questions
    here. In surveys of Department of Health and Human Services,
    employees over the past 3 years, the reported morale of SAMHSA
    employees has not been among the lowest ratings for HHS for the
    entire agency. You made some comments, Dr. Chavez, at the
    beginning about morale. Did you say that it's improving? Where
    are we with the problem of morale in the agency? All the errors
    I've gotten said it ranks among the lowest of any agency.
        Dr. Chavez. We have taken several steps as we outlined in
    the report that we submitted to you to try to lift morale. One
    of the big issues that we have faced that we had mentioned to
    you earlier has been that even though there seems to be a sense
    that maybe our administrative costs have been very high in our
    program management fund, we have reduced our staffing in so
    many areas, and this has had a tremendous impact on staffing
    because of the increased workload. We have increased our
    workload tremendously in the past 5 years. There are more
    specific things that we are involved in that I would like Dr.
    Autry to respond to, because this is something that he's been
    working with very carefully.
        Mr. Autry. Thank you, Dr. Chavez. We're very concerned
    about staff morale, and one of the key things that we've noted
    is that morale relates to two key elements. One is the workload
    that people have received, and that has been increased, as you
    saw, from the decrease in staff going back to 1993. We've also
    absorbed a number of programs, high-risk programs, most
    notably, and school violence programs that came to us from
    Congress. We've done that within the existing staff levels. So
    that has increased the workload. We also find that when ideas
    that staff have developed are put forward are either not
    supported in the administration or not supported in the
    Congress, that also leads to low morale.
        Quite frankly, I don't know of a harder working, more
    dedicated staff across any Federal agency than we have in
    SAMHSA, and they really believe in what they do and they put
    their heart and soul into doing it. We have established a
    quality-of-worklife committee that's made up of both management
    and employees to look at things that we can do to improve
    morale. We're in the process of implementing a transit subsidy
    program that would help in that regard. We're looking at
    redistributing workload across the agency. We've also started a
    process of management called appreciative inquiry, which is
    where you take the elements within the agency that are working
    well, and you look at the lessons that you can learn for what
    made that work well and apply it in areas where things might
    not be working quite so well.
        We've also started doing cross-center and also cross-agency
    collaboration on projects to make sure that all staff are
    involved as we go forward in planning and budgeting
    implementation. We also have had a series of focus groups, some
    with management employees mixed with some employees by
    themselves have honest and frank discussion of the difficulties
    that they've encountered that, perhaps, have contributed to low
    morale.
        We do fully expect to see that there will be an increase in
    morale, and it certainly is a commitment on our part as we go
    forward to try to have SAMHSA to be the kind of place that not
    only you want to work at because of the important work we do,
    but because of the atmosphere we create as we work with one
    another.
        Mr. Mica. The centers you talked about earlier, did you
    have 22 regional centers and combined them into 7? Is that it?
        Mr. Autry. Those were administrative offices, some within
    the Office of the Administrator, and some within the centers.
    They were collapsed into seven.
        Mr. Mica. What about regional operations?
        Mr. Autry. We don't have regional operations at the present
    time. There are many days, quite frankly, we wish we did have.
        Mr. Mica. All of that is located here?
        Mr. Autry. Correct.
        Mr. Mica. I just wondered if anything had been sent out to
    regional centers. But that's OK.
        Mr. Autry. I'll make one comment on that we have worked
    closely with the regional offices and HRSA, the Health
    Resources and Services Administration, to make sure that the
    regional offices are informed of the activities that we do. We
    find them an invaluable resource looking at treatment needs
    across the region and State, and they were very instrumental to
    us in our national treatment system regional meetings and
    national prevention system regional meetings.
        Mr. Mica. Dr. Chavez, it took 18 months to develop
    guidelines for urinalysis in 1987 to 1988. It's my
    understanding that SAMHSA has now contemplated what will turn
    into a 10-year review process for hair analysis or other
    methodologies. I'm told now it's put off to 2003. What's the
    problem?
        Dr. Chavez. I would like to have Dr. Autry respond to that
    because he's the expert on the hair analysis. I think he's
    testified before you in the past.
        Mr. Autry. Mr. Chairman, it's a pleasure to revisit this
    subject with you. One of the things that we put in place going
    back now about 2\1/2\ years ago is that we developed a matrix
    of all of the standards that any drug testing methodology must
    meet in order to be certified for use in the Federal program.
    We have worked with industry, worked with laboratories, worked
    with medical review officers to assess the current state of the
    science of all the different testing technologies and
    methodologies to identify the gaps that exist in terms of
    meeting those standards and have laid out protocols that are
    necessary to fill in those gaps. All of our meetings have been
    open to the public, involved both industry as well as Feds, and
    laboratory people. You can find summaries of all the meetings
    that we've had in the current state of the science
    www.health.org/workpl.htm.
        Mr. Mica. My understanding that some agencies like the
    Federal Reserve already use hair testing and have settled on
    that.
        Mr. Autry. A number of companies do. One of the largest
    manufacturers of hair testing in this country is a company
    called Psychometrics. They estimate they have about 2,000
    employers of various sizes who do use this. That is actually a
    small proportion of those individuals that are subject to
    testing. We make available to whoever wants the latest
    scientific evidence about the effectiveness of that. One of our
    big concerns is that there is not an appropriate quality
    assurance or quality review mechanism in place to assess the
    accuracy of the ongoing testing.
        Mr. Mica. Finally, for the record, and I'd like for it to
    appear at the end of the record, request the agency to provide
    us with detail relating to their programs which were briefly
    outlined dealing with our corrections and criminal population
    and the proposal, more details relating to the $10 million
    proposal that we've heard a little bit about today.
    Additionally, I'd like them to list the top 20 programs in the
    country for treatment and we can use the successes treatment 1
    year drug free, or 2 years drug free, and we can categorize
    those into sort of tough cases or average drug treatment cases
    because I know some were repetitive, tough every instance and I
    always hear you can't compare one with the other; first,
    second-time offender or drug abuser versus someone who's been
    repetitive. I would just like those to appear at the end of the
    record of this hearing. That would be helpful also as a
    guideline to offer. We will leave the record open for at least
    3 weeks to accomplish getting those responses.
        We have additional questions for the witnesses. Our intent
    is not to call you in here and just give you grief. Our intent
    is to try to assess what's going on. We requested the GAO
    report. They came back with information. We have a
    responsibility to conduct oversight. When I have members of the
    package like Mr. Cummings who has 60,000, at least he told me
    in that range, people addicted and has a community, we'll be
    going there in a week or so, 2 weeks. We're going next week to
    Honolulu, can't wait for 18 hours of flight, Sunday, Monday, to
    do that for Mrs. Mink, but our purpose is not to give the
    agency a hard time. It's to see how we can improve the
    expenditure of funds.
        When you go to California as I did last week at the request
    of members and you see what's going on, I wish some others
    could have seen it, the methamphetamine problem was just beyond
    anything, so much child abuse, 40 percent of murders, hundreds
    of children literally abandoned by their families. It does such
    devastation to these folks. We need to even rededicate
    ourselves more to finding workable cost effective solutions to
    this problem. So if it takes having hearings every day, or
    twice a week or whatever, wherever we have to go we're going to
    get this done. When we get complaints about how things are
    operating and some of those things have been imposed by
    Congress, we need to see that corrective measures are taken. We
    will do our best to work in that regard.
        I appreciate the witnesses coming forward today. We look
    forward to working with you.
        Mrs. Mink.
        Mrs. Mink. I just want to make a comment. I am a little bit
    troubled with the emphasis on the need to evaluate the
    effectiveness of any specific treatment methodology because I
    think we know that in all kinds of diseases, that because you
    don't have 100 percent cure rate doesn't necessarily mean that
    the particular treatment is not a suitable one. It may not be
    suitable for the specific individual because of the
    individual's own unique propensities or other kinds of mental
    pressures. So I do want to say that while it's important to
    evaluate the outcomes and to determine which ones have the best
    outcomes, I don't think, however, that necessarily leads to a
    conclusion that the treatment that has the lower outcomes is
    necessarily not proven to be satisfactory for a variety of
    clientele.
        Mr. Mica. Thank you. That's why I asked for this sort of
    the tougher-than-average cases. This is for my own information.
    We have thousands of treatment programs out there, and I'm
    interested in what are successful models. We heard some. We
    have Washington, I think New York and several other States, and
    I think Mr. Cummings rightfully pointed out that there are some
    commonalities to have standards of certain things that we can
    point to where programs are successful and maybe we can
    replicate this, maybe we can't. Maybe we should go home.
        Mr. Cummings. Mr. Chairman, my ranking member and I, we
    agree on most things, and I think we agree on this. I guess my
    concern, Mrs. Mink, in my community and the way this even came
    up for me was just listening to recovering addicts whose really
    saw what was effective for them. And I know that everybody may
    be different, but they actually said, ``Cummings, if it was up
    to us, we'd close down that program, that program, that
    program, and then we would keep these open.'' And these are
    people who have nothing to gain. They want to make sure that
    programs are effective because they feel, and a lot of them are
    very angry because they saw what they went through and then
    they look at what other people go through. The other thing that
    they said was a lot of these people who go through the programs
    and that they consider shams, then come back and they are
    trying to help them get off of drugs.
        So they see it in every which way. I agree with you. I
    think we have to be very careful because you can evaluate to
    the degree that you destroy. You can take something apart so
    much that you destroy it. But on the other hand, I think we
    hold people to standards constantly, and I think we have to
    have at least some general standards to look at and say, OK,
    are we having some effectiveness, are we accomplishing
    something here?
        And I guess the reason why I'm so concerned about this is I
    think it goes to the credibility of the entire process. I think
    it's easier to make the case for more Federal dollars if we do
    have some standards, and we're able to do some measuring. That
    way--you know what they say, Mrs. Mink. People will on come
    back and say, oh, treatment doesn't work. At least we'll be
    able to say we've got some standards, those standards are being
    met and we are being effective. So when we see tragic stories
    like the chairman just mentioned, we can say there is something
    we can do about that. It worked in Nevada, it worked in Idaho
    and damn it, it will work here. That's what I was concerned
    about.
        Mr. Mica. I thank the gentleman. I thank the ranking
    member. Being no further business to come before the
    subcommittee on criminal justice drug policy and human
    resources this meeting is adjourned.
        [Whereupon, at 12:25 p.m., the subcommittee was adjourned.]
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