[House Hearing, 108 Congress]
[From the U.S. Government Publishing Office]





        MEASURING THE EFFECTIVENESS OF DRUG ADDICTION TREATMENT

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

                                HEARING

                               before the

                   SUBCOMMITTEE ON CRIMINAL JUSTICE,
                    DRUG POLICY AND HUMAN RESOURCES

                                 of the

                              COMMITTEE ON
                           GOVERNMENT REFORM

                        HOUSE OF REPRESENTATIVES

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                             MARCH 30, 2004

                               __________

                           Serial No. 108-222

                               __________

       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

                     TOM DAVIS, Virginia, Chairman
DAN BURTON, Indiana                  HENRY A. WAXMAN, California
CHRISTOPHER SHAYS, Connecticut       TOM LANTOS, California
ILEANA ROS-LEHTINEN, Florida         MAJOR R. OWENS, New York
JOHN M. McHUGH, New York             EDOLPHUS TOWNS, New York
JOHN L. MICA, Florida                PAUL E. KANJORSKI, Pennsylvania
MARK E. SOUDER, Indiana              CAROLYN B. MALONEY, New York
STEVEN C. LaTOURETTE, Ohio           ELIJAH E. CUMMINGS, Maryland
DOUG OSE, California                 DENNIS J. KUCINICH, Ohio
RON LEWIS, Kentucky                  DANNY K. DAVIS, Illinois
JO ANN DAVIS, Virginia               JOHN F. TIERNEY, Massachusetts
TODD RUSSELL PLATTS, Pennsylvania    WM. LACY CLAY, Missouri
CHRIS CANNON, Utah                   DIANE E. WATSON, California
ADAM H. PUTNAM, Florida              STEPHEN F. LYNCH, Massachusetts
EDWARD L. SCHROCK, Virginia          CHRIS VAN HOLLEN, Maryland
JOHN J. DUNCAN, Jr., Tennessee       LINDA T. SANCHEZ, California
NATHAN DEAL, Georgia                 C.A. ``DUTCH'' RUPPERSBERGER, 
CANDICE S. MILLER, Michigan              Maryland
TIM MURPHY, Pennsylvania             ELEANOR HOLMES NORTON, District of 
MICHAEL R. TURNER, Ohio                  Columbia
JOHN R. CARTER, Texas                JIM COOPER, Tennessee
MARSHA BLACKBURN, Tennessee          ------ ------
------ ------                                    ------
------ ------                        BERNARD SANDERS, Vermont 
                                         (Independent)

                    Melissa Wojciak, Staff Director
       David Marin, Deputy Staff Director/Communications Director
                      Rob Borden, Parliamentarian
                       Teresa Austin, Chief Clerk
          Phil Barnett, Minority Chief of Staff/Chief Counsel

   Subcommittee on Criminal Justice, Drug Policy and Human Resources

                   MARK E. SOUDER, Indiana, Chairman
NATHAN DEAL, Georgia                 ELIJAH E. CUMMINGS, Maryland
JOHN M. McHUGH, New York             DANNY K. DAVIS, Illinois
JOHN L. MICA, Florida                WM. LACY CLAY, Missouri
DOUG OSE, California                 LINDA T. SANCHEZ, California
JO ANN DAVIS, Virginia               C.A. ``DUTCH'' RUPPERSBERGER, 
JOHN R. CARTER, Texas                    Maryland
MARSHA BLACKBURN, Tennessee          ELEANOR HOLMES NORTON, District of 
PATRICK J. TIBERI, Ohio                  Columbia
                                     ------ ------

                               Ex Officio

TOM DAVIS, Virginia                  HENRY A. WAXMAN, California
                     J. Marc Wheat, Staff Director
                         Nicole Garrett, Clerk
                     Tony Haywood, Minority Counsel


                            C O N T E N T S

                              ----------                              
                                                                   Page
Hearing held on March 30, 2004...................................     1
Statement of:
    Curie, Charles, Administrator, Substance Abuse and Mental 
      Health Services Administration; and Nora D. Volkow, 
      National Institute on Drug Abuse, National Institutes of 
      Health.....................................................    12
    McLellan, Thomas, Ph.D., director, Treatment Research 
      Institute, Philadelphia, PA; Charles O'Keeffe, Virginia 
      Commonwealth University, Richmond, VA; Karen Freeman-
      Wilson, executive director, National Drug Court Institute, 
      Alexandria, VA; Jerome Jaffe, M.D., professor, University 
      of Maryland, Baltimore, MD; Catherine Martens, senior vice 
      president, Second Genesis, Silver Spring, MD; and Hendree 
      Jones, Ph.D., research director, Center for Addiction and 
      Pregnancy, Baltimore, MD...................................    44
Letters, statements, etc., submitted for the record by:
    Cummings, Hon. Elijah E., a Representative in Congress from 
      the State of Maryland, prepared statement of...............     9
    Curie, Charles, Administrator, Substance Abuse and Mental 
      Health Services Administration, prepared statement of......    15
    Freeman-Wilson, Karen, executive director, National Drug 
      Court Institute, Alexandria, VA, prepared statement of.....    74
    Jaffe, Jerome, M.D., professor, University of Maryland, 
      Baltimore, MD, prepared statement of.......................    83
    Jones, Hendree, Ph.D., research director, Center for 
      Addiction and Pregnancy, Baltimore, MD, prepared statement 
      of.........................................................    96
    Martens, Catherine, senior vice president, Second Genesis, 
      Silver Spring, MD, prepared statement of...................    88
    McLellan, Thomas, Ph.D., director, Treatment Research 
      Institute, Philadelphia, PA, prepared statement of.........    46
    O'Keeffe, Charles, Virginia Commonwealth University, 
      Richmond, VA, prepared statement of........................    56
    Souder, Hon. Mark E., a Representative in Congress from the 
      State of Indiana, prepared statement of....................     3
    Volkow, Nora D., National Institute on Drug Abuse, National 
      Institutes of Health, prepared statement of................    25

 
        MEASURING THE EFFECTIVENESS OF DRUG ADDICTION TREATMENT

                              ----------                              


                        TUESDAY, MARCH 30, 2004

                  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 2 p.m., in 
room 2247, Rayburn House Office Building, Hon. Mark E. Souder 
(chairman of the subcommittee) presiding.
    Present: Representatives Souder, Cummings, Blackburn and 
Davis.
    Staff present: Marc Wheat, staff director and chief 
counsel; Alena Guagenti, legislative assistant; Nicole Garrett, 
clerk; Tony Haywood, minority counsel; and Jean Gosa, minority 
assistant clerk.
    Mr. Souder. The subcommittee will come to order. Good 
afternoon, and I thank you all for coming. Today we will 
continue our subcommittee study of drug addiction treatment, or 
as President Bush refers to it in the National Drug Control 
Strategy, ``Healing America's Drug Users.'' It is estimated 
that at least 7 million people in the United States need 
treatment for drug addiction. Getting effective help to those 7 
million people and getting them to accept that help is one of 
America's greatest public health challenges.
    Everyone agrees that we should help drug addicts get 
effective treatment. What is far more difficult is to find a 
consensus on how to measure what effective treatment is, but it 
is vital that we find that consensus because in an era of tight 
budgets, we must be able to focus our limited resources on the 
most effective treatment methods.
    Last year, President Bush took what I believe to be a very 
significant step in that direction when he unveiled the Access 
to Recovery Initiative. Beginning this fiscal year, the 
President's initiative will provide $100 million to the 
Substance Abuse and Mental Health Services Administration 
[SAMHSA], to supplement existing treatment programs. That 
amount of money is intended to pay for drug treatment for most 
Americans who want it but can't get it, many of whom can't 
afford the cost of treatment and don't have insurance to cover 
it.
    If fully funded at $200 million per year as requested by 
the President, it could help up to 100,000 more addicts get 
treatment. The program also has enormous potential to open up 
Federal assistance to a much broader range of treatment 
providers than are used today. Through the use of vouchers, the 
initiative will support and encourage variety and choice in 
treatment and could open up and support a significant number of 
new options for drug users to get treatment. Finally, and most 
important for our purpose today, the emphasis on accountability 
should help us make significant progress in the most difficult 
issues of drug treatment policy, finding and encouraging 
programs that truly work, helping and healing the addicted, as 
well as ensuring a meaningful and effective return on 
taxpayers' dollars spent on treatment.
    Earlier this month, SAMHSA published a request for 
applications spelling out the qualifications for programs to 
administer the new funds and inviting those programs to apply. 
The RFA, request for application, contains new performance 
measures designed to help us determine what programs are 
working for the patients and which ones aren't. I am especially 
looking forward to discussing Access to Recovery Initiative 
with the person most responsible for implementing it, my fellow 
Hoosier, SAMHSA administrator Charlie Curie.
    With SAMHSA up for reauthorization this year, I'm also 
eager to discuss with him the agency's plans for the future of 
drug treatment. We are also pleased to be joined by Dr. Nora 
Volkow, director of the National Institute on Drug Abuse at the 
National Institutes of Health, which is the Federal 
Government's pre-eminent authority on the nature of drug 
addiction and the science of drug treatment. We are pleased to 
be joined in the second panel by a number of experts in the 
field of drug addiction treatment.
    We welcome Dr. A. Thomas McLellan, director of the 
Treatment Research Institute in Philadelphia, PA; Mr. Charles 
O'Keeffe at the Virginia Commonwealth University in Richmond, 
VA; the Honorable Karen Freeman-Wilson, executive director of 
the National Drug Court Institute in Alexandria, VA; Dr. Jerome 
Jaffe, professor at the University of Maryland in Baltimore, 
MD; Ms. Catherine Martens, senior vice president of Second 
Genesis in Silver Spring, MD; and Dr. Hendree Jones, research 
director at the Center For Addiction and Pregnancy in 
Baltimore, MD. We look forward to discussing these issues with 
you.
    [The prepared statement of Hon. Mark E. Souder follows:]

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    Mr. Souder. Now I will now yield to our distinguished 
ranking member, Mr. Cummings, for his opening statement.
    Mr. Cummings. Thank you very much, Mr. Chairman, for 
holding this important hearing on measuring the effectiveness 
of drug treatment. I have often said it is one thing to treat 
drug addiction. It is another thing to be effective in 
treatment. As you know, Mr. Chairman, drugs kill 20,000 
Americans each year, and drug abuse and the illegal drug trade 
contribute to most of the violent crime and social problems we 
experience here in the United States. Providing effective 
treatment to people who have become drug dependent is necessary 
to reduce the demand for illegal drugs that drives consumption 
and fuels crime and social dysfunction. The President has 
proposed substantial increases in drug treatment funding, 
including increases for the substance abuse prevention and drug 
treatment block grant, which accounts for 40 percent of public 
funding for drug treatment, and the new Access to Recovery 
Voucher Initiative for which State applications are being 
accepted this spring.
    Under both, the block grant and Access to Recovery, drug 
treatment funding is being accompanied by new requirements for 
outcomes measurement and reporting in an effort to increase 
accountability and effectiveness in drug treatment programs 
funded with taxpayers' dollars. I have often said that the one 
thing that Republicans and Democrats appear to agree on is that 
the taxpayers' dollar must be spent effectively and 
efficiently. These are appropriate goals in addition to 
expanding the capacity of the drug treatment system to ensure 
that treatment is accessible to those in need. We should seek 
to ensure that the treatment we fund is the very best that it 
can be. The value of treatment cannot be overstated. Numerous 
studies attest to the effectiveness of treatment in reducing 
not only the consumption of drugs and alcohol, but also the 
social harms associated with addiction, including violent 
crime, property crime, unemployment, risky health behaviors 
contributing to HIV and hepatitis infection and so on.
    And yet, public funding for drug treatment has been derided 
by some critics who view drug treatment programs as a revolving 
door for addicts who lack a moral commitment to abstinence. 
Addiction research tells us, however, that relapse is a 
component of the disease of addiction and a part of the 
recovery process for most recovering addicts. Moreover, 
temporary abstinence and reduced consumption are beneficial for 
the patient and the community in which the patient lives and 
treatment contributes to these intermediate steps as well as 
the ultimate goal of permanent abstinence. The National 
Institute on Drug Abuse publication, ``Principles of Drug 
Addiction Treatment,'' a research-based guide, cites several 
conservative estimates showing that every $1 invested in 
addiction treatment programs yield a return of between $4 and 
$7 in reduced drug-related crime, criminal justice costs and 
theft alone. When savings related to health care are included, 
total savings can exceed costs by a ratio of 12 to 1. The guide 
further states that drug addiction is a complex illness that 
nonetheless is just as treatable as other chronic diseases in 
which patient behavior is a factor, including diabetes, asthma 
and hypertension.
    Evaluations of treatment programs must take into account 
not only the complexity of the illness, but also the very 
different life circumstances patients in a variety of treatment 
settings in which patients receive treatment. The diversity and 
types of treatment programs poses a challenge to efforts to 
establish criteria that will allow for meaningful comparisons. 
Applying criteria in a manner that is fair and that yields 
useful evaluations is critical. We have two very distinguished 
panels of witnesses who will offer their insights on this 
important subject today, and I am happy that my State of 
Maryland is so well represented.
    We are fortunate to have both NIDA and SAMHSA before us on 
this panel. And I want to thank you, Mr. Chairman, in 
particular for allowing Dr. Hendree Jones and Catherine Martens 
to testify today as minority witnesses on the second panel. Dr. 
Jones is research director for the Center For Addiction and 
Pregnancy at Johns Hopkins Bayview Medical Center in Baltimore. 
Ms. Martens is senior vice president of Second Genesis, a 
therapeutic communities program in Silver Spring, MD. Taking 
into account the perspectives of treatment providers is 
critical to the development of evaluation methods that will 
yield meaningful and useful information, leading to more 
effective treatment. And I am glad that we will hear these 
important perspectives today.
    With that said, Mr. Chairman, I look forward to hearing the 
testimony of our distinguished witnesses and I hope that this 
hearing helps to move us forward toward the goal of reducing 
drug abuse and dependency in this great country. With that, I 
yield back.
    [The prepared statement of Hon. Elijah E. Cummings 
follows:]

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    Mr. Souder. I thank you for your statement. I ask unanimous 
consent that all Members have 5 legislative days to submit 
written statements and questions for the hearing record and 
that any answers to written questions provided by the witnesses 
also be included in the record. And without objection, it is so 
ordered. I also ask unanimous consent that all exhibits, 
documents and other materials referred to by Members and the 
witnesses may be included in the hearing record and that all 
Members be permitted to revise and extend their remarks. 
Without objection, it is so ordered. Now it is the policy of 
this committee and the full Government Reform Committee to 
swear in our witnesses, so if you would stand and raise your 
right hands.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that the witnesses have 
answered in the affirmative. I apologize. I wasn't paying 
attention. Do you have an opening statement?
    Mrs. Blackburn. No.
    Mr. Souder. I was so intent on reading the materials in 
front of me, I apologize. We will start with Mr. Curie.

STATEMENTS OF CHARLES CURIE, ADMINISTRATOR, SUBSTANCE ABUSE AND 
  MENTAL HEALTH SERVICES ADMINISTRATION; AND NORA D. VOLKOW, 
NATIONAL INSTITUTE ON DRUG ABUSE, NATIONAL INSTITUTES OF HEALTH

    Dr. Curie. Thank you, Mr. Chairman and members of the 
subcommittee. Good afternoon. I am Charles Curie, Administrator 
of the Substance Abuse and Mental Health Services, part of the 
U.S. Department of Health and Human Services. At this time, I 
ask that my formal written testimony be included in the record 
of this hearing. In the time I have with you today, I will 
describe how SAMHSA is working to promote and provide effective 
substance abuse treatment to people nationwide, and I will 
describe how we are measuring the effectiveness of those 
efforts. The importance of substance abuse treatment prevention 
services is undeniable. And I am pleased to be appearing here 
today with my colleague, Dr. Nora Volkow of NIDA, where 
partnership is critical in us accomplishing that goal.
    According to our 2002 national survey on drug use and 
health, of the 22.8 million people aged 12 and older who needed 
treatment for alcohol or drugs, only 2.3 million of them 
received specialized care. Over 85 percent of people with 
untreated alcohol or drug problems said they didn't think they 
needed care. Of the 1.2 million people who felt they did need 
treatment, 446,000 tried but were unable to get treatment.
    The result, continued addiction, lost health, employment 
and education and often criminal involvement. That is a huge 
human and economic cost. Yet we know Federal investments in 
substance abuse treatment and prevention are cost effective and 
beneficial. Treatment is effective. Recovery is real. SAMHSA's 
national treatment improvement evaluation study found a 50 
percent reduction in drug use 1 year after treatment. It 
reported up to an 80 percent reduction in criminal activity, a 
43 percent drop in homelessness and a nearly 20 percent rise in 
employment. Our findings are corroborated by other SAMHSA and 
NIDA studies. We are also working to prevent substance abuse in 
the first place. The President set aggressive goals to reduce 
youth drug use in America.
    With effective prevention efforts, rates are dropping; 11 
percent in the past 2 years among 8th, 10th and 12th-grade 
students, according to NIDA's most recent monitoring the future 
survey. That is roughly 400,000 fewer teen drug users in these 
2 years. And that means the President's 2-year goal has been 
exceeded. Let me remind everyone what SAMHSA is all about.
    In contrast to NIH, SAMHSA is not a research agency. We 
don't conduct or fund research. SAMHSA is a services agencies. 
That means taking our work and our substance abuse prevention 
and treatment services programs to where people are in 
communities nationwide. That's where our programs, policies and 
budget priorities are driven by the vision of a life in the 
community for everyone. That's why they're driven by a mission 
of building resilience and facilitating recovery one person at 
a time. And that is why each and every one of our program 
outcomes is being measured against the yardstick of recovery, 
resilience and that life in the community for every man, woman 
and child. Our vision and mission are aligned with those of 
President Bush and Health and Human Services Secretary, Tommy 
Thompson. We appreciate their leadership and support for our 
vision of a life in the community for everyone. Three concepts 
at the heart of today's hearing guide our work: Accountability, 
capacity and effectiveness [ACE]. We assess ACE by gathering 
and analyzing data about our programs. But we are not 
collecting data for the sake of collecting data.
    Today we are asking why we are collecting the data and 
whether they measure outcomes that are meaningful for real 
people working to make recovery a reality. If they don't, they 
simply won't be collected. That's why we have been working with 
the States to change the ways in which we assess our 
discretionary and block grant programs. It is an approach that 
focuses questions and expectations on success and substance 
abuse treatment and prevention, measured in real-time outcomes 
for real people. The result has been the identification of and 
agreement on seven outcome domains, the very outcomes that help 
people obtain and sustain recovery.
    First and foremost is abstinence from drug use and alcohol 
abuse. Without that, recovery and a life in the community are 
impossible. Two other domains, increased access to services and 
increased retention and treatment, relate directly to the 
treatment process itself. We measure whether our programs are 
helping people who want and need treatment get the care they 
need, over the duration they need it and with the social 
supports that are most beneficial to each individual.
    The remaining four domains focus on sustaining treatment 
and recovery, increasing employment or a return to school, 
decreasing criminal justice involvement, increasing in 
stabilized family and living conditions and an increase in 
support from and connectiveness to the community. These 
measures are true measures of recovery. They measure whether 
our programs are helping people achieve and sustain recovery. 
By focusing our program outcome data collection on just these 
seven domains over time, we can foster continuous program and 
policy improvement. We can know whether our efforts to move new 
scientific knowledge from NIDA to the front lines of service 
delivery or science to services efforts are working for people.
    SAMHSA's addiction technology transfer centers are an 
example. They encourage the adoption of evidence based 
practices by alcohol and drug abuse treatment programs and 
providers. We work with NIDA to disseminate new knowledge 
specifically related to the results of NIDA research. We will 
know whether these efforts are paying dividends in reaching 
recovery and promoting and abstinence from drugs, giving people 
an opportunity to obtain sustained recoveries at the heart of 
the President's Access to Recovery Initiative. That is the 
first place we will use the seven domains to assess our 
outcomes.
    As you know and has been indicated, Access to Recovery is a 
new substance abuse treatment grant program funded at $100 
million in fiscal year 2004, and for which the President is 
seeking $200 million in fiscal year 2005. ATR fosters consumer 
choice, improved service quality and increases treatment 
capacity by providing individuals with vouchers to pay for 
substance abuse treatment they need. At the same time, SAMHSA 
has been working with the States to transform its substance 
abuse prevention and treatment block grant program into a 
performance-based system. To begin, States will be asked to 
voluntarily submit data on the seven domains as we integrate 
performance accountability into the system. SAMHSA has invested 
significant resources to help States build their State data 
infrastructures. We will work with them to promote better 
accountability not just for where the dollars are being spent, 
but how effectively those dollars are being used.
    By focusing program measurement and management on the seven 
outcome domains, SAMHSA, States and communities and this 
subcommittee can gain a powerful tool to guide the policies and 
program directions of today and tomorrow. For the first time, 
we can paint a picture of the effectiveness of drug treatment 
as it relates to recovery. We will ensure that our programs 
remain focused on the real-time needs of people working toward 
recovery and a life in the community. Thank you for the 
opportunity to appear before the subcommittee. I will be 
pleased to respond to any questions at the appropriate time. 
Thank you.
    Mr. Souder. Thank you very much.
    [The prepared statement of Dr. Curie follows:]

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    Mr. Souder. We will hear from Dr. Nora Volkow, Director of 
the National Institute for Drug Abuse at NIH.
    Ms. Volkow. Good afternoon. Thank you for inviting the 
National Institute on Drug Abuse to join with our colleagues at 
SAMHSA and others to participate in this very important 
hearing. I am pleased to be here at my very first hearing 
before Congress. What I would like to do today is share with 
you what science is teaching us about the chronic relapsing 
nature of addiction and the impact it has had on how we treat 
patients and how we measure treatment effectiveness. Every one 
of us in this room is here because we want to do something 
about the tremendous burden that drug abuse has on our society. 
Illicit drug use costs our Nation $161 billion a year. But that 
number is very small compared to the impact that drugs can have 
on individuals, families and communities. Drug abuse can lead 
to crime, domestic violence, child abuse, among others. It is 
also a leading factor for many diseases, including HIV-AIDS, 
and hepatitis.
    Fortunately, our investments in biomedical research to 
improve the health of all Americans are paying off especially 
how we approach and treat addiction. Research shows that 
addiction is a chronic relapsing disorder associated with long-
lasting changes in the brain that can affect all aspects of a 
person's life. New advances are beginning to increase our 
understanding of the developmental nature of addiction. 
Addiction is a disease that starts in adolescence and sometimes 
even in childhood. The urgency to combat substance abuse and 
addiction is highlighted by the numbers; 2.9 million 12 to 17-
year-old individuals are currently using illicit drugs. This is 
a time when the brain is undergoing major changes in both 
structure and function. If we do not intervene early, drug 
problems can last a lifetime.
    For this reason, NIDA is encouraging new research such that 
pediatricians and other primary care physicians have the tools, 
skills and knowledge to screen every patient as early as 
possible. We are also working with our colleagues from SAMHSA 
and others to rapidly bring new treatments to providers. For 
example, a little over a year ago with the help of many of you 
in this room, we were able to bring the new medication 
buprenorphine to qualified physicians. For the first time, 
doctors can treat patients who are addicted to opiates such as 
heroin and Oxycontin in their own offices. Over 3 decades of 
research demonstrate that treatment works. We have summarized 
these findings in one of our most popular publications to date, 
the principles of drug addiction treatment, commonly referred 
to as the Blue Book. This Blue Book has been distributed to 
over 12,000 providers and provides the basic principles that 
research studies have shown to be necessary for successful 
treatment. As with other chronic illnesses, treatment for drug 
addiction in most cases is a long-term process. In fact, the 
effectiveness of treatment for addiction is similar to that of 
other chronic relapsing disorders such as diabetes, asthma, 
hypertension and heart disease and many forms of cancer. 
Indeed, treatment compliance, drop out rates and relapse are 
similar for all of these chronic diseases.
    The chronic nature of drug addiction dictates the need for 
ongoing care. The importance of this strategy is illustrated by 
stories of after care in criminal justice settings. Studies in 
California and Delaware have shown that when treating drug 
abusers while they are in prison and continuing to provide 
treatment and other services while they transition to the 
community reduces drug use by 50 to 70 percent. It also reduces 
the likelihood that their return to prison by about 50 percent.
    However, without the after-care component, the effects of 
treatment largely disappear. In addition, because drug 
addiction is associated with disruption across multiple 
dimensions of a person's life, treatment requires that not just 
the drug use but also its consequences be treated, which can 
include medical complications such as HIV-AIDS and hepatitis, 
mental illness such as depression, anxiety, suicide, criminal 
justice involvement, unemployment and problems with family and 
social functioning among others.
    Conceptualizing drug addiction as a chronic relapsing 
disease that requires ongoing treatment and that affects 
multiple dimensions of an individual's life that need to be 
addressed for recovery will require that we change the way we 
measure treatment effectiveness. We particularly applaud SAMHSA 
for focusing on the multiple dimensions of drug abuse outcomes 
because this is consistent with our scientific understanding of 
the complexities of this illness. Like other areas of health 
care, standardized measures of drug abuse treatment 
effectiveness have not yet been developed and I commend this 
committee for addressing this important topic. Thank you very 
much. I would be happy to answer any questions you may have.
    [The prepared statement of Ms. Volkow follows:]

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    Mr. Souder. I thank you both for your testimony. I believe 
your statement was very clear, Mr. Curie, but I want to ask it 
again for the record because as the administration moved in to 
several of these new initiatives, one of the most common 
questions was, were new grantees going to be treated 
differently in accountability than previous grantees? As I 
understood your statement, you said whether or not it was 
discretionary or block granted, you were looking for a 
continuity of measurement where all would be measured in 
similar ways?
    Dr. Curie. That is correct. We are able to operationalize 
Access to Recovery and we are asking States or tribal entities 
who are responding to that request for applications [RFA] to 
demonstrate how they will either entice or assure measurement 
from providers who are eligible providers to receive the 
voucher. At the same time, as we move ahead with performance 
measures on the block grant and other targeting capacity 
expansion grants, we are looking at the seven domains of common 
measurements to be required of all grantees. The primary reason 
is there has been consensus in the field that these seven 
domains represent recovery and represent measurement of someone 
who is in recovery, and that is really the goal of all of our 
services that we are funding.
    Mr. Souder. Dr. Volkow just talked in her written testimony 
about the impact of comprehensive treatment. And in the written 
testimony, it also says that in the studies in Delaware and 
California, that offenders who are treated in prison are less 
likely, if they have comprehensive treatment, to end up back in 
prison. But if they do not receive after care despite receiving 
in prison treatment they have poorer outcomes. My question to 
you is, are we interconnecting the different programs at this 
point in the Department of Justice in what you are doing and 
what can we do to encourage more of that type of cooperation? I 
know, for example, in the Fort Wayne area, we both know well, 
they have Justice Department grants for continuum of care.
    And Congressman Davis has a bill that I support on housing 
questions. But are we seeing these things coming together, 
because so many of us see people who have been in a treatment 
program and they go right back in and the question is how can 
we integrate and look at this more holistically from the 
Federal Government level.
    Dr. Curie. I think the answer is yes, we are making great 
progress in that area. We do have joint programs with the 
Department of Justice. For example, we are funding the 
treatment components of reentry courts. Fort Wayne is an 
example of a reentry court. And we have an understanding, a 
relationship with Justice, that our responsibility is to fund 
community-based treatment for individuals who are coming out of 
the justice system, and to collaborate on drug courts. And 
again, we have a commitment between both departments to 
continue to foster that relationship. I think we are all in 
agreement that the treatment and recovery support systems on 
the community based side of things need to be integrated, and 
you don't want to see a separate criminal justice and 
community-based system of care. But if we truly are working for 
individuals to have that life in the community, it needs to be 
part of the overall public health focus.
    Mr. Souder. Before I followup with Dr. Volkow on that 
particular question, when you give block grant money to the 
States, is there any guidance to them that says we want this 
integrated with the drug courts, with other reentry programs 
and not just OK, we are pursuing this thing at the Federal 
level and these different agencies and you're pursuing this?
    Dr. Curie. For the block grant there are various directives 
and statute that are on the block grant. The States do have a 
lot of latitude. That's the very thing we are examining as we 
move to PPGs is how we can measure and incent, if you will, a 
system with further integration.
    The other thing I might mention, there are block grant 
dollars, I know, in a wide range of States that are going 
toward treating individuals who are coming out of the criminal 
justice system. Also with Access to Recovery, nothing precludes 
the State, in fact, we have encouraged this one scenario, a 
State or a tribal organization may want to use the vouchers in 
connection with the drug court or the reentry court program and 
actually begin their voucher program with that specialty 
population. And we anticipate we are going to see those types 
of models proposed.
    Mr. Souder. Dr. Volkow, have you seen any of these 
integrated studies? Are you setting up any tracking to see 
whether or not we are getting the results when we have a drug 
court, a reentry program and a prison treatment program or 
community-funded program? Are you able to see enough of these 
that you can start to research it and to see whether what was 
suggested in the State studies might, in fact, be true?
    Ms. Volkow. One of our priority areas is how to actually 
develop knowledge that optimizes the way that we bring the 
prisoners back into the community. We have a strategy that, for 
lack of a better term, we are calling an ``NIDA goes to jail'' 
and it has multiple components. One of them is to generate the 
knowledge and to create the infrastructure. One of the things 
that we have started is what we call the Criminal Justice Drug 
Abuse Treatment Studies [CJDATS] and these are seven of our 
criminal justice systems working with academic centers to 
develop research protocols to optimize our reentry of the 
prisoner back into the community. Another component is to 
interact with SAMHSA, and also to interact with the Department 
of Justice to bring education about the signs of addiction and 
the treatments that are available. So that is the educational 
component.
    And finally, the other aspects we are working with, which 
we are also addressing is the issue on research that 
unfortunately is common in the substance abuse area. Many of 
the individuals that end up in prison are frequently associated 
with co-morbid mental illnesses.
    So that is another area where we don't have sufficient 
research. And in parallel to this initiative, there is also 
parallel one for the criminal juvenile offenders.
    Mr. Souder. Can I ask one supplemental question? I know all 
the members are interested in this as well. I didn't mention, 
and nor did you, the Labor Department or the Education 
Department. Are we looking at any attempts to look at 
vocational education and/or employment as part of this rehab 
where that would be integrated as well?
    Dr. Curie. Yes. In fact, one of the major domains, 
employment and education which reflect a dimension of recovery, 
we are looking at collaborating with labor. We are looking at 
potentially--I know a reentry program was proposed by the 
President which would be focused on just that and with the 
efforts between Justice and HHS at this point around bringing 
individuals back into the community to succeed. It would make a 
lot of sense to be engaged in that process to make sure we have 
a comprehensive approach. Also on a related side of the 
equation, on the mental health agenda side, we have an action 
agenda around transforming the mental health system, which will 
address co-occurring disorders which has a clear connect to 
addictive disorders. And with that, we have Labor at the table 
collaborating with us around models that work to help people 
gain employment.
    Mr. Souder. Mr. Cummings.
    Mr. Cummings. Thank you all very much for being here. Ms. 
Volkow, tell me exactly what you mean--what is your definition 
of after-care? You said it is important that you have after-
care. And I want to know what are the essential ingredients for 
what you deem to be effective after-care?
    Ms. Volkow. The after-care for someone who has been in jail 
or after-care for any drug abusing person that ends up in a 
health care facility seeking treatment.
    Mr. Cummings. Both?
    Ms. Volkow. What it basically requires is that it starts, 
and this is actually one of the things that has been clearly 
summarized in the principles of drug addiction and what has 
been, there is consensus that in the initial reentry of the 
person you are focusing on stopping the drug use while at the 
same time starting to engage the patient on realizing what are 
the positive and negative aspects of taking drugs. Once that 
individual recognizes his position on this stance, he is taken 
to the next step, which is to teach that individual what are 
the actions that he needs to do in order to optimize his 
chances to not take drugs.
    So that is the first stage. Once that is achieved, the 
patient goes into what we call after-care and the patient is 
released into the community and that requires that there has to 
be followup and there are several programs that can be 
utilized. There is nothing like a recipe that works for 
everyone.
    So the first thing that has to be realized is that the 
treatments have to be tailored for the unique circumstance and 
characteristics of the patient, and that will require that the 
several aspects that SAMHSA is focusing on are addressed. You 
need to address not just the substance abuse, but the 
integration of the individual and the support of the community, 
which ideally should include the family. And if the family 
doesn't exist, what does the integration require? If it is an 
adult, that they have employment. And if it is a younger 
person, that they are able to continue in the educational 
system.
    At the same time, what science has taught us is that self-
help groups are usually very beneficial. And in certain 
instances, the notion of medication can help drug-addicted 
persons stay away from drugs.
    And finally, but not because it is least important, 
unfortunately substance abuse is frequently coupled with morbid 
mental illness. And if the issue of mental illness is not 
addressed, they are very unlikely to succeed in getting that 
person out of drugs. That is what the after-care entails, being 
able to monitor all of these different dimensions that have 
unfortunately been affected by the drug addiction process.
    Mr. Cummings. I was waiting for you to say and you finally 
did say it, a job is helpful, isn't it?
    Ms. Volkow. One of the things we have come to realize is 
that we are human beings. One of the most important aspects 
that motivates our behavior is to be part of a group; to be 
part of a community, and to feel that we are appreciated and we 
can contribute to that community. It is one of the most 
important aspects that motivates our actions in life. So when 
you bring a person into community and you make him feel he is 
part of it, you actually achieve a great deal through that 
process.
    Mr. Cummings. Mr. Curie, you were with us in Fort Wayne?
    Dr. Curie. Yes, I was.
    Mr. Cummings. If you recall when we were in Fort Wayne with 
the chairman, a lot of those judges came forward and talked 
about how they were so upset that State law--that is what they 
were talking about, I think--because somebody had a drug 
offense on their record, it had precluded them from getting so 
many jobs. And when I go to the inner city of Baltimore, I talk 
about that because they think it is only a problem in the inner 
city. And so then I just heard Ms. Volkow talk about how jobs 
are a part of getting that person back into society.
    Are there any efforts to try and look at some of these 
State laws on the part of either of you? And I don't know if 
that comes under your purview, so we can get people to have 
some hope and able to get back and circulate in society, since 
that is such a crucial part of recovery.
    Dr. Curie. I am not aware of any formal reviews of looking 
at that. I think it would be a worthwhile endeavor to consider, 
especially since we are using recovery now as our framing of 
service delivery. Historically, and I think Dr. Volkow was, 
when she is talking about after-care, historically, I think 
from the public sector side of things, as we finance services, 
we have focused primarily on the treatment or the treatment 
intervention and not on the whole recovery picture. We have 
begun focusing on the whole recovery picture recognizing that 
relapse is less likely to occur if people are attaining those 
real life goals of employment, education, stable housing, 
connectiveness to family and friends, and connectiveness to the 
community. So as we are basically embarking, I would say, in a 
relatively new chapter as we look at what we are financing. I 
think the type of review you described would be worthwhile 
because historically you never heard us talking necessarily to 
labor or to education about how we help individuals build a 
life. We used to think that if we provided access to care and 
some forms of care, we are done with our mission. We are 
recognizing today that we are not finished with our mission.
    Mr. Cummings. Just one other thing. When I talk to people 
in my district who are recovering addicts, one of their biggest 
concerns is a job. And the more I think about it combined with 
what you just said, I mean, it really makes sense. One, they 
need another family. In other words, the family that got them 
on drugs, they need to get away from that group or they will be 
right back where they started. Two, I guess it does give them a 
sense of worth. Three, it gives them a whole lot more eyes 
looking over their shoulder, like the woman who is their boss 
or the person that they become familiar with and becomes a 
friend that they eat lunch with or people that go out and play 
baseball after work.
    So basically what we are talking about is sort of a 
shifting from one lifestyle and trying to shift them over to 
another lifestyle, that includes new people and new 
opportunities to change and get away from what sent them there 
in the first place.
    Dr. Curie. Exactly. Goals, aspirations, you mentioned hope 
earlier. It is all part of it. Your experience parallels mine. 
When I ask a question of people what they need, people who have 
an addictive disease or disorder, they don't define that they 
need a clinical program. They define that they are looking for 
a job, a home and a date on the weekends to build a new life. 
And a job also strikes not only giving someone a sense of 
worth, but in our society, the basic question you're asked when 
you enter a neighborhood is what do you do? And if you don't 
have an answer to that question, already you're on a slippery 
slope in terms of acceptance in that community. So a job goes 
to basically identity in this society.
    Mr. Cummings. Just as a footnote when you are at a party 
and a fellow is talking to a young lady, she wants to know what 
do you do, do you work and have job.
    Mr. Souder. Congressman Blackburn has been very involved in 
this before she came to Congress, and we had an excellent 
hearing in her district as well, a number of remarkable people 
in Tennessee.
    Mrs. Blackburn. That is exactly right. Thank you, Mr. 
Chairman and to my colleague. He was speaking in terms of 
family and I was sitting here making some notes before he 
started speaking on that issue, abouit the importance of a 
family or an extended family or well-placed mentors. I do 
applaud our President in the fact that he has developed 
mentoring programs and that he is a supporter of faith-based 
initiatives. As the chairman mentioned, the hearing we did in 
our district and the very active work and participation that is 
taking place on that.
    So I agree with what he is saying, that those life skills 
that many times our educational system no longer teaches. It is 
important that we have families and mentors to fill that void 
and to teach those skills to young people. I thank you both for 
being here and appearing before us. I appreciate it.
    Dr. Volkow, I want to thank you specifically for using the 
front and back of your paper. We conservatives like to see 
that. It is wonderful that we doubled up there. You know just 
think what we could do to cut the use of paper in half if we 
used the front and back of the paper, so we thank you for that. 
A couple of questions that I do have looking through your 
testimony, Dr. Curie. I want to start with you first, please. 
As you reference the programs in the studies that you have 
done, one of the things I am not seeing is the complete 
universe of individuals in your programs. I am going to ask 
these questions in bulk just to save time and let you answer 
them.
    Out of the individuals in the program and the length of 
time they were in their programs, one of the things from the 
State level that we have learned is that short programs don't 
work, longer programs do work. Out of this universe, what is 
the recidivism rate and do you have any documented evidence on 
tying the length of the program to the recidivism rate? In 
looking at your accountabilities, and I appreciate your 
spelling out the seven domains, I think that is really 
excellent, do we know how much we are spending per individual 
to move them through this program?
    And let me go ahead and finish here. When we look at the 
States, and both of you mentioned working with the States, as 
you move them through this, have you developed some type of 
software that you or some type of program that they are going 
to be able to submit this accountability data to you? And our 
grantees, if they are not accountable, is there a process for 
withholding money or moving them out of the program? I know 
that is a lot to throw out, but I have got 5 minutes, so I 
wanted to be sure I got out of all of these things before you.
    Dr. Curie. Understood. I can share with you information 
about specific programs and the link between longevity within 
the program and relapse and we have that mainly on specific 
programs, sometimes by State. There is no real comprehensive 
national picture of that and that is one reason we want the 
seven domains to be consistent among all grants because we 
think that will help us begin to paint more of a national 
picture.
    Mrs. Blackburn. Mr. Chairman, I would like to request that 
we have that submitted for the record and for our review.
    Dr. Curie. And as we move ahead in terms of working with 
the States, State data infrastructure is a real critical issue. 
When you speak to the States, you understand that there are 
many demands on their particular State budget. At the same 
time, they have State legislators and Governors who want to 
have this information for them to make informed decisions. So 
there is an alignment of goals. We are providing both resources 
and technical assistance to States to help and develop the data 
infrastructure. Also working with States, there are certain 
States that have excellent data information systems that can be 
used as models for other States.
    We are also looking to work with the National Association 
of State Alcohol and Drug Abuse Directors to accommodate that. 
But that is a priority and it is going to be essential in order 
for us to gain the data we need to measure performance.
    Mrs. Blackburn. Thank you, sir. Go ahead. Thank you, Mr. 
Chairman.
    Mr. Souder. Mr. Davis.
    Mr. Davis. Thank you very much, Mr. Chairman and I thank 
you for calling this hearing. I have gotten very much into this 
whole business. In fact, I am leading an initiative effort in 
Illinois to get a referendum on the November ballot calling for 
drug treatment on demand. We have to get 300,000 signatures and 
we have gotten about 60,000 that I have in my office in a safe 
right now. Let me tell you the headlines in the Chicago Sun 
Times on Monday, saying that Chicago is now No. 2 in the Nation 
in drug overdoses. Philadelphia is No. 1. Chicago is No. 2. And 
of course lots of folks thought that the increase would be in 
the inner city area of Chicago, but it is actually more 
prevalent in the suburban communities outside of Chicago and 
especially with teenagers using heroin.
    And so it is a big issue and a big problem. One of the 
questions we find people are asking as we deal with our 
referendum effort is how effective is treatment, that is, if 
individuals get treated, then so what? What is the difference 
between the recidivism rate for those who are treated and those 
who are not? And we got into it really because there is such a 
close relationship between crime and drug use and abuse. I 
mean, most of the crime that we encounter is in some way, 
shape, form or fashion drug related or drug connected. And so 
we got to thinking that if we could reduce drug use, we also 
could reduce crimes and save ourselves a tremendous amount of 
money and human misery and other problems associated with it.
    Is there a discernible difference in different kinds of 
treatment and their effectiveness? Do we have enough data to 
suggest that people who treat it one way, the recidivism rate 
might be one thing. If they are treated another way, it may be 
something different?
    Ms. Volkow. Yes, there is some data for certain drug 
addictions, particularly for heroin, where we have compared the 
relapse rate for one type of treatment versus the other. And in 
the case of heroin we of course have methadone and 
buprenorphine, and indeed, studies have shown very, very 
clearly and cogently that treatment with these medications 
significantly reduces relapse and also the relapse reduction is 
significantly greater than basically other types of treatment 
intervention.
    For heroin addiction, that is definitely the case. For 
other types of addictions, there is not enough research to 
compare one modality versus another. There are two aspects that 
I think are very, very relevant. When you compare one modality 
versus the other, you have to consider that not every addict is 
the same nor are their circumstances. And that's why I made the 
point that you have to be able to tailor the treatment 
accordingly to the needs of the individual. It is not going to 
be a transparent comparison in one versus the other.
    Another thing I want to reiterate because it is extremely 
important and it has carried the field tremendously, is the 
notion that when you provide treatment and there is relapse, 
automatically it is felt that there was failure when, in fact, 
relapse may not be failure. When you are treating someone for 
hypertension, if the blood pressure has been stabilized for 6 
months and 1 day it goes up, did you fail? You did not fail. 
You restart treatment. Even though relapse is part of the 
process, it does not necessarily mean that our medications have 
failed and that is one of the aspects that we have to start to 
change in the way we evaluate treatment. We are setting up the 
comparisons of different treatment modalities. We have the 
clinical trials network whose function it is to do exactly what 
you are asking, to compare the different modalities and to 
optimize what is best for a given individual.
    Mr. Davis. Thank you, Mr. Chairman. I have to run to 
another hearing, but I would like to ask one additional 
question if I could, and that is, is there enough information 
that we have been able to evaluate relative to faith-based 
efforts? And I mean we had an event Saturday and I had about 
400 people in recovery and since I have been working so closely 
with them, I have learned so many things that I haven't really 
thought about in terms of who is addicted.
    A lot of people seem to think that a lot of individuals who 
are addicted are thrill seekers and macho people and that many 
of the people who become addicted are lacking in self-esteem 
and somehow or another, whatever it is, they end up using. We 
were doing role playing and all of that to get them ready to go 
out and help get these signatures. And there were some 
individuals who simply could not ask a person to sign a 
petition because they could not look at them. And even when 
they would be talking they would be looking away. And of 
course, the faith-based stuff seemed to help with that 
somewhat. Is there any data related to the effectiveness of 
faith-based efforts?
    Ms. Volkow. The answer is that there has not been enough 
research in this area. We are currently funding several grants 
that are specifically addressing the role of spirituality in 
the recovery process because most of the treatments that are 
available for drug addiction incorporate faith-based approaches 
into their systems. We are specifically requesting in all of 
our program announcements and request for proposals that faith-
based organizations, we are encouraging them to apply for these 
funds.
    Unfortunately, there is not enough research that has been 
done, but we are actually encouraging the community to come and 
request grants so that we can start to look at these questions 
that you are asking.
    Mr. Davis. Thank you very much, Mr. Chairman, and I 
appreciate your leadership in this area.
    Mr. Souder. If you have additional written questions that 
you want to submit, you can do that as well. If I could ask a 
followup on that faith-based point. We have been doing a series 
of field hearings around the country, both on narcotics and on 
faith-based. And one of the things we heard in San Antonio as 
well as Los Angeles and a few other places is that in faith-
based drug treatment programs, one of the things that has been 
an effective measure, and disagree with me if this is 
incorrect, but I think most people agree that the more inclined 
a person is to want to get off their addiction, the more 
success there is, not saying that you have to have voluntary 
compliance or speaking about the program to make it more 
successful. But the more one is prepared to have a life 
changing experience, the more likely you are for success. And 
one of the roles of the faith based organizations is preparing 
their heart for a change in their life that prepares them for 
the drug treatment.
    Is that one of the things you might be looking at in the 
research, and has that come up before?
    Because that is a little different than saying it is 
precisely a drug treatment program. It is saying that because 
they are willing to make a life change and they are 
transforming their life, that has prepared them now mentally to 
go through a drug program.
    Dr. Volkow. What you are saying is correct. It is a basis 
of a therapy called transcendental therapy, and it has been 
shown to be effective not just for drug addiction but other 
types of behavioral disorders, where the main element is to 
make the person aware that they want to really incorporate the 
sense that they want to make a change in their life. This is an 
extremely important component of whether a person will succeed 
or not.
    Yet at the same time, you also state that what we have 
shown, it does not necessitate treatment be voluntary, but the 
motivation of the person to change is indispensable.
    As for your question about what is the role of faith-based 
organizations in helping drive the person to really accept and 
incorporate that need to change and willingness to change is 
one of the items that may indeed be playing a role. But we have 
to do the stories to demonstrate it.
    The question scientifically is, what are the active 
ingredients that determine the benefits for faith-based 
approaches? And it is likely that one of them may be, but that 
is why we are doing the work. And we do not have answers yet. 
So one can just predict. From previous research, it does make 
sense that this is one of the variables.
    Mr. Currie. I would say one common denominator among all 
programs, whether they are faith-based or they're not faith-
based, could, again, be the seven domains being a way of 
judging outcome and effectiveness over time as well. And I 
think those domains can be utilized with a wide range of 
interventions.
    Also, I think with faith-based approaches, recovery is such 
an individualized process. As Congressman Davis said, if there 
were 400 people in the room, there will probably be 400 
different stories of recovery, some with common elements.
    But the role that faith plays, sometimes, it is an upfront 
role as you just described. Sometimes, it's a role that, once 
they've been through a medically based program in order to 
sustain recovery in the 12-step program, the spiritual 
component of that helps them sustain recovery.
    So I think faith can play a role at different levels in an 
individual's life, and again, I think the biggest challenge for 
us in using recovery as we are framing both public policy and 
public finance is that it is such an individualized process.
    Mr. Souder. I want to ask one other question. The most 
spectacular failure, certainly in North America and possibly 
the world, is Vancouver, British Columbia, right now in their 
needle-exchange program. And now on top of having the world's 
highest HIV infection rate, they have this huge expanded market 
of actual heroin addicts. And now this high-THC marijuana, it 
has now corrupted several officials in their government. They 
are being prosecuted, going down the path of Colombia, more or 
less, and what happened in Mexico before those governments 
started to tackle it.
    In Vancouver, they started this program in 1988. They are 
now up to 2 million needles that they are distributing on the 
street. And people call that harm reduction. And I wanted to 
have two clarifications here.
    One is, there is a difference between harm reduction 
defined that way, which is more of a maintenance question. In 
other words, a heroin addict is getting a needle. The 
presumption is that you reduce AIDS, which has not necessarily 
been proven. The presumption is that you reduce AIDS, but you 
wouldn't treat the heroin. That is different than the treatment 
programs you are talking about. You are not talking about 
maintenance. You are talking about changing someone's 
addiction.
    And the second thing I wanted to make sure that we were 
clear on is that do we have any data, or what percentage of 
people who actually get the needle exchange go to treatment? Or 
in fact, does giving them the needle perpetuate it, and then 
they do not see the need for treatment?
    Dr. Volkow. Actually, it is interesting, because you were 
making the statement in the way that you were saying, which is 
absolutely correct, that just providing needles by itself is 
not helping anyone.
    But what research has shown is that needle-exchange 
programs in the line of a comprehensive drug-treatment program 
have been shown to reduce HIV, and also includes the likelihood 
that these individuals will stay for treatment. So needle 
exchange by itself is not going to solve a problem. Not at all.
    And it also addresses another aspect that is very relevant 
when we look at one thing. We sort of say we are looking at 
treatment. And the other aspect I view, which is very relevant, 
is that of prevention. So what is the message that we are 
sending with respect to prevention in terms of just exchanging 
needles?
    And that is why, when we bring up that issue, we basically 
say what science has taught us is that needle-exchange programs 
in line with a comprehensive drug-abuse treatment program have 
shown in fact to reduce the cases of HIV when they are 
combined. Not by itself.
    Mr. Currie. You are exactly right. The treatment programs 
we are talking about are not about harm reduction. In fact, 
when we talk about prevention and recovery, we are not talking 
about harm reduction but harm elimination. It's bottom line the 
risk factors you need to eliminate in the prevention scenario. 
As one attains and sustains recovery, they begin to manage 
their illness. They begin to manage their life. And that goes 
much beyond a harm-reduction vision.
    Mr. Souder. I thank you both for your testimony, and we 
will probably have some written followups, not only from me but 
from other members in the subcommittee.
    Thank you for coming.
    Mr. Souder. If the second panel could come forward. As you 
come forward, if you could remain standing so that we could do 
the oath. If witnesses would raise their right hands.
    [Witnesses sworn.]
    Mr. Souder. Let the record show that each of the witnesses 
responded in the affirmative.
    Thank you all for being here today. Our first witness is 
Dr. Thomas McLellan, director of Treatment Research Institute 
in Philadelphia, PA.

   STATEMENTS OF THOMAS MCLELLAN, PH.D., DIRECTOR, TREATMENT 
    RESEARCH INSTITUTE, PHILADELPHIA, PA; CHARLES O'KEEFFE, 
 VIRGINIA COMMONWEALTH UNIVERSITY, RICHMOND, VA; KAREN FREEMAN-
  WILSON, EXECUTIVE DIRECTOR, NATIONAL DRUG COURT INSTITUTE, 
 ALEXANDRIA, VA; JEROME JAFFE, M.D., PROFESSOR, UNIVERSITY OF 
    MARYLAND, BALTIMORE, MD; CATHERINE MARTENS, SENIOR VICE 
   PRESIDENT, SECOND GENESIS, SILVER SPRING, MD; AND HENDREE 
   JONES, PH.D., RESEARCH DIRECTOR, CENTER FOR ADDICTION AND 
                    PREGNANCY, BALTIMORE, MD

    Dr. McLellan. Thank you. I was already told that one person 
wrote on both sides. I wrote on no sides, so I will just read 
it here.
    I am Tom McLellan. I am a researcher in the substance-abuse 
treatment field from the University of Pennsylvania, 
Philadelphia, and the Treatment Research Institute there.
    I am not an advocate and neither I nor my institute 
represent any treatment or Government organization. I offer 
evidence on the effects of treatments for alcohol, opiate, 
cocaine and amphetamine addictions based on my own work of over 
400 reviewed studies and based on reviews. I'm the editor of 
the journal Substance Abuse Treatment, so I see many reviews of 
other work.
    I have five very simple points to make. First, addiction 
treatment can be evaluated. It's not something that you have to 
wonder about. The same standards of evidence apply as apply to 
the evaluation of medications and interventions commonly done 
in the Food and Drug Administration. There are over 700 
published studies of contemporary treatments so there is an 
evidence base.
    Point two, effectiveness does not mean cure. We do not have 
a reliable cure. Yes, there are many people in the field who 
have become abstinent and lived productive lives. They are 
probably not going to be able to drink or use drugs socially 
again. So there is not a cure. On the other hand, evaluation 
perspective and a determination of effectiveness shouldn't just 
mean that the patient feels better.
    The scientific basis for effectiveness means three things, 
as it's commonly evaluated. First is the significant reduction 
of the substance use. Alcohol, cigarettes, opiates, cocaine, 
amphetamine--significant reduction.
    Second is improvement in personal health and social 
function. Basically, a reduction of the society's 
responsibility for the individual.
    And the third piece of evidence is reduction in public 
health and public safety threats. And that is what we mean by 
effective.
    Point three, not all treatments are effective. Some 
treatment programs are quite competent. Some aren't, like any 
other field. Certain treatments do not work. We have talked 
about them already. Detoxifications, for example, do not work 
unless they are followed by continuing care. Acupuncture does 
not work unless it is part of some other broader treatment.
    Many contemporary treatment components have not been 
evaluated. They have simply been adopted well before modern 
methods have been brought to bear. And also many evidence-based 
treatments, treatments that were discussed by Doctors Volkow 
and Curie, are not in practice because of financing and 
training issues, and I will discuss that later.
    Better treatments have the following characteristics, in 
general. I am happy to answer specific questions but in 
general, longer is better, in an outpatient setting and one 
which includes monitoring. One of the Congressmen asked for one 
of the components, and monitoring is an important one.
    Better treatments include tailored social and medical 
services. Better treatments typically involve family.
    Fourth point, addiction treatment is not the same as it 
used to be, but the evaluation of addiction treatment is the 
same as it used to be. And it does not fit anymore.
    Not so long ago, over 60 percent of addiction treatment was 
delivered in a residential facility someplace. You went 
someplace to that famous 28-day treatment, and the question 
was, how long do the good effects last? So you did a 6-month, 
12-month post treatment evaluation. In general, relapse rates 
were 50 percent just about anywhere you went.
    Now, addiction treatment isn't delivered in residential 
facilities anymore. Over 90 percent of addiction treatment in 
this country is done on the street in outpatient settings. 
People are ambulatory.
    My point there is, it's too late to wait 6 months, 12 
months after they are out of that kind of care. What you want 
to know is, are people attaining abstinence? Are they attaining 
employment? Are they being re-arrested? Are they using 
expensive hospital resources? That evaluation has not caught on 
yet.
    The kinds of studies that have been done have to be able to 
give real accountability in the field, if you ask my opinion, 
now because that is where treatment is, it's on the street.
    The final thing I have to simply say is that the basic 
infrastructure of the U.S. treatment system is in very bad 
condition. Program closures or takeovers are over 20 percent a 
year. Program directors make less money than prison guards and 
have fewer benefits. The great majority of programs have no 
full-time physician, no psychologist, no social worker. That is 
the majority of treatment programs in the country. Counselor 
turnover rates are comparable to the fast-food industry. The 
pay is terrible, and there aren't standards.
    Though there are well-studied, excellent medications and 
therapies available, thanks to the work of the National 
Institute on Alcoholism and National Institute of Drug Abuse 
and CSAT, frankly, most cannot be adopted by the present 
system. This is a system that can't be regulated into 
effectiveness. It's going to have to have financing, 
incentives, to bring professionals into the field, to retain 
them, and it needs the kind of infrastructure that will provide 
the kinds of things that are associated with better treatments 
has to be available. And that concludes my testimony.
    [The prepared statement of Dr. McLellan follows:]

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    Mr. Souder. Thank you. We will now go to Mr. O'Keeffe from 
the Virginia Commonwealth University.
    Mr. O'Keeffe. Thank you, Mr. Chairman, members of the 
committee. It is a privilege to be here this afternoon.
    Others testifying today will address more directly the 
measurement of the success of treatment effectiveness. I hope 
to provide the committee with a perspective on overall 
treatment policy. Together, these perspectives will, I hope, 
help the committee in its deliberations about the best 
strategies to improve drug addiction treatment.
    The main point I wish to make today is that Federal policy 
is not optimal for the development and/or deployment of new 
treatments. There have been some recent improvements, but much 
more needs to be done.
    As you know well, Mr. Chairman, because of longstanding 
strong Federal regulation, the system for treating opiate 
dependence has evolved as one separated, even isolated, from 
the normal practice of medicine. This has resulted in a 
disconnect between the findings of the research community and 
the practices of treatment providers.
    In 1972, thanks to the work of the country's first drug 
czar, Dr. Jerome Jaffe, proposals related to the appropriate 
use of methadone as addiction treatment were included in the 
Nixon administration's initiative on drug abuse. This 
initiative established stringent regulations regarding 
eligibility for treatment, dosage to be administered, level of 
counseling, length of treatment and criteria for take-home 
dosing.
    To prevent abuse and diversion of methadone, the 
subsequently promulgated regulation created a closed system 
that allowed treatment only through specialty clinics. And 
according to Dr. Jaffe, the drafters of the regulations did not 
intend for medication dispensing to be forever limited to a few 
large clinics. Although they recognized that access to 
treatment by individual physicians might be temporarily 
limited, they believed that the regulations would be revised as 
knowledge expanded and as opiate maintenance treatment became 
less controversial.
    Sadly, this was not the case. Those temporary regulations 
remained and have been significantly expanded over the 
subsequent 30 years.
    We learned in the 1960's that treatment could be effective. 
However, because the general portrayal of patients addicted to 
opiates as miscreants, treatment was confined to a small number 
of specialty clinics generally located in larger metropolitan 
areas and controlled by stringent regulations. This depiction 
of patients generally led communities to resist allowing 
treatment programs to locate in any but the least desirable 
areas. Physicians were reluctant to treat addicted patients 
because of the public perception of these patients, the 
treatment locations and the complexity of the regulations.
    Consequently, a non-physician-oriented treatment system 
began to develop. Addicted patients became clients of programs 
that eventually developed a fortress mentality. Because 
treatment moved further away from the mainstream practice of 
medicine and more and more clients were seen by counselors and 
advisers instead of patients seen by physicians, more and more 
regulations were needed to assure that appropriate treatment 
protocols were followed.
    Treatment programs became increasingly insular under a maze 
of complicated rules, further distancing physicians and the 
health care community from the care of these patients.
    Meanwhile, the research community lead by NIDA was making 
inroads into new treatment methods, pharmaceutical products and 
improvement in the treatment of co-occurring diseases. These 
developments led to new products, new uses for old products and 
new approaches to the treatment for this chronic, relapsing 
brain disease.
    It is essential that Federal policy now ensures that these 
new emerging developments be transferred to the practice of 
medicine as quickly and as responsibly as possible so that more 
patients will have access to treatment.
    Nearly 6 million Americans affected by this disease remain 
untreated. This untreated population continues to impose a 
significant burden on both the criminal justice system and the 
public health system. Both NIDA and CSAT have recognized this 
treatment gap and are working toward closing it.
    These efforts are commendable, but the executive branch is 
constrained by legislative requirements, constrained by 
mandates and restraints, constrained by the patchwork of 
Federal and State regulations, which has grown so complex that 
very few physicians are willing to begin treating patients 
because of the infrastructure required by the rules.
    In a sense, over time, we have created a monopolistic 
system which has arisen from the complex regulatory environment 
which now discourages new treatment providers from entering the 
field. We are discouraging treatment with evermore burdensome, 
monopoly building regulation.
    Congress recognized this problem and enacted the Drug 
Addiction Treatment Act of 2000 which, for the first time in 
over 80 years, provides an opportunity for qualified physicians 
to treat addicted patients in their own office or clinic 
setting. While this legislation was a major step in bringing 
the treatment of addiction closer to the practice of medicine. 
And your bill, Mr. Chairman, will correct some of the 
oversights of data. We are clearly not at the end of the road.
    There are crucial next steps, not the least of which is the 
daunting task of encouraging and enabling 5 million Americans 
to seek and receive treatment for their disease.
    DATA began the process of de-stigmatization and its 
treatment, but it did not end that process. This committee can 
help ensure that policies, priorities and funding are all 
concessive to the effective treatment.
    Perhaps, it's time for a re-examination of existing 
treatment policies and their consequential regulatory 
requirements that discourage adequate treatment. NIDA and the 
institute of medicine have the responsibility and access to the 
expertise to provide recommendation for sorely needed policy 
and regulatory change which they lack authority and incentive 
to make.
    The public health as well as this committee would be well 
served by seeking their advice on legislation designed to 
remove existing impediments to effective treatment.
    Thank you, Mr. Chairman.
    [The prepared statement of Mr. O'Keeffe follows:]

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    Mr. Souder. Thank you. Our next witness is the honorable 
Karen Freeman-Wilson, executive director of the National Drug 
Court Institute in Alexandria.
    Thank you for being here.
    Ms. Freeman-Wilson. Mr. Chairman and members of the 
subcommittee, I would like to thank you for the opportunity to 
represent the National Drug Court Institute and address this 
very important issue.
    Dr. McLellan has already talked about the importance of 
measuring client outcomes during the course of treatment when 
it is still possible to alter the treatment plan for the 
client's benefit. I will not duplicate his discussion except to 
underscore my agreement that traditional approaches of 
measuring pre-to-post changes in client functioning have 
unfairly obscured the true effects of drug treatment services 
because they assess outcomes after treatment has been withdrawn 
from what is a chronic and relapsing condition.
    Although it is the position of our organization that these 
and other observations heard here today are applicable to 
treatment in all contexts, I will frame my conversation in the 
context of our findings in the drug court arena.
    Drug courts are a unique blend of treatment, case 
management, intense supervision and support services along with 
judicial case processing. The success or failure of 
participants in recovery depends heavily on their access to 
quality effective treatment in drug court.
    There are a number of indicators that can be reviewed to 
determine whether treatment is effective in drug court. The 
first is the rate at which offenders report to treatment 
pursuant to a court order and the length of stay and the rate 
of completion once they arrive.
    Next is the offender's abstinence from the use of alcohol 
and other drugs. Each drug court is required to monitor 
abstinence through regular, random and observed drug testing. 
This means that most participants are tested at least two to 
three times a week.
    Another measure of the effectiveness of treatment in the 
drug court context is the ability of the offender to comply 
with aspects of the drug court program. Is the person actively 
engaged in community service? Are they actively involved in job 
search, vocational training or school? Are they attending self-
help meetings? Are they appearing as ordered for court review 
hearings and meetings with probation officers and other court 
staff? Are they paying their fines and fees?
    Another factor which may assist in the determination of 
whether treatment is effective is the status of the offender's 
personal relationships during the drug court program. Is there 
a spouse, significant other, parent or child who regularly 
accompanies the offender to court, probation and counseling 
sessions? How successful is the participant in improving their 
living conditions as indicated by living most of the time in 
their own apartment or house, with their families, in someone 
else's apartment, room or house, or in sober housing?
    The measures discussed above address our evaluation of 
treatment while an offender is actively involved in the court 
process.
    Another related measure is the completion of educational or 
vocational programs and elevation in job status after 
treatment. One of the most important factors to the success or 
failure of drug courts and treatment is the individual's 
decrease in criminal involvement or activity. That is measured 
generally by recidivism.
    While all of the factors discussed above are important, 
some are easier to measure than others. It's relatively simple 
to maintain and compile statistics with drug testing. It's easy 
to review whether a person reports for treatment or engages in 
treatment.
    In looking at the more challenging measures, you must ask: 
How do you gauge the quality of relationships? How do you look 
at the number of trips a family member takes to court?
    In conclusion, there are a number of considerations that 
must be made in an effort to standardize measurements to 
achieve more effective treatment research. First, it's 
important to take any measurement at three key points in time: 
Before, during and after treatment, whenever possible. There is 
an inherent challenge involved in measuring indicators prior to 
treatment because there will be a need to rely heavily on self-
reporting. I detail the other points and measures in my 
testimony.
    In concluding, I would recommend that this committee call 
for the development and adoption of a core validated data set 
to be captured in all federally funded evaluation-and-research 
studies to drug abuse treatment.
    I would also recommend that this committee put its weight 
behind the adoption and enforcement of best practice standards 
for drug treatment programs with suitable performance 
benchmarks that programs must meet in order to establish that 
they are providing evidence-based interventions with 
appropriate and documented treatment integrity. National 
organizations such as NADCP are ideally suited to review the 
research to establish performance benchmarks and to promulgate 
suitable standards for their respective disciplines.
    Thank you.
    [The prepared statement of Ms. Freeman-Wilson follows:]

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    Mr. Souder. I need to correct the record with something 
because I was trying to sort it out, and it was in the 
footnotes of your testimony.
    I was very confused when I read this: executive director, 
Alexandria, VA, because, I am saying, I think she was Attorney 
General of Indiana and on the Governor's drug commission. So 
first off, you are one of us, not part of this Washington group 
here. So I welcome a fellow Hoosier. I should have caught that 
earlier in my introduction of you, thank you very much for 
coming.
    Dr. Jaffe is a professor at the University of Maryland in 
Baltimore. Would you elaborate, did I understand Mr. O'Keeffe 
to say that you were the first drug czar?
    Dr. Jaffe. I have been called that, Mr. Chairman.
    Mr. Chairman, members of the subcommittee, I thank you for 
inviting me to speak to you on measuring the effectiveness of 
treatment.
    In January, Join Together, a project of Boston University 
School of Public Health, released a study called, ``Rewarding 
Results: Improving the Quality of Treatment for People With 
Alcohol and Drug Problems.'' I had the privilege of chairing 
the panel that produced the report. I will offer some 
highlights of the report here and will submit the entire report 
for use by the subcommittee.
    First, some preliminary thoughts on evaluation. First, how 
one evaluates or measures the effectiveness of treatment 
programs depends very much on the purpose for undertaking the 
evaluation. For example, an employer who wants to know if a 
program covered by the company's insurance plan is effective 
may be interested in knowing not only whether or not the 
problem drug or alcohol use is stopped but also how soon the 
employee can return to work.
    Another agency may be more interested in knowing if 
treatment has resulted in decreased criminal activity.
    Depending on resources and goals, one can obtain 
information directly by finding and interviewing patients or 
indirectly by analyzing data bases. It's also possible to look 
at surrogate measures of outcome, measures that correlate 
highly with good outcome, such as retention in treatment.
    Federal agencies have put out a number of guidelines that, 
if properly implemented, could improve the overall quality of 
treatment. The guidelines aimed at improving quality are 
unlikely in and of themselves to do the job. They cannot compel 
high-quality treatment.
    Crucial to high-quality treatment is a well-trained work 
force as well as better application of findings that have 
emerged and will continue to emerge from research.
    But in the real world of treatment where there are about 
12,000 programs, two major problems impede the implementation 
of those guidelines.
    First, many programs are quite small and even many large 
ones lack the financial resources to put guidelines into 
practice.
    Second, because the job is stressful and salaries are low, 
there is a high turnover of personnel, not only among first-
line counselors and clinicians but also among program 
supervisors and managers. With such turnover, much of the 
investment that programs make in clinical and management 
training is lost.
    The Join Together panel concluded that unless there are 
clear and continuing incentives to provide quality treatment, 
quality will always take second place to program survival or 
expansion. What is needed to drive quality improvement is a 
commitment by those who pay for treatment to reward good 
outcome. In other words, reward results.
    Again, depending, the results can vary. Merely publicizing 
results can have the effect of stimulating pride in the better 
programs and stimulating a sense of urgency in the less 
effective ones. You can make the rewards more tangible by 
paying more to the better programs or directing more patients 
to those programs.
    Implementing systems that look at outcomes will require 
additional resources. These shouldn't be carved from what is 
now available for treatment. Rewarding results should be seen 
as a means to improve outcome. It is not a pathway to getting 
more treatment for less money.
    The Join Together panel recommends that rewarding results 
be defined as a national goal. On the road to reaching that 
goal, there are many technical and political obstacles to be 
overcome. And many upon different groups will have to be 
persuaded that it can be done and should be done.
    I thank you for your time and would be happy to answer 
questions.
    [Note.--The Join Together report entitled, ``Rewarding 
Results, Improving the Quality of Treatment for People with 
Alcohol and Drug Problems,'' may be found in subcommittee 
files.]
    [The prepared statement of Dr. Jaffe follows:]

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    Mr. Souder. Thank you very much for your testimony.
    The next witness is Catherine Martens, senior vice 
president of Second Genesis in Silver Spring, MD.
    Ms. Martens. Thank you, Mr. Chairman, Congressman Cummings.
    As the chairman said, my name is Cathy Martens, and I am 
the executive director of Second Genesis and a member of the 
Board of Directors of the Therapeutic Communities of America.
    As a provider, Second Genesis appreciates the opportunity 
to provide the committee with our written testimony about 
measuring the effectiveness of drug treatment.
    Second Genesis is the oldest therapeutic community-based 
substance provider in the Mid-Atlantic region and Maryland's 
largest provider.
    As a successful nonprofit for over 35 years, we continue to 
serve the substance-abuse populations in Washington, DC, 
Virginia, and Maryland. We have criminal justice programs, 
programs for women and their children and a highly respected 
integrated program for clients with co-occurring disorders.
    Society cannot continue to pay for the individuals who 
unsuccessfully cycle through various treatment options and 
criminal justice systems. In the Outlook and Outcomes 2002 
Report from Maryland, an untreated substance abuser on the 
street costs society an estimated $43,300 a year. An 
incarcerated substance abuser costs $39,600 a year.
    In contrast, 8-months of residential treatment at Second 
Genesis costs only $17,280, and for the remaining 4 months of 
the year and beyond, the recovering taxpayer is a productive 
member of society and a taxpayer.
    Second Genesis clinical professionals have determined that 
the shorter the stay of the client, the more likely that client 
is to relapse.
    Our own data collection demonstrates that 6 months after 
leaving residential treatment, 70 percent of long-term clients 
reported no alcohol or other drug use in the 30 days prior to 
that survey. The overall success rate of our program is 63 
percent, significantly higher than that of the Maryland 
Statewide average of 47 percent for similar clients.
    As a provider, we are largely publicly funded, which 
requires us to report to Government contract officers, 
foundations and other sources of funding, proof that the 
dollars that they have invested with us have produced concrete 
results. We use the HATS reporting protocol to report regularly 
and electronically to data collection systems for our 
contractors. The majority of this information is in actual 
real-time.
    We collect information on our clients at admission, halfway 
through treatment, at discharge and 90 days post-treatment. 
However, in order to provide this outcome information, the 
burden of reporting has grown enormously. We are also 
responsible for staff training and other increasing costs 
associated with the outcome-based data collection.
    Second Genesis has approximately 40 counselors that spend a 
minimum of 10 percent of their job completing outcome-related 
paperwork. This number does not include all of the other 
paperwork that must be completed for each client. It becomes 
increasingly burdensome to dedicate staff hours and training to 
data collection at the expense of direct client treatment.
    We are mandated to maintain this data to prove program 
effectiveness. Additionally, Second Genesis employs three full-
time individuals who manage all aspects of this data collection 
and its analysis. However, funding to comply with Federal and 
other contractual mandates has not followed suit.
    We collect information on all of the SAMHSA seven domains, 
yet it is the analysis of this data that is truly important.
    In summary, substance abuse treatment programs should be 
constructed on and funded on evidence-based methodologies that 
are outcome-based and meet appropriate performance standards. 
According to Therapeutic Communities of America, any outcome 
measures should have the following considerations: addicted 
individuals must be placed in the appropriate level, type and 
standard of care to achieve positive and quality results. 
According to the NIDA research report, Therapeutic Communities 
[TC], for individuals with multiple serious problems, research 
again suggested outcomes were better for those who receive TC 
treatment for 90 days or more.
    Treatment and any other performance standards must be 
client-based and should flow as a function of the client 
necessitating a coordinated and comprehensive continuum of care 
for that client. Any measure or performance standard should 
recognize that different treatment methodologies, should 
reflect the timeframe from which favorable impact outcomes are 
likely to occur. This consideration also includes modifications 
to treatment, when necessary, in working with special 
populations.
    Any measure should recognize Therapeutic Community 
residential programs and permit at least 8 to 12 months of 
continuous treatment. Outcomes and measures should be no 
different in application to addicted individuals than any other 
chronic disease. Realistic goals for specific substance-abuse 
populations should be established. In the case of substance 
abuse, unlike any other illness, our system is often in danger 
of undertreating the client.
    No Federal or State measurement or performance standard 
should be mandated without providing necessary direct funding, 
technical assistance and capacity building to the service 
providers.
    Thank you for the opportunity to testify before you, and I 
would welcome any questions you might have. Thank you.
    [The prepared statement of Ms. Martens follows:]

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    Mr. Souder. Thank you.
    Our final witness today is Dr. Hendree Jones.
    Dr. Jones. Hendree.
    Mr. Souder. Hendree Jones, a research director for the 
Center for Addiction and Pregnancy in Baltimore, MD.
    Dr. Jones. Good afternoon, Mr. Chairman.
    And a special hello to Ranking Member Elijah Cummings, who 
represents the patients and families in Baltimore City where 
Johns Hopkins Bayview Medical Center for Addiction and 
Pregnancy is located. And thank you very much for inviting me 
to testify.
    I serve as the director of research for the Center For 
Addiction and Pregnancy [CAP]. It is located at Johns Hopkins 
Bayview Medical Center. And I am also a NIDA-funded researcher 
on drug treatment effectiveness. Additionally, my program is a 
member of the Maryland Addiction Directors Council and State 
Association of Addiction Services, a national organization of 
State alcohol, drug-abuse treatment associations and provider 
associations whose mission is to ensure the accessibility and 
accountability of quality drug and alcohol treatment and 
prevention services.
    I have spent a lot of time thinking about how to expand and 
improve drug treatment effectiveness, and obviously, we need to 
close the tremendous treatment gap. We also need to invest in 
the best treatment options, ensuring that our science makes it 
onto the streets and makes it into everyday practice.
    CAP's outcomes actually demonstrate that drug and alcohol 
treatment can be effective, and I want to share some of our 
latest successes with you: 75 percent of the women who are 
enrolled in CAP have drug-free deliveries and are drug-free 3 
months after completing our treatment program; 81 percent of 
our children are drug-free at delivery; 70 percent of our women 
maintain custody of their children; 15 percent of our women 
actually decrease dependency on welfare; and 95 percent of our 
women actually remain HIV-negative while in treatment.
    Our average CAP baby is born at a normal time, at a very 
healthy birth weight, with normal alertness. Investing in CAP 
treatment can actually save $12,000 per infant through a 
reduction in the neonatal intensive care unit stays.
    CAP successes are actually typical of many treatment 
programs across the country that treat women with children. And 
let me tell you a little bit how we have been able to achieve 
those outcomes.
    CAP was founded in 1991, and it is an outpatient as well as 
residential treatment program. And we have a number of 
ancillary support services, including the drug abuse treatment 
that we provide. We provide transportation to and from the 
program. We have onsite OB/GYN care and onsite pediatric care 
and also onsite child care for women attending the outpatient 
treatment. And we have intensive outreach services. So if a 
client doesn't show up for treatment, we are out there on the 
streets looking for the patient to bring her back in. And it is 
these ancillary support services that help us achieve our 
outcomes.
    There are other recommendations I have for improving the 
quality of treatment services. The ability to conduct studies 
and actually measure outcomes will improve the quality of 
treatment. CAP has been able to conduct these studies because 
we have been funded by NIDA. And we have been able to look at 
specific treatment interventions, and this information has 
actually informed our practice and improved it.
    Transferring science to service also improves the quality 
of care. And what we have learned from studies we need to be 
able to implement into a first-line, frontline provider 
service. Without the technology that was discussed by Dr. 
Volkow, including the Clinical Trials Network and SAMHSA's 
Addiction Technology Transfer Centers, the addiction treatment 
field will be much slower to accept these new technologies.
    We also need to be funding new techniques, including 
emerging medications as well as medications and behavioral 
interventions, to put the best practice into place.
    We need to be able to recruit and retain a qualified 
addiction treatment work force. The development of course work 
in medical and nursing schools is key to encouraging 
practitioners to recognize drug dependence or abuse as well as 
to know where to provide referrals for those patients to treat 
them.
    We also need to not forget our recovering community who has 
long been the frontline providers in this treatment.
    Finally, it would be good to develop loan forgiveness 
programs and repayment programs in order to facilitate people 
to stay in this typically low-paying field.
    Funding access to the full continuum of care will certainly 
help to improve treatment quality. Patients are often not able 
to go from one level of care to the next, and CAP patients are 
certainly not an exception to this barrier. Funding the full 
continuum of treatment is very difficult for different 
jurisdictions given the pressure on the limited amount of funds 
that we have, as well as the limitations that exist on current 
funding mechanisms like Medicaid.
    If we were to increase the fiscal year 2005 substance abuse 
prevention and treatment block grants, Access to Recovery 
programs, and target capacity expansion programs, we could help 
meet the pressing needs for treatment.
    Additionally, better Medicaid coverage would also improve 
treatment for women with children. We need to be moving toward 
a system of uniform treatment-outcome measures across funding 
streams to help improve treatment quality.
    Moving toward this system of uniform performance measures 
across Federal funding streams will help benefit providers by 
reducing the large paperwork demands that are increasing and 
help us to be able to more clearly react to the different types 
of outcomes that are demanded by potentially different 
providers.
    These savings could hopefully help us reinvest in provider 
training and back into treatment.
    When SAMHSA determines the performance outcome measures, I 
hope they will consult with the providers as well as the States 
because outcome data is first and foremost generated at the 
provider level.
    Thank you very much for holding this hearing today and for 
highlighting the importance of drug treatment. My patients and 
the Center for Addiction and Pregnancy staff and I applaud you. 
And I would be happy to take questions.
    [The prepared statement of Dr. Jones follows:]

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    Mr. Souder. We have three votes. We have approximately 7 
minutes left in the first vote.
    Are all of you able to stay for a little bit longer? Nobody 
has a plane or anything? We are going to go vote.
    It will probably be about 20 minutes until we get back 
unless we have to hold the vote open for a while.
    The subcommittee stands in recess.
    [Recess.]
    Mr. Souder. The subcommittee will come back to order.
    I want to thank each of you for your testimony and each of 
you for your years of work.
    I want to start with two different categories. So let me 
start. Dr. Jaffe and I believe Mr. O'Keeffe both talked about 
how to put some incentives into the system for behavior. I 
don't know whether Dr. McLellan referred to that, too.
    Could you describe a little bit more, you said, I believe 
it was Mr. O'Keeffe. Was it you who said regulation alone 
wouldn't do it; we need to have incentives? And Dr. Jaffe 
referred to incentives as well.
    What exactly do you mean by incentives? Are you saying that 
you can't be eligible for certain programs unless you do this? 
That there would be a bonus if you did certain things? Longer 
stays? Different things?
    And if we gave those, would it give incentives for programs 
to cherry pick, take the easiest to treat as opposed to the 
hardest to treat?
    Dr. Jaffe. When you put incentives in for producing 
results, you always run the risk that those who are trying to 
get results will pick the easiest cases. This is true in 
medicine in general. It's probably true of life in general.
    And one has to develop the methodology--there is some in 
place that is just not perfected yet--of adjusting for how 
difficult the initial cases are so that you can fairly compare 
practitioners or programs in terms of what they have achieved. 
And that is the one area where carefully comparing programs 
will need further investment to really make that a fair 
process.
    When you ask about what incentives you can have, the 
incentives can vary.
    They can vary from just posting the scores of programs in 
the city. It can appeal to pride. It can appeal to consumers, 
the people who are seeking treatment. They can vote with their 
feet. If you rank the hospitals in terms of their mortality 
rates for bypass surgery, you quickly find that people seek 
treatment at the hospitals that have the lowest mortality 
rates.
    So you don't necessarily have to pay more, but clearly the 
providers, I mean the payers, whether it is the government or 
insurance plans or employers could begin to say, we pay more 
for better outcomes. The net effect of that is that those 
programs that give bad outcomes get paid less, and ultimately 
they are either going to have to merge with more effective 
programs or go out of business. That is what happens to any 
organization that delivers a less than adequate product.
    The real question there, however, is whether or not at the 
State level there will be the political will to stop paying for 
a particular program. Programs often develop their own 
political support. They are not without allies and the 
bureaucrat that tries to say, we are not going to pay you 
anymore because you are substantially below standard, may find 
he has a very short tenure in the bureaucracy. I say that 
having been on both sides of this issue.
    Mr. Souder. I don't know if anybody else has a comment, but 
I would ask Ms. Freeman-Wilson, could you comment a little bit 
on that, coming out of the Gary area where, in the region, 
there are success stories and not success stories, but 
certainly Gary itself to some degree, East Chicago, have 
overwhelming challenges.
    We are going through the very thing that Dr. Jaffe just 
talked about in education. What do you do when a school system 
is relatively disorganized and how do you get the political 
will? And what if the treatment programs were concentrated in 
that area and somebody didn't see how to do that? Yet, 
fundamentally, there are basic truths in trying to address the 
question, because we have been funding some programs which, we 
are all kind of familiar with, are less effective than other 
programs. But they have a bureaucratic momentum and a size and 
a number of people who have been through a comfortability with 
the insurance or connections.
    How do we put this kind of accountability in and yet 
address the difficult questions that would be, for example, in 
northwest Indiana.
    Ms. Freeman-Wilson. There are two examples in the Gary area 
that really speak to Dr. Jaffe's point. They are the Safe and 
Drug Free Schools program and the second is the drug court 
there, because what happened with both of those programs is 
that they did evidence some success. And that success was 
proven through a very clear evaluation process, one that was 
not only given to the participants and those who ran the 
programs, but those who also funded the programs both at the 
Federal level, at the State level and then, ultimately, the 
local level. Because the local officials, city and county 
officials were looked to pick up the funding, particularly for 
the drug court program, and they were willing to pick it up 
because it showed a reduction in recidivism, it showed more 
sustained treatment, and it also showed that after a year and 
after 2 years, that there was still a sustained reduction in 
recidivism.
    The challenge in both the Safe and Drug Free Schools 
program and the drug courts and in other drug courts in the 
region has been the consistency of their treatment. I think 
that the numbers that were posted in Gary were there because of 
not necessarily the treatment, although the treatment was 
helpful, but also the use of nonconventional programs and self-
help support groups like NA, like AA and like the presence of 
the Salvation Army programs.
    So when the panelists here talk about the importance of 
treatment, I think that, and the challenges that you cited in 
the northwest Indiana region, I think that those are very 
evident, if you look at the type of treatment that is important 
to advance the cause forward.
    Mr. Souder. Ms. Martens, what is your reaction, as a 
provider, to posting results that everybody could see, putting 
some form of accountability. How would we do this so that we 
didn't have incentives to kind of game the system to some 
degree?
    Ms. Martens. In the State of Maryland, Congressman Souder, 
that is already being done. We are talking real-time outcomes. 
And actually we just got a RFP yesterday, which mandates 
providers to adhere to real-time data collection.
    Mr. Souder. If I had a cousin who I wanted to send, I could 
look at the different treatment centers and have some sort of a 
common comparison across?
    Ms. Martens. Not really, because there is no treatment on 
demand in Maryland, if you are not in the criminal justice 
system.
    Mr. Souder. What if I wanted to pay for it?
    Ms. Martens. If you wanted to pay for it, yes, you could 
find treatment. And I would liken it to the charter school 
initiatives, where the efficacy of what you do is judged, as 
Dr. Jaffe said. You are not going to choose a school for your 
child that has the highest failure rate in the city or the 
State.
    One of the things I was going to mention to you that 
Maryland is doing, and I really commend the State for doing 
this, is that we have benchmarks to meet to get paid for each 
client. So you get paid a little bit at the beginning. And as 
that client goes through treatment and successfully completes, 
and there is a balloon payment in the end for your efficacy 
with that client. So you are really being paid for your 
outcomes with each individual client, which is a very 
interesting way for the State to get what they pay for.
    Mr. Souder. I know Director Walters testified in front of 
this committee when we first began to look at how they were 
going to tackle the treatment initiative, and he was proposing 
to do that at the Federal level.
    Dr. McLellan you said that you felt that some of our 
measurements weren't adapting for outpatient as opposed to 
inpatient. What is your reaction to what they have proposed 
there?
    Dr. McLellan. You'll get the kind of thing that Dr. Jaffe 
and Judge Wilson are talking about if you do post-treatment-
only evaluation. If you evaluated first grade schools in the 
State of Maryland by the number of people who graduated from 
high school or college, you'd never figure out what was the 
best thing to do in first grade to make that happen.
    The kind of model that Judge Wilson is talking about is 
much more iterative and proactive. Feedback occurs week to week 
to week. And just as in a medical condition blood pressure is a 
clinical measure, it is also an outcome. So you don't have 
somebody coming in from the outside taking the blood pressure. 
They take the blood pressure measure because it is both an 
outcome and it is a point that gives you decisions for the next 
thing that you do. If the blood pressure doesn't go down, you 
change.
    So I think that is what I am talking about. You need the 
kind of immediate feedback, especially since 90 percent of your 
treatment is in an outpatient setting, those individuals, 60 
percent of whom are coming from the criminal justice system, 
they are not away someplace in a program, they are in the 
community. So immediately you want to know, what is the urine 
test? Are they getting employed or are they getting job 
training? Are they hooking up with an AA sponsor? All the 
things that Judge Wilson talked about and it is possible to do.
    Mr. Souder. That kind of leads to my other big category of 
questions. One of the more interesting things that happened 
back when I was a staffer, this must have been in the late 
1980's. A number of my conservative Republican friends all of a 
sudden found themselves in the administration. And one of our 
principles was, well, we ought to block-grant things. We, as 
conservatives, believe we shouldn't have so much control and so 
many regulations.
    We heard Ms. Martens say that the paperwork was becoming 
burdensome and that they were having to have all these 
different people instead of actually being practitioners and so 
on. And as we held an oversight hearing, all of a sudden my 
conservative friends were having so many of these regulations. 
Their comeback was, well, the only variable is accountability 
which we have been hearing about on this same panel, talking 
about too many regulations and we need more measurements and 
more flexibility to treat the patients.
    Our dollars aren't increasing as fast as the demands.
    But, by the way, we need more information and you are 
suggesting a very comprehensive evaluation type of approach. 
And part of the reason, I remember Becky Norton Dunlop, who was 
at the Justice Department at that time, said, what we found out 
was, when we didn't require all this type of thing, that most 
people were honest, but a bunch of people started ripping us 
off. And our theft and fraud rate went up so dramatically that 
it was more expensive than the paperwork burden. And, 
furthermore, the public wouldn't support this type of effort if 
when they hear these cases that were having some of this in, 
that is, dogging Medicaid or the food stamps program, where you 
find some person and they get on 60 Minutes or 20/20 and this 
person has been ripping off the Federal Government for this 
amount of money. So next, we put a whole bunch of regulations 
on for everybody in the system.
    How would you suggest we do this? Because we want to make 
sure our dollars are effective. There isn't a Member of 
Congress, anybody on the street. Everybody I know who is on 
drugs has been through multiple treatment programs. And we go 
through this effectiveness thing and then we put a whole bunch 
of requirements on. How would you address this dilemma?
    Dr. McLellan. Just to start, I am certainly not the expert 
here, there is a big difference between paperwork, which 
everybody in this place will tell you is overwhelming. For 
example, in Philadelphia, it takes 3 to 4 hours worth of 
paperwork to get somebody into treatment, and it is paperwork, 
meaning that it is stuff that you fill out that you have no use 
for.
    I am not talking about that and I don't think anybody here 
is either. I am talking about as a regular part of the 
treatment process, the counselors, the people who are working 
on the team, are measuring whether they are going to work, 
whether they are still using drugs, all clinical, just like the 
blood pressure. The blood pressure isn't paperwork in a 
hypertension clinic, it is critical. You have to know what is 
going on so you can make an adjustment.
    That is the point that everybody is, that Judge Wilson 
keeps making, to use information to make decisions. That is not 
paperwork, and it shouldn't be burdensome.
    Mr. Souder. Any other comments on that? In other words, if 
we could separate it out, these are the absolutely critical 
things for medical reasons, for drug treatment and these are 
things that we might need for tracking for financial reasons or 
insurance companies, one last question.
    Ms. Martens. Dr. McLellan is absolutely right, the day-to-
day paperwork that we do because treatment is holistic. Doctor 
is absolutely correct. I need to know what your drug test was 
yesterday, how was your family visit, are you getting your GED? 
These are very important things, and they are always part of 
treatment.
    It is all of these other things that are now layered onto 
it that just take so much time that it really takes time away 
from direct client treatment.
    Mr. Souder. I will say, I mean, you have helped clarify 
that those are the things that you need there, and then there 
are other things we need for waste and fraud reasons which you 
may refer to as paperwork. But quite frankly, I believe it was 
actually in this committee room when Chris Shays headed the 
Human Services Subcommittee in my first term I was vice chair 
on a Medicaid fraud case. And the hardest clients to serve are 
those who have no insurance, have no immediate family and have 
some chronic condition and have moved around.
    We have a place in Fort Wayne, a health center that has a 
lot of these patients. And we were asking the GAO and the 
Inspector General, and we had HHS here and asked why they 
hadn't terminated this one company that had been found in court 
of defrauding the Federal Government of $1 billion. And they 
were in multiple regions in the country and our computers 
hadn't caught them under different names.
    But the reason that HHS hadn't terminated them was because 
something like 20 percent of these highest risk people who 
nobody else would take, no nursing home would take, the State 
government really couldn't do it or they had to have a place to 
put the people, nobody would take them, so we were having this 
company that was bilking because they claimed the reimbursement 
wasn't enough--probably true--to cover the cost of it, so they 
started doing that type of thing.
    And part of the reason we have the paperwork side for 
addresses, information, for tracking is that. But what we need 
to do is separate: here is the paperwork necessary for that 
part and what parts are medically necessary for drug treatment. 
And that has been helpful for me for clarification as we kind 
of tackle that.
    I yield to Mr. Cummings.
    Mr. Cummings. Thank you very much, Mr. Chairman.
    I thank all of you for your testimony. One of the things in 
listening to the chairman, I see all the money that we spend in 
government; and I hear the complaints from constituents, well, 
we spend money on certain things and then we don't spend money 
on other things.
    I really want to have some sympathy with regard to the 
paperwork. I really, really want to, but it is very difficult. 
I see taxpayers' hard-earned dollars being paid to treatment 
facilities, doing a great job, by the way, but I also think 
that with those dollars comes a certain level of 
accountability.
    And I know you are talking about two separate things. I 
heard you, Mr. Chairman, and I am not sure where the divide 
actually comes. But I want to go to you, Dr. McLellan.
    One of the things you talked about, and it is a very 
interesting viewpoint; I really think that when the public 
watches this, they would be almost shocked, although I agree 
with you, that winning here is not necessarily getting somebody 
off of drugs forever. And I think we still have to educate the 
public to understand that. Because I think a lot of times the 
public sees a person on drugs, like a lady I saw in my 
neighborhood just the other day, who they once knew as a bright 
high school student and now they see them sitting on some 
steps, dirty, nodding, looking quite, you know, out of it.
    And they say to themselves, you know, OK, I want to do 
something for that person, but if you told them that reducing 
the amount of drugs they use, perhaps getting a job, perhaps 
coming up with having good relationships with family and a 
support system could be part of the measurement of success, I 
think the general public couldn't fully understand that and 
comprehend it, because they want to see that person the way 
they saw them in high school when they were cheerleaders.
    So I think we do have to educate the public about all the 
kind of measurements that you all talked about. And I think 
that because the public wants to see the dollars spent 
effectively and efficiently. And so it doesn't necessarily 
equal effective and efficient spending of dollars when they 
hear those kinds of measurements.
    So I am just wondering, I mean, you have heard all of your 
fellow witnesses up here talk. I mean, are there any 
measurements that have been left out, anybody, that you didn't 
hear?
    In other words, you talk about measuring tools, the things 
that you need to measure success. Have you heard of anything 
that has been left out that should be considered when measuring 
success? Because one of my concerns is--and I know we have a 
lot of great treatment providers, but one of my greatest 
concerns is that young people--I live in a district that has 
probably some of the highest addictions in the country. And I 
talk to recovering addicts and a lot of them will tell me they 
have gone to certain programs that they found out from going 
through them. And by the way, it gets out on the street which 
programs are, ``real,'' and which ones are not. And they tell 
me that if they go to an unreal program, it can do more harm 
than good, but yet our Federal dollars are being spent.
    So I am trying to figure out, you know, how do we make 
sure? It may take time to kind of sift away the fair programs 
and get the better ones out there so that people can have 
effective treatment. And I am just trying to figure out how do 
we do that. Do you all have any suggestions?
    Dr. McLellan. I can give you an example. I urge you to look 
at it. It is precisely the kind of program that Dr. Jaffe is 
talking about, and that is the State of Delaware. Now, it is a 
small State and it is a very interconnected State, but they 
basically gave up. They said, look, we don't know what to tell 
you to do, but we know what we want. And we are going to put 
criteria into play so that, I will summarize very quickly, your 
treatment programs, when you open your doors, you will get 80 
percent of your contract last year. However, if you meet the 
following criteria, you can make as much as 120 percent of your 
contract last year.
    And I will summarize and tell you that several programs 
weren't able to do it. They closed. New places came and they 
were able to do it, and they are functioning now. And what the 
State is doing is, they are adding criteria. They started with 
retention, because it was the easiest to measure and all the 
programs agreed with it and that knocked out several programs. 
Now they are moving toward no new arrests. And if they are 
successful, they have a commitment from the Justice Department 
to put additional money into the treatment side, because it's 
worth it, it's worth it to the Justice Department, but only if 
they are able to make those--if they can buy success, in other 
words.
    Mr. Cummings. Anybody else have something?
    Now, you all heard the testimony of the other two witnesses 
earlier and you heard my questions with regard to jobs. And it 
seems as if in most States people are placed in a position, 
particularly if they get a conviction where they are locked out 
of so many jobs. And I am just wondering, when you are trying 
to help somebody move forward, you know, there are a lot of 
barbers in Baltimore. I don't know why a barber, why it is such 
a big deal. I have met so many barbers who have had drug 
problems. Apparently, that is one field that is still open. And 
the reason you get to know them is because they talk about it.
    Dr. McLellan. They also teach barbering in jail.
    Mr. Cummings. And, see, that is good. I am glad you threw 
that in.
    But if that person came out of prison and there was a law 
that said if you have, say, a drug conviction or you had some 
drug problems or whatever that you can't be a barber, then that 
person is precluded from making an income.
    See, one of the problems that happens, and I don't know why 
people don't think about this, people have fines and child 
support. And I believe people ought to pay child support. I 
mean, there are a lot of things that go against the person and 
basically forces them back into jail or to addiction. In some 
kind of way, we have to grapple with that.
    And Judge Wilson, I mean, in courts, I am sure you see 
that. A guy comes in or lady comes in and says, look, I am 
doing the best I can, but I can't get a job. And if I don't get 
a job, you are going to send me back to jail. Or, you know, the 
reason I went back to being involved in drugs was so that I 
could address making sure I pay my fines, pay my child support, 
pay whatever I've got to pay.
    And then, even more so, a job becomes very significant. Am 
I right?
    Ms. Freeman-Wilson. That is it exactly, Congressman 
Cummings. And there are two things we look at.
    One is, when we talk to people about how they develop their 
court programs, we always encourage pre-plea programs because 
if you have a pre-plea program and you successfully complete 
it, then you are not saddled with the conviction.
    But then as we move toward the discussion of reentry 
nationally, then we have to look at how the laws in the States 
affect the ability of the reentry participants to reenter 
society and become effective members of society. And so our 
organization along with a number of organizations, have 
embarked upon surveys of State laws, not just to survey those 
laws, but to look at ways to encourage legislators to begin to 
move those laws away from being punitive. Because if, in fact, 
you expect a person to reenter society, become a tax-paying 
citizen, how you saddle them with a conviction. Now don't get 
me wrong, there are some folks that need to have convictions on 
their records; we need that red flag on those records. But in 
many instances, it is not appropriate in the case of those 
individuals who have convictions for possession of drugs, for 
other property-related crimes, one-time convictions, so that we 
need to look at ways to have our laws in the States and to 
encourage the States to develop those laws in a way that you 
don't saddle the folks the first time around so that they can 
come out and get jobs, and pay support and pay taxes and all of 
those things that evidence them as members of society who are 
productive.
    Dr. Jones. I would like to add something on a much more 
kind of grass-roots level.
    One of the other hats I wear at Johns Hopkins is overseeing 
an after-care program for heroin-dependent individuals who have 
completed a 3-day or 7-day detoxification. It is a 6-month 
NIDA-funded after-care program, and we have four goals. And one 
of the main goals is getting that person a job.
    Now, a lot of our patients have criminal justice 
involvement. And what we have found is that there are jobs 
available--perhaps not the best job. I mean, a lot of them are 
in barber shops, doughnut shops, working construction. But what 
we found is that these patients are particularly scared about 
even getting a job.
    Some of them have even had a job. And working through that 
you know, let us put a resume together. These people never had 
a resume, and they are actually sitting down and filling out a 
questionnaire. We sit there with them and we say, can you come 
up with two people who could vouch for you? And sometimes they 
will remember, oh, yeah, I did that in the past and that was 
pretty good, I have a good contact here.
    And then the next step, after they've filled out their 
resume is practicing interviewing skills, and we do it 
videotaped so they can see what they look like, learn how to 
answer questions.
    And then we take them out, and we have what we call job 
fairs and we go to places that have hired our patients 
previously. So what we are doing is we're trying to build in 
small successes and maximize opportunities of the likelihood 
for them getting a position. And we do; 39 percent of our 
patients are actually employed. And a lot of them have criminal 
justice involvement.
    So it is possible to overcome this, but it takes a 
tremendous amount of hand-holding and working through the steps 
to give them success.
    Ms. Freeman-Wilson. Dr. Jones raises an important point and 
that is to engage the participation of the business community 
in this dialog. We can talk all the time about people needing 
jobs, but there are people who give jobs and unless they 
believe that someone coming out of her program or someone 
coming out of a drug court or out of a therapeutic community is 
a good employment risk, and I would argue that they are better 
because you know, more likely than not, that those folks are 
drug free, whereas those who aren't being tested, who aren't in 
treatment, you don't have that guarantee.
    But we have to engage the chambers of commerce. We have to 
engage State government. We have to engage the other larger 
employers, be they hospitals, manufacturers, in that 
conversation about employing not only the individuals who look 
good on a resume, but those whose resumes may be a little 
blemished.
    Mr. Cummings. I remember when I first started practicing 
law, one of the things I wanted to do was to see exactly how 
these 12-step programs worked. And I was just fascinated by the 
fact that when I went, just to see how they worked, they had 
these people sitting around talking about all their business. 
You know, it was interesting.
    Dr. McLellan. It is called ``sharing.''
    Mr. Cummings. That sounds a little bit more clinical. And I 
just wonder, how important is that to the things, to all your 
theories of effective drug treatment? How important is sharing? 
I am just curious.
    Dr. McLellan. It is not an opinion. There are studies to 
show it. It is very effective and it makes so much sense. 
Environments change people. So you have been to treatment 
programs, I can see that, and you can see the kind of 
environment that is there and you can accept that those people, 
while they're there, are honest and are industrious and have 
the values you want to see.
    When they go back out to the environment that produced the 
drug abuse to begin with, or in concert with their genetics 
produced that, that is very likely to change them back, very 
likely unless they are involved on a regular basis. This is 
what they call ``after-care.''
    This is the continuing care that Dr. Volkow talked about; 
everybody here has talked about it. One of the best because it 
is cheap. Actually, it is free. It is everywhere, it's all the 
time. It is AA, NA, these 12-step programs. The fact is, only 
about a quarter of the people that are referred to them 
actually will go ahead and really lock up and then you have a 
guarantee. Those people do very well.
    We need alternatives and we need new kinds of things for 
people that don't want to do that.
    Ms. Martens. Congressman Cummings, I want to use one of our 
programs in your district as an example to you.
    In all of your questions, you were asking, it is one thing 
for us to get a mom clean and sober. It is another thing, and I 
know you can appreciate this in Baltimore, a mom who reads at a 
third grade level, does math at a second grade level. She has 
been getting high since she was in middle school because her 
mom did it and her grandma did it and her dad has been locked 
up forever. Kid has so many problems.
    We've got Hemmett Kennedy Kreger. So we're working on her 
GED while she's in treatment, case managing her to figure our 
what kind of skill set she would like to develop.
    As Dr. Jones was saying, it's the little things. How to go 
to the office downtown and get your child's immunization 
record, that sounds easy to us; that can cause mom to think, I 
am going to get high because I can't do that. These little 
things that we take for granted in our life have to be case 
managed throughout this entire treatment process. The mayor and 
I are working now because there are few places for us to put 
mom, in a house that does not trigger her addiction. She 
remembers the noise on North Avenue, she remembers the smell. 
She remembers what you look like, and you may be a trigger for 
her addiction.
    If you don't treat the client holistically, a mom may not 
maintain her recovery, I think that is one of the reasons that 
therapeutic communities have been so successful because it 
involves every part of the client's life. Mom's relationship 
with her boyfriend may be a trigger for her addiction, so she 
can't go back into that neighborhood or live with her family. 
And if we don't look at the whole picture and find jobs, 
education, housing, and as Dr. McLellan was saying, the 12-step 
support system, you can't leave a Second Genesis program 
without having a sponsor in the community and already knowing 
where your meetings are going to be. Where is a meeting you can 
take your kids?
    These may sound like really simple problems, but they are 
huge for a mom that may be in a fourth or fifth generation of 
the addiction cycle.
    Mr. Cummings. That is interesting. In Baltimore, there is 
an entire community of recovering addicts. They invited me to 
speak at something. I thought it was going to be like 30 
people. It was like 700. And I realized that and I guess it is 
like another family.
    So going back to what you were saying, Dr. McLellan, I 
guess it is a shifting. You shift over to this family where you 
are doing the 12 steps and you make new relationships and 
everybody is trying to, they are trying to get to recovery or 
trying to be recovered.
    On the other hand, if they shift back into that old 
community, then again, as you were saying, something pulls them 
back in. And it could be one incident, because I remember one 
time I did a little tour, and there was a woman in Baltimore 
who had been off of heroin for 15 years. For 15 years. Had a 
great job, doing well. Had one incident that happened in the 
family, and she was back on. And it was incredible to me. And 
she said she stopped going to the 12-step programs.
    So I think that we as a committee have to look at we are 
talking about generation after generation after generation. And 
it is so costly to try to treat the kids and treat everybody 
that, at some point, I think that is why we are so concerned 
about effective treatment, because like you said, this doesn't 
only affect the client, it affects everybody in their vicinity, 
which really says a lot.
    Thank you, Mr. Chairman, for your patience.
    Mr. Souder. I want to raise a point and see if anybody has 
any comment about this, because one of the most explosive 
issues we deal with here, the way we are playing it through, is 
the faith-based questions. Yet what becomes pretty clear to me 
is that to expand this program we need political support beyond 
a more traditional liberal Democratic community. If you don't 
have the conservative faith-based community with it, there 
isn't enough political support.
    In Indiana, as Judge Wilson knows full well, it gets really 
nasty in political campaigns if you take a position that you 
ought to give more flexibility for people who come out of 
prison and then one of them gets arrested. Right now, we have a 
situation where an Indianapolis news media has stated that 10 
percent of the people at the Bureau of Motor Vehicles in 
Indianapolis are former convicts. Well, that was before they 
went to work there. There are other problems since they have 
gone to work there. That means, in fact, that they've hired 
people in that position, but politically, it is going to be a 
debatable issue this fall because that is a high number and 
it's lining a lot of Federal jobs.
    There are barriers because it is so politically explosive. 
There is a big law-and-order type of mentality with it. And 
unless there is a way of including in jobs that part of the 
reason is that we have had 16 years of Democratic Governors, 
which I don't view as great, in Indiana. But they have been 
getting As on the score cards on faith-based because they came 
to realize, particularly in the minority community, that if 
they don't match it with suburban churches as well, we weren't 
going to get the support for the follow-through. Because an 
employer may be making, if he is guaranteed there is drug 
testing, the type of decision that you referred to, which is, 
he knows he has a clean employee.
    But there are other risks. For example, a number of my 
friends who have hired people have had reoccurring problems 
because not everybody is rehabbed all the way. One of our major 
volunteer programs in Fort Wayne for people coming out of 
prison went broke because one of the people relapsed and stole 
everything they had. They stole their computers, stole a number 
of other things. They were too marginal. And they came back, a 
number of those people, not because they viewed it as a 
business, per se, but because they are faith motivated and felt 
they had a motivation.
    And unless we can figure out how we are going to make some 
coalitioning between the Prison Fellowship and conservative 
Christian people to back up the kind of the institutional 
support from the government, it is going to be very hard to 
figure out how we are going to provide this comprehensive 
follow-through in jobs and the political support for adequate 
dollars. Because when we start to split these things off, it is 
ironic that we have these political divisions.
    And our distinguished judge and attorney general of Indiana 
knows what we are talking about, because we have had some very 
tough debates in Indiana, and we continue to have them on this 
very subject. That makes it really dicey when any politician 
walks out there and says, we need to look for housing, we need 
to provide for job employment, we need to open up the 
opportunities. And then there is something that occurs or there 
is a backlash or somebody says, what do I have to do, commit a 
crime to get a job? And politically, we have to figure out how 
we're going to work this kind of stuff through, because we have 
put more money into treatment, but it isn't at the levels where 
we need.
    And partly this is underneath it, particularly when you 
look at the after-care.
    Dr. Jaffe. One of the major conclusions of our panel was 
that if you want to get broadened public support for the 
resources that you need to provide good treatment for those who 
need it, the public has to believe that treatment is effective.
    Now, it's not ever going to be perfect. There is always 
somebody who is going to relapse even after 15 years. If 99 
percent of people who leave prison don't do anything, somebody 
will take a job and steal from his employer. That is a virtual 
guarantee.
    But if people are convinced that the people who pay for 
treatment are looking at the programs and making certain that 
they are all competent and that the programs that aren't 
effective are being eliminated, or at least they are not being 
funded with the taxpayers' dollars, they are going to be more 
willing to come up with those resources.
    So what we saw was that evaluation and rewarding the 
effective programs is a way to build public support as this 
kind of treatment competes for resources against other 
priorities in the public sphere. There is not enough money for 
everything that needs to be done, and treatment needs to 
compete, we know that. One of the ways it can compete more 
effectively is to assure decisionmakers that all the programs 
are at least at some minimum standard of competence.
    Mr. Souder. It is in the job's follow-through question, 
too, that part of the problem here is. If we took the targeted 
jobs credit and said that in the targeted jobs credit it should 
be those who are highest risk in the society for being 
unemployed, and I'll bet if we look at that, that we would find 
a fair percentage of those people have been through a drug 
treatment program.
    So, theoretically, this could be turned on us saying the 
people getting the targeted jobs are the people who have 
committed a crime when we have high unemployment. What I am 
trying to get at is, unless we have a broader base of support 
that understands the concept behind this, both from the risk of 
crime to society, but also an obligation and an understanding 
that if these people can get rehabbed, they are going to be 
better in their family lives.
    But politically we have a problem here, particularly, for 
example, we put in the targeted jobs credit that the people who 
have been arrested should go to the front of the line because 
they are the hardest to employ.
    Ms. Freeman-Wilson. Congressman Souder, I would say the way 
to transcend that goal is to really convince the people who you 
referred to of the equal opportunity nature of this problem. It 
doesn't matter whether you are conservative or liberal, it 
doesn't matter where you live, it doesn't matter what you look 
like. Congressman Davis talked about it earlier when he said 
not only were they having problems in Chicago, but I know 
because we've worked with the drug courts in King County, IL. 
There is a heroin epidemic in the suburbs. So if we can get 
those groups, the church groups both in the cities and in the 
suburbs to take that message to the public--and quite frankly, 
some already know because it is happening in their homes--then 
I think we will have transcended that political albatross or 
potential political albatross.
    Mr. Souder. Often it is, bluntly, put quieter in the 
suburbs because to go and buy the stuff in the lower-income 
neighborhoods and the crime and the related violence that comes 
from it is in the lower-income neighborhoods and often the 
parents in the suburbs are too busy to be in denial and don't 
want to be embarrassed. And yet, it is kind of an interesting 
thing because trying to get that public is a whole other task 
we face. Any other closing comments?
    Dr. McLellan. I don't think anybody here is saying fund 
more of what we have. Take the opportunity to use measurement 
and to take the things that you know you want to buy and link 
those two together, and then I think that is going to knock the 
political albatross off your neck.
    Ms. Martens. I think, Congressman Souder, when you asked 
about the faith-based communities, what we have used 
effectively is the potential of collaboration, because there is 
a great deal of stigma involved, as Judge Wilson was saying. To 
begin to get the faith-based community involved, we do 
mentoring programs with them, and we ask them to hold NA and AA 
meetings in their churches. They have parties in our women's 
and children's programs, and that begins to invest them in the 
process that, as Dr. Jaffe was saying, this is an equal 
opportunity destroyer. It does not matter who you are.
    Especially with our programs in Baltimore, we are 
effectively using the faith-based community to be our partners. 
They don't want to be doing drug treatment. There is really a 
myth that, you know, the pastor in your church will be able to 
heal you. Wouldn't it be great if it were that easy?
    Mr. Souder. Well, I want to make sure that we have in the 
record it is an equal opportunity, in other words, in the sense 
of people using drugs. But there is no question that the 
violence is not equally spread, that the dealing is not equally 
spread, that the impact on employment in groups that are 
already at high risk that have added to it, that when we are 
doing a returning offenders program in Allen County, the bulk 
of them are going into the lowest income, poorest housing areas 
where there aren't jobs and where the people are moving out of 
some of the school systems because drugs are in every school, 
as evidenced in our highest-income school in the county that 
has probably the biggest drug-dealing problem but there are 
more students.
    They don't have the shootings in the school. There is, for 
whatever reasons, probably a higher percentage of parental 
involvement in the school, more income, different types of 
things. And I mean I can go into an urban school in Fort Wayne 
and say, how many have seen a shooting. I will see 75 percent--
a shooting other than hunting for a deer--75 percent will say 
``yes.'' I can go into Homestead or Carroll or other schools 
that are in the suburbs or rural school and get none to 10 
percent.
    There is a difference in the impact of it, even though it 
is an equal opportunity destroyer, and most drug users in 
America are White, just like everything else. But it has a 
disproportionate impact because the families may not have the 
health insurance, may not have the support group around them, 
may not have the connection to get a job. So there is 
disproportionate negative impact, which is what we at the 
Federal Government have to be looking at.
    One last question, why, if the programs aren't effective, 
hasn't the market in health insurance or the people that pay 
the insurance made some adjustment? In other words, why would 
they want to pay two or three times to send somebody through a 
program if a program that lasted just a little bit longer would 
have had more success? Why hasn't the market adjusted?
    Ms. Martens. The problem is so big, Congressman Souder. I 
will use our District of Columbia facility as an example for 
you. All of our clients come from CSOSA. They are federally 
mandated by CSOSA. CSOSA is putting our clients through a 28-
day program. I have a man right now who is 82 years old and has 
been shooting heroin since he was 13 and he is in a 28-day 
program. I couldn't change one of my bad behaviors in 28 days, 
much less shooting heroin in my neck since I was 13.
    Mr. Souder. If this was a private sector, you have private 
people.
    Ms. Martens. Very few are private pay.
    Mr. Souder. Are most people in drug treatment in private 
pay?
    Ms. Martens. No. If you had a problem, Congressman, you 
know Father Martin's Ashley in Havre de Grace would probably be 
a very effective program.
    Mr. Souder. I didn't understand. Did you say 80 percent at 
this point is public pay?
    Dr. Jaffe. Thirty-eight percent, I think, in 1997. It is in 
our report. Thirty-eight percent, I think, is private sector 
and about 62 percent is now public sector with the bulk of that 
coming from the Federal Government directly or indirectly.
    Ms. Martens. Block grant.
    Mr. Souder. Thank you very much for your testimony today. 
It has been very important as we move through drug treatment 
and appreciate your cooperation. With that, the subcommittee 
stands adjourned.
    [Whereupon, at 5:20 p.m., the subcommittee was adjourned.].
    [Additional information submitted for the hearing record 
follows:]

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