Drug Control: Observations on Elements of the Federal Drug Control
Strategy (Letter Report, 03/14/97, GAO/GGD-97-42).
Pursuant to a congressional request, GAO provided information on the
federal drug control strategy, focusing on: (1) findings of current
research on promising drug approaches in drug abuse prevention targeted
at school-age youth; (2) promising drug treatment strategies for cocaine
addiction; (3) GAO's recent work assessing the effectiveness of
international efforts to reduce illegal drug availability, including
interdiction; (4) whether the U.S. Coast Guard's performance measures
for its antidrug activities conform to the principles of the Government
Performance and Results Act of 1993 (GPRA); and (5) summaries of several
of GAO's recent products on federal drug-prevention and
treatment-related efforts.
GAO noted that: (1) recent research points to two types of promising
drug prevention approaches for school-age youth; (2) the first approach
emphasizes drug resistance skills, generic problem-solving,
decisionmaking training, and modification of attitudes and norms that
encourage drug use; (3) three approaches have been found to be
potentially promising in the treatment of cocaine use; (4) these
approaches include avoidance or better management of drug-triggering
situations, exposure to community support programs, drug sanctions, and
necessary employment counseling, and use of a coordinated behavioral,
emotional, and cognitive treatment approach; (5) despite some successes,
United States and host countries' efforts have not materially reduced
the availability of drugs in the United States for several reasons; (6)
international drug trafficking organizations have become sophisticated,
multibillion dollar industries that quickly adapt to new U.S. drug
control efforts; (7) the United States faces other significant and
long-standing obstacles, such as inconsistent funding for U.S.
international drug control efforts, competing foreign policy objectives,
organizational and operational limitations, and a lack of ways to tell
whether or how well counternarcotics efforts are contributing to the
goals and objectives of the national drug control strategy, which
results in an inablity to prioritize the use of limited resources; (8)
in drug-producing and transit countries, counternarcotics efforts are
constrained by competing economic and political policies, inadequate
laws, limited resources and institutional capabilities, and internal
problems such as terrorism, corruption, and civil unrest; (9) measuring
the effectiveness of U.S. antidrug activities has been a continuing
problem in assessing the results of the national drug control strategy;
(10) in reauthorizing the Office of National Drug Control Policy (ONDCP)
in 1993, Congress specified that ONDCP's performance measurement system
should assess changes in drug use, drug availability, the consequences
of drug use, and the adequacy of drug treatment systems; (11) to
implement the statutory requirements, which are consistent with
recommendations in GAO's 1993 report, ONDCP is developing national-level
measures of drug control performance; (12) similarly, the Coast Guard is
developing performance measures to assess the results of its antidrug a*
--------------------------- Indexing Terms -----------------------------
REPORTNUM: GGD-97-42
TITLE: Drug Control: Observations on Elements of the Federal Drug
Control Strategy
DATE: 03/14/97
SUBJECT: Drug trafficking
Drug treatment
Drug abuse
Rehabilitation programs
International relations
Smuggling
Law enforcement
Strategic planning
Behavioral sciences research
IDENTIFIER: DOJ Operation Weed and Seed Program
DOJ Treatment Alternatives to Street Crime Program
DOJ Organized Crime Drug Enforcement Task Force Program
Peru
Columbia
Mexico
Brazil
Ecuador
Venezuela
San Diego (CA)
El Paso (TX)
Panama
National Drug Control Strategy
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Cover
================================================================ COVER
Report to Congressional Requesters
March 1997
DRUG CONTROL - OBSERVATIONS ON
ELEMENTS OF THE FEDERAL DRUG
CONTROL STRATEGY
GAO/GGD-97-42
Drug Control
(186765)
Abbreviations
=============================================================== ABBREV
ATP - Adolescent Transitions Program
CSAP - Center for Substance Abuse Prevention
CSAT - Center for Substance Abuse Treatment
DEA - Drug Enforcement Administration
DOJ - Department of Justice
FBI - Federal Bureau of Investigation
GPRA - Government Performance and Results Act
HHS - Department of Health and Human Services
HIV - Human Immunodeficiency Virus
INS - Immigration and Naturalization Service
IPR - interpersonal relations
IOM - Institute of Medicine
NIDA - National Institute on Drug Abuse
NIJ - National Institute of Justice
ONDCP - Office of National Drug Control Policy
SAMHSA - Substance Abuse and Mental Health Services Administration
SFP - Strengthening Families Program
SSDP - Seattle Social Development Project
TASC - Treatment Alternatives to Street Crime
VA - Department of Veterans Affairs
Letter
=============================================================== LETTER
B-275944
March 14, 1997
The Honorable Frank R. Wolf
Chairman, Subcommittee on
Transportation and Related Agencies
Committee on Appropriations
House of Representatives
The Honorable John Edward Porter
Chairman, Subcommittee on Labor, Health
and Human Services, and Education
Committee on Appropriations
House of Representatives
The federal government's investment in the war on drugs has grown to
over $15 billion in fiscal year 1997. Yet the availability of drugs
on U.S. streets and the number of persons using illegal drugs
continue to be serious problems. We have reported many times over
the past decade on federal antidrug efforts. This report responds to
your October 30, 1996, request that we provide information to help
Congress examine and improve the federal government's drug control\1
strategy.
Specifically, this report (1) identifies findings of current research
on promising approaches in drug abuse prevention targeted at
school-age youth; (2) describes promising drug treatment strategies
for cocaine addiction; (3) summarizes our recent work assessing the
effectiveness of international efforts to reduce illegal drug
availability, including interdiction; (4) assesses whether the U.S.
Coast Guard's performance measures for its antidrug activities
conform to the principles of the Government Performance and Results
Act of 1993 (GPRA); and (5) summarizes several of our recent products
on federal drug prevention- and treatment-related efforts.
--------------------
\1 As defined in the Anti-Drug Abuse Act of 1988, P.L. 100-690,
"drug control" is any activity conducted by a national drug control
program agency involving supply reduction and demand reduction.
Supply reduction includes international drug control; foreign and
domestic drug enforcement intelligence; interdiction; and domestic
drug law enforcement, including law enforcement directed at drug
users. Demand reduction includes drug abuse education, prevention,
treatment, research, and rehabilitation.
BACKGROUND
------------------------------------------------------------ Letter :1
In 1995, an estimated 22.7 million Americans had used at least one
illicit drug in the past year--17.8 million had used marijuana, 3.7
million had used cocaine; and 428,000 had used heroin.\2 From 1992 to
1995, there was a pronounced rise in the estimated drug use rates
among school-age youths--the estimated rate of marijuana use by 8th
grade students increased from 7.2 percent to 15.8 percent; the
estimated rate of marijuana use by 10th graders rose from 15.2
percent to 28.7 percent; and for 12th graders, the estimated rate of
marijuana use increased from 21.9 percent to 34.7 percent. According
to the Office of National Drug Control Policy (ONDCP) social costs of
illegal drug use were estimated at $67 billion annually. In
addition, ONDCP reported that in the 1990s there were 100,000
drug-related deaths, approximately 20,000 deaths per year.\3
In 1988, Congress created ONDCP to lead the nation's war on drugs.
The federal budget for drug abuse control climbed from $1.5 billion
in fiscal year 1981 to about $15.1 billion in fiscal year 1997.\4
Approximately $1.8 billion of the over $15 billion authorized by
Congress to implement the 1996 national drug control strategy is
devoted to international programs with the goals of shielding U.S.
air, land, and sea frontiers from the drug threat; breaking foreign
drug sources of supply; and destroying international drug-trafficking
organizations. (A more complete discussion of the national drug
control strategy goals is in app. I.)
In 1988, we provided Congress with an overview of the drug problem
and the federal response.\5 The report described the drug problem in
the 1980s nationally and in six major cities where drug problems were
among the worst in the nation. In 1993, in conjunction with our
report on the reauthorization of ONDCP,\6 we summarized the results
of our work to date on U.S. antidrug efforts and the participation
of federal, state, and local agencies in the national drug control
strategy. These two reports identified the immensity of the
challenges facing the antidrug effort, challenges that range from
helping foreign governments break their dependence on drug-related
revenues to helping drug users in this country turn away from what
they may see as the allure of drugs.
We recommended in our 1993 report that ONDCP,\7 as the coordinator of
the federal drug control effort, (1) develop additional measures to
assess progress in reducing drug use, (2) develop performance
measures to evaluate the contributions made by major components of
current antidrug efforts and significant new initiatives, and (3)
incorporate these measures into annual drug control strategies.
GPRA was enacted in 1993 to, among other things, improve performance
measurement by federal agencies. It provides a useful framework for
assessing the effectiveness of federal drug control efforts. It
requires agencies to set goals, measure performance, and report on
their accomplishments. Under GPRA, it is envisioned that federal
agencies will move away from their concentration on traditional
workload measures, such as staffing and activity levels, and move
toward a focused assessment of their results.
--------------------
\2 National Household Survey on Drug Abuse: Population Estimates
1995, Substance Abuse and Mental Health Services Administration,
1996.
\3 The National Drug Control Strategy, 1996. Office of National Drug
Control Policy, Washington, D.C.
\4 In constant 1987 dollars. National Drug Control Strategy: 1996.
Office of National Drug Control Policy, Washington, D.C.
\5 Controlling Drug Abuse: A Status Report (GAO/GGD-88-39, Mar. 1,
1988).
\6 Drug Control: Reauthorization of the Office of National Drug
Control Policy (GAO/GGD-93-144, Sept. 29, 1993).
\7 GAO/GGD-93-144.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :2
Recent research points to two types of promising drug prevention
approaches for school-age youth. The first approach emphasizes drug
resistance skills, generic problem-solving/decisionmaking training,
and modification of attitudes and norms that encourage drug use (the
psychosocial approach). The second approach involves the coordinated
use of multiple societal institutions, such as family, community, and
schools, for delivering prevention programs (the comprehensive
approach.) Both approaches have reduced student drug use as well as
strengthened the individual's ability to resist drugs in both short-
and longer-term programs.
Three approaches have been found to be potentially promising in the
treatment of cocaine use. These approaches include (1) avoidance or
better management of drug-triggering situations (relapse prevention
therapy); (2) exposure to community support programs, drug sanctions,
and necessary employment counseling (community
reinforcement/contingency management); and (3) use of a coordinated
behavioral, emotional, and cognitive treatment approach
(neurobehavioral therapy). Drug abuse clients using these approaches
have maintained extended periods of cocaine abstinence and greater
retention in treatment programs.
While these prevention and treatment approaches have shown promising
outcomes in some programs, sufficient evaluative research has not
been done to test their effectiveness and their applicability among
different populations in varied settings. This research should help
policymakers better focus efforts and resources in an overall drug
control strategy.
Despite some successes, United States and host countries' efforts
have not materially reduced the availability of drugs in the United
States for several reasons. First, international drug-trafficking
organizations have become sophisticated, multibillion dollar
industries that quickly adapt to new U.S. drug control efforts.
Second, the United States faces other significant and long-standing
obstacles, such as inconsistent funding for U.S. international drug
control efforts, competing foreign policy objectives, organizational
and operational limitations, and a lack of ways to tell whether or
how well counternarcotics efforts are contributing to the goals and
objectives of the national drug control strategy, which results in an
inability to prioritize the use of limited resources. Third, in
drug-producing and transit countries, counternarcotics efforts are
constrained by competing economic and political policies, inadequate
laws, limited resources and institutional capabilities, and internal
problems such as terrorism, corruption, and civil unrest.
Although there is no panacea for resolving all of the problems
associated with illegal drug trafficking, in our February 1997
report,\8 we recommended that the Director of ONDCP: (1) complete
the development of a long-term plan with meaningful performance
measures and multiyear funding needs that are linked to the goals and
objectives of the international drug control strategy; (2) at least
annually, review the progress made and adjust the plan, as
appropriate; (3) enhance support for the increased use of
intelligence and technology to improve U.S. and other nations'
efforts to reduce supplies of and interdict illegal drugs; and (4)
lead in developing a centralized lessons-learned data system to aid
agency planners and operators in developing more effective
counterdrug efforts.
Measuring the effectiveness of U.S. antidrug activities has been a
continuing problem in assessing the results of the national drug
control strategy. In reauthorizing ONDCP in 1993, Congress specified
that ONDCP's performance measurement system should assess changes in
drug use, drug availability, the consequences of drug use, drug
treatment capacity, and the adequacy of drug treatment systems. To
implement the statutory requirements, which are consistent with
recommendations in our 1993 report,\9 ONDCP is developing
national-level measures of drug control performance.
Similarly, the Coast Guard is developing performance measures to
assess the results of its antidrug activities. It appears from our
review of the Coast Guard's strategic and performance plans that it
has taken steps toward conforming with certain GPRA principles.
However, it is too soon to tell whether performance measurement
systems being developed by ONDCP and the Coast Guard will be fully
consistent with the results-oriented principles of GPRA.
--------------------
\8 Drug Control: Long-Standing Problems Hinder U.S. International
Efforts (GAO/NSIAD-97-75, Feb. 27, 1997).
\9 GAO/GGD-93-144.
OBJECTIVES, SCOPE, AND
METHODOLOGY
------------------------------------------------------------ Letter :3
In responding to your request, we adopted the following approach in
meeting the objectives agreed upon with the Subcommittees.
We identified and summarized findings and conclusions from our
recent, relevant reports and testimonies that examined U.S. antidrug
programs and activities, including international initiatives and
domestic measures, aimed at interdicting illegal drugs and reducing
drug use through prevention or treatment. We identified and reviewed
selected literature on drug prevention and drug treatment research
and evaluated syntheses of research literature, including data on
program outcomes, to identify promising approaches in drug abuse
prevention that focus on school-age youth. (See app. II for
additional information on the methodology we used.)
To obtain information on the U.S. Coast Guard's performance measures
for its antidrug activities, we interviewed officials responsible for
managing the Coast Guard's drug interdiction program and reviewed key
agency documents such as the Coast Guard's preliminary performance
plans (for implementing the GPRA). We compared the Coast Guard's
performance measurement plans with GPRA to determine whether they
conform to the principles of the act.
We did our review from November 1996 to January 1997 in accordance
with generally accepted government auditing standards. We obtained
comments on a draft of this report from ONDCP. These comments are
discussed at the end of this letter.
TWO DRUG PREVENTION APPROACHES
SHOW PROMISE AMONG SCHOOL-AGE
YOUTH
------------------------------------------------------------ Letter :4
Recent research demonstrates basically two types of prevention
approaches that show promise when used in programs with school-age
youths. The first approach emphasizes individual drug resistance
skills, generic problem-solving/decisionmaking training, and
modification of attitudes and norms that encourage drug use (the
psychosocial approach). The second approach involves the use of
multiple societal institutions (e.g., schools, families, media, and
community), working together in collaborative fashion, to achieve a
multicomponent approach to prevention (the comprehensive
approach).\10 These approaches have been used in several notable
programs. However, the extent to which these promising approaches
yield results in a wide range of community settings remains an open
question.
The major aim of drug abuse prevention programs is to prevent the
initial use of both illicit and nonprescribed legal drugs and avert
subsequent drug-related problems (like AIDS and other sexually
transmitted diseases.) For youths already experimenting with drugs,
or using them on a recreational basis, prevention programs may be
aimed at early screening and intervention activities, with the end
goal of eliminating drug use, or at least long-term cessation.
In addition, drug prevention programs have focused on strengthening
the individual's ability to resist drugs. This has taken the form of
helping individuals to minimize the drug "risk factors" in their
lives as well as building up their psychological "protective
factors." Risk factors that have been related to an individual's
subsequent drug use activity include a variety of personal, social,
and community factors, including societal norms favorable to drug
use, easy access to drugs, and favorable parental attitudes toward
drug use. Enhancing one's coping skills, problem-solving ability,
and self-esteem, however, provides some alternative means of
strengthening the individual's protection or resilience to drug use
in high-risk situations.
The strategies used in prevention programs can be classified by three
interventions (universal, selective, and indicated) that target
different audiences: (1) universal interventions are directed at the
general population, (2) selective intervention strategies target
individuals or subgroups at risk for drug abuse, and (3) indicated
interventions are directed at individuals who already are using drugs
but have not yet met the criteria for a diagnostic disorder.
Prevention activities can be conducted in school settings, in peer
groups, within the family context, or within the larger community.
Drug prevention activities can encompass a wide array of functions.
They include the provision of information and education classes or
training programs to enhance one's knowledge of drug abuse and
alternative lifestyles, teaching skills to cope with or manage
potential high-risk drug situations, enhancing generic skills for the
solution of general life problems and decisionmaking, as well as
encouraging communities to implement societalwide institutional
approaches to drug problems.
The following features are associated with positive outcomes in many
studies of prevention programs: (1) increasing awareness of the
social influences that promote drug use (for example, peer pressure);
(2) modifying societal norms or expectations concerning drug use; and
(3) targeting multiple aspects of youths' lives through use of
school, family, peer, and community factors.
Drug prevention programs that use the psychosocial and comprehensive
approaches have shown promising results among school-age youth in
reducing drug use and strengthening the individual's ability to
resist drugs. Although information dissemination, effective
education, and alternatives to drug use are approaches that have been
used in prevention programs, they have not been shown to be
consistently effective when utilized individually. However, they
have been included in promising comprehensive approaches to drug
prevention.
Our review of the research on drug prevention programs that have
outcome data revealed several programs that show promise when using
the psychosocial or comprehensive approach. Some of the most notable
psychosocial and comprehensive drug programs include (1) the
Adolescent Alcohol Prevention Trial (psychosocial), which
demonstrated that the increase in initial use of marijuana for
intervention participants was 65-percent less than that of a
comparison control group at 1 year follow-up and 23-percent less than
control group participants for alcohol; (2) the Life Skills Training
Program (psychosocial) showed 44 percent fewer intervention
participants reported use of three drugs over a specified period of
time, as compared to control group participants; and (3) the
Midwestern Prevention Project--also known as Project Star or I-Star
(comprehensive), showed a 20- to 40-percent net reduction in the use
of two drugs by school-age youth over a 3-year period.
--------------------
\10 Institute of Medicine, Pathways of Addiction: Opportunities in
Drug Abuse Research (Washington, D.C.: National Academy Press),
1996, pp. 141-145.
THREE APPROACHES SHOW PROMISE
IN THE TREATMENT OF COCAINE
ABUSE AND DEPENDENCY
------------------------------------------------------------ Letter :5
Three approaches have been found to be potentially promising in the
treatment of cocaine abuse and dependency:
-- "Relapse prevention" provides users with the ability to better
recognize drug "triggering" events, places, people and
situations, and helps individuals develop better coping
strategies to resist their specific triggers.
-- "Community reinforcement/contingency management" consists of
several community-oriented components, including the
participation of the client's family member or significant other
in the treatment process; management incentives or rewards for
drug abstinence; employment counseling when needed; and
encouragement of participation in recreational activities as
health alternatives to a drug-free lifestyle.
-- "Neurobehavioral therapy" consists of a comprehensive
behavioral, emotional, and cognitive treatment approach,
utilizing individual therapy, drug education, and self-help
group involvement. According to research results, each approach
has demonstrated positive outcome results with regard to
extended periods of cocaine abstinence and greater client
retention in treatment.
The National Institute on Drug Abuse (NIDA) has also supported the
testing of 20 major drugs in the treatment of cocaine. However, no
medication has been shown to be consistently effective in the
treatment of cocaine, and no medication has been submitted to the
Food and Drug Administration for approval for this purpose.
Attaining abstinence is a major goal of drug treatment. Once initial
abstinence is attained, efforts are directed toward maintaining
continued abstinence over more extended periods of time. Individual
objectives of treatment can include the social and personal
rehabilitation of the individual (including improved health and
reduced psychological problems), enhancement of familial
relationships, reduction of criminal behavior and resolution of legal
problems, improved coping skills, and attainment of educational and
occupational aspirations.
The range of treatment services can include diagnostic assessment,
detoxification (when necessary), medication, counseling, drug
education, psychotherapy, case management, and self-help group
participation. The Institute of Medicine (IOM) and others have
identified four types of treatment modalities in which these services
are delivered: (1) outpatient methadone maintenance facilities
(primarily for opiate users), (2) outpatient nonmethadone or
drug-free facilities, (3) chemical dependency programs, and (4)
long-term residential therapeutic communities.
Our review of recent cocaine treatment research identifies several
programs that have shown positive outcome results using
cognitive/behavioral therapies. For example, one relapse prevention
program\11 showed cocaine dependent clients were able to remain
abstinent at least 70 percent of the time while in treatment. A
community reinforcement/contingency management program\12 showed that
42 percent (or almost half) of the participating cocaine-dependent
clients were able to achieve nearly 4 months of continuous
abstinence. And a neurobehavioral program\13 showed that more than a
third (38 percent) of the clients were abstinent from the drug at the
6-month follow-up.
--------------------
\11 Kathleen Carroll and others, "Psychotherapy and Pharmacotherapy
for Ambulatory Cocaine Abusers," Archives of General Psychiatry, 51
(1994), 177-187.
\12 Stephen Higgins and others, "Achieving Cocaine Abstinence With a
Behavioral Approach," American Journal of Psychiatry, 150:5 (1993),
763-69.
\13 Stephen Shoptaw and others, "The Matrix Model of Outpatient
Stimulant Abuse Treatment: Evidence of Efficacy," Journal of
Addictive Diseases, 13:4 (1994), 129-41.
EXPERTS SAY ADDITIONAL RESEARCH
IS NEEDED FOR DRUG ABUSE
PREVENTION AND TREATMENT
------------------------------------------------------------ Letter :6
Regardless of early positive results in certain drug abuse prevention
and treatment approaches, research experts suggest that additional
research is needed to better identify and understand elements of
effective prevention and treatment. They say substantiating early
program results through further research and evaluation is an
important step in advancing promising drug prevention and treatment
approaches. It is also important in helping policymakers to better
direct the nation's efforts and resources toward reducing or
eliminating drug abuse or dependency.
Prevention initiatives for future research that NIDA, IOM, and others
have mentioned include (1) the utility of booster sessions in
extending positive program outcomes, (2) determining the mix of
approaches that yield the most significant outcome results, and (3)
how best to disseminate positive findings to the larger community,
and (4) assessing those types of approaches that work best for
different population groups. Future cocaine treatment initiatives
mentioned include (1) identifying improved or additional
cognitive/behavioral strategies to reduce relapse, (2) testing the
effectiveness and safety of new medications to prevent or reduce drug
intake, and (3) identifying the necessary components of
cognitive/behavioral strategies and medications that lead to
successful outcomes.
See appendix II for a detailed description of the results of our
review of selected literature on drug prevention for school-age youth
and cocaine treatment approaches.
SUMMARY OF SELECTED GAO
PRODUCTS ON FEDERAL PREVENTION-
AND TREATMENT-RELATED EFFORTS
------------------------------------------------------------ Letter :7
Recognizing the link between drugs and crime, Congress authorized
federal grants-in-aid to states and localities to assist them in
addressing drug-related crime in their communities. We have reported
on three such programs during the past few years--drug courts,
Operation Weed and Seed, and Treatment Alternatives to Street Crime
(TASC).
Title V of the Violent Crime Control and Law Enforcement Act of 1994
authorized the award of federal grants to states and localities to
establish drug courts. In 1995, we reported that (1) in exchange for
dismissed charges or reduced sentences, drug-using, primarily
nonviolent defendants were being diverted to drug courts where judges
monitor their progress through frequent status hearings; (2) drug
court programs varied in length, participant eligibility, funding,
and other practices; (3) as of March 1995, there were at least 37
drug courts operating nationwide; (4) 33 of these drug courts had
accepted over 20,000 defendants; (5) most drug courts did not accept
offenders with prior violent convictions, and none accepted those
currently charged with a violent offense; and (6) drug courts had not
been operating long enough to determine their overall
effectiveness.\14
Operation Weed and Seed is a Department of Justice grant program.
Its strategy is to support community-based, multiagency efforts to
weed out crime from targeted neighborhoods, then seed the site with a
variety of programs and resources to prevent crime from recurring.
In 1994, we reported that (1) community involvement was important to
the program's effectiveness and long-term success; (2) community
residents at local sites needed to be involved in/control steering
committees and help design and implement activities; (3) the emphasis
on activities varied at local levels and community policing was a
strong component of many programs; (4) weeding efforts had removed
criminals from communities and increased interagency cooperation; (5)
program officials believed that Justice should increase its funding
for seeding activities so that seeding and weeding activities would
have equal funding; (6) Justice had established guidelines to monitor
program funds and compliance with its policies and also an
interagency work group to coordinate social services agencies'
recommendations on seeding programs and exchange information; and (7)
the program's management structure provided for federal, state,
local, private agency, and citizen participation.\15
The TASC program is an offender case management program designed to
link drug-using offenders within the criminal justice system to
community-based drug abuse treatment as an alternative or supplement
to criminal penalties. In a 1993 report, we concluded that TASC
appeared promising as a way to help reduce offender drug use. The
TASC program model incorporated many elements that had been found to
contribute to effective drug abuse treatment, including (1)
coordinating criminal justice and treatment efforts, (2) providing
incentives to enter treatment, (3) matching offenders with the most
appropriate treatment, and (4) monitoring with drug testing.\16 (See
Related GAO Products at the end of this report for a list of other
products on treatment and prevention.)
--------------------
\14 Drug Courts: Information on a New Approach to Address
Drug-Related Crime (GAO/GGD-95-159BR, May 22, 1995).
\15 Weed and Seed: Program Objectives (GAO/GGD-94-128R, May 10,
1994).
\16 Drug Control: Treatment Alternatives Program for Drug Offenders
Needs Stronger Emphasis (GAO/GGD-93-61, Feb. 11, 1993).
OBSTACLES TO U.S.
INTERNATIONAL DRUG CONTROL
EFFORTS
------------------------------------------------------------ Letter :8
Over the past 10 years, U.S. agencies involved in counternarcotics
efforts have attempted to reduce the supply and availability of
illegal drugs in the United States by implementing the U.S.
international drug control strategy. Although these efforts have
achieved some successes, we found that the flow of cocaine, heroin,
and other illegal drugs into the United States continues, and the
availability of drugs and the cultivation of drug crops have not been
reduced.\17
Between 1988 and 1995, illegal drug cultivation and drug-related
activities increased throughout South America, Mexico, the Caribbean,
Southeast Asia, and other countries. The total net area of
cultivation for coca leaf and opium poppy increased. Between 1988
and 1995, about 56,000 hectares\18 of coca plants were eradicated.
However, while the areas under cultivation have fluctuated from year
to year, farmers planted new coca faster than existing crops were
eradicated. Thus, the net area under cultivation increased from
186,000 hectares to 214,800 hectares, or by about 15 percent.\19 Also
during this period, the amount of opium poppy under cultivation
increased by over 46,000 hectares, or by about 25 percent. Moreover,
Drug Enforcement Administration (DEA) and National Narcotics
Intelligence Consumers Committee data on the availability of illegal
drugs, as measured by the average price and purity of the drugs,
showed that the price and purity of cocaine have remained relatively
constant since 1988. According to a DEA official, all other factors
being equal, had the United States achieved substantial success in
reducing supply, and demand remained constant, the prices of these
drugs would have increased, and the purity would have decreased.
The amount of cocaine and heroin seized between 1990 and 1995 had
little impact on the availability of illegal drugs in the United
States in satisfying estimated U.S. demand. In 1996, the National
Narcotics Intelligence Consumers Committee estimated the potential
cocaine production for 1995 at about 780 metric tons, of which about
230 metric tons were seized worldwide. The remaining amount was more
than enough to meet U.S. demand, which was estimated at about 300
metric tons per year. Heroin production in 1995 was estimated to be
over 300 metric tons, while seizures were about 32 metric tons, and
U.S. demand was between 10 and 15 metric tons.
When confronted with threats to their activities, drug-trafficking
organizations use a variety of techniques to quickly change their
modes of operation, thus avoiding capture of their personnel and
seizure of their illegal drugs. For example, when air interdiction
efforts have proven successful, traffickers have increased their use
of maritime and overland transportation routes. According to recent
U.S. government reports, even after the capturing or killing of
several drug cartel leaders in Colombia and Mexico, other leaders or
organizations soon filled the void, and adjusted their areas of
operations.
In carrying out its foreign policy, the United States seeks to
promote U.S. business and trade, improve human rights, and support
democracy as well as reduce the flow of illegal drugs into the United
States. These objectives compete for attention and resources, and
U.S. officials must make tough choices about which to pursue more
vigorously. As a result of U.S. foreign policy decisions,
counternarcotics issues have often received less attention than other
objectives. Our work has shown the difficulties in balancing
counternarcotics and other U.S. foreign policy objectives.
Sometimes, resources are shifted to satisfy other policy objectives.
For example, as we reported in 1995, $45 million originally intended
for counternarcotics assistance for cocaine source countries was
reprogrammed by the Department of State to assist Haiti's democratic
transition.\20 A similar diversion occurred in the early 1990s, when
U.S. Coast Guard assets in the Caribbean were reallocated from
counternarcotics missions to the humanitarian mission of aiding
emigrants in their mass departures from Cuba and Haiti.
We have reported that in some cases the United States has not
adequately controlled the use of U.S. counternarcotics assistance
and it was unable to ensure that the assistance was used as intended.
Despite legislative requirements mandating controls over
U.S.-provided assistance, we found instances of inadequate oversight
of counternarcotics funds. For example, between 1991 and 1994, we
issued three products in which we concluded that U.S. officials
lacked sufficient oversight of aid to ensure that it was being used
effectively and as intended in Peru and Colombia.\21 In 1996, we
reported that the government of Mexico had misused U.S.-provided
counternarcotics helicopters when it used them to transport Mexican
military personnel during the 1994 uprising in the Mexican state of
Chiapas.\22
During this period, we reported on other significant long-standing
obstacles faced by the United States in its international drug
control efforts, including the inconsistency in the amount of funds
applied to international drug control programs, difficulty in
obtaining bilateral and multilateral donor support for U.S. drug
control efforts, and organizational and operational limitations. For
example, several of our products have identified problems involving
competing priorities and interagency rivalries, lack of operational
coordination, and inadequate staffing of joint interagency task
forces.
Regarding obstacles confronting foreign governments' antidrug
efforts, we have repeatedly reported that narcotics-related
corruption is a long-standing problem in U.S. and foreign
governments' efforts to reduce drug-trafficking activities. For
example, we reported in 1991 and 1993 that corruption in Colombia and
Peru--two of the countries most significantly involved in producing
and shipping cocaine--had spread throughout the civilian governments,
the military force, and the police force and that even though the
governments were attempting to reduce corruption, its pervasiveness
made such action difficult.\23 We also reported that corruption
remained a serious, widespread problem in Colombia and Mexico, the
two countries most significantly involved in producing and shipping
cocaine.\24 In March 1996, the State Department reported that
persistent corruption within Mexico continued to undermine both
police and law enforcement operations. Drug-related corruption also
remained widespread, although to a lesser extent, throughout several
island nations in the Caribbean\25 and in Bolivia and Peru.
The governments involved in drug eradication and control have other
problems that cause competition for limited resources. As we
reported in 1988, six drug-producing countries' efforts to curtail
drug cultivation were constrained by political, economic, and/or
cultural problems that far exceeded counternarcotics program
managers' abilities to resolve.\26 Many of the source countries
lacked the political will necessary to reduce coca and opium poppy
cultivation partly because drug trafficking contributes to their
economies. Also, as we reported in 1992, severe economic problems in
Brazil, Ecuador, and Venezuela limited these governments' ability to
devote the resources needed to develop effective drug control
efforts.\27 Internal strife in the source countries is yet another
problem that competes for resources. For example, two primary source
countries--Peru and Colombia--must allocate scarce funds to support
military and other internal defense operations to combat guerilla
groups, which negatively affect counternarcotics operations. In
Peru, for example, we reported that terrorist activities had hampered
antidrug efforts.\28
Inadequate resources and institutional capabilities of these and
other foreign countries have limited arrests and convictions of drug
traffickers. For example, in 1991 we reported that the lack of
resources and adequately trained police personnel hindered Panama's
ability to address drug-trafficking and money-laundering
activities.\29 Also, in 1994 we reported that Central American
countries did not have the resources or institutional capability to
combat drug trafficking and depended heavily on U.S.
counternarcotics assistance.\30 Our more recent work indicates that
these problems have persisted over time. For example, we reported in
1995 that the Colombian national police had only 10 helicopters
available for interdiction and eradication operations in the entire
country.\31
There is no easy remedy for overcoming all of the obstacles posed by
drug-trafficking activities. International drug control efforts
aimed at stopping the production of illegal drugs and drug-related
activities in the source and transit countries are only one element
of an overall balanced national drug control strategy. Alone, these
efforts will not likely solve the U.S. drug problem. Overcoming
many of the long-standing obstacles to reducing the supply and
smuggling of illegal drugs requires a long-term commitment. As
stated in our February 1997 report,\32
we believe the United States can improve the effectiveness of
planning and implementing its current international drug control
efforts by (1) developing a multiyear plan with measurable goals and
objectives and a multiyear funding plan; (2) at least annually,
review the progress made and adjust the plan, as appropriate; (3)
enhance support for the increased use of available intelligence and
technologies and increasing intelligence and technology, and (4) lead
in developing a centralized "lessons-learned" data system to aid
agency planners and operators in developing more effective
counterdrug efforts.
--------------------
\17 GAO/NSIAD-97-75.
\18 One hectare equals 2.47 acres.
\19 According to officials at the Department of State, initial
information indicates that, during 1996, significant reductions
occurred in the amount of coca under cultivation in Peru.
\20 Drug War: Observations on U.S. International Drug Control
Efforts (GAO/T-NSIAD-95-194, Aug. 1, 1995).
\21 Drug War: Observations on Counternarcotics Aid to Colombia
(GAO/NSIAD-91-296, Sept. 30, 1991); The Drug War: U.S. Programs in
Peru Face Serious Obstacles (GAO/NSIAD-92-36, Oct. 21, 1991); and
The Drug War: Colombia Is Implementing Antidrug Efforts, but Impact
Is Uncertain (GAO/T-NSIAD-94-53, Oct. 5, 1993).
\22 Drug Control: Counternarcotics Efforts in Mexico
(GAO/NSIAD-96-163, June 12, 1996).
\23 The Drug War: Observations on Counternarcotics Programs in
Colombia and Peru (GAO/T-NSIAD-92-2, Oct. 23, 1991) and The Drug
War: Colombia Is Undertaking Antidrug Programs, but Impact Is
Uncertain (GAO/NSIAD-93-158, Aug. 10, 1993).
\24 Drug War: Observations on the U.S. International Drug Control
Strategy (GAO/T-NSIAD-95-182, June 27, 1995) and Drug Control:
Counternarcotics Efforts in Mexico (GAO/NSIAD-96-163, June 12, 1996).
\25 Drug Control: U.S.Interdiction Efforts in the Caribbean Decline
(GAO/NSIAD-96-119, Apr. 17, 1996).
\26 Controlling Drug Abuse: A Status Report (GAO/GGD-88-39, Mar. 1,
1988).
\27 The Drug War: Extent of Problems in Brazil, Ecuador, and
Venezuela (GAO/NSIAD-92-226, June 5, 1992).
\28 The Drug War: U.S. Programs in Peru Face Serious Obstacles
(GAO/NSIAD-92-36, Oct. 21, 1991).
\29 The War on Drugs: Narcotics Control Efforts in Panama
(GAO/NSIAD-91-233, June 16, 1991).
\30 Drug Control: Interdiction Efforts in Central America Have Had
Little Impact on the Flow of Drugs (GAO/NSIAD-94-233, Aug. 2, 1994).
\31 Drug War: Observations on U.S. International Drug Control
Efforts (GAO/T-NSIAD-95-194, Aug. 1, 1995).
\32 GAO/NSIAD-97-75.
SUMMARY OF OUR WORK ON FEDERAL
DOMESTIC DRUG INTERDICTION
PROGRAMS
------------------------------------------------------------ Letter :9
We have reported over the past few years on various aspects of
domestic drug interdiction. For example, criminal activities such as
illegal drug sales produce a tremendous amount of currency that would
be regarded as suspicious unless it was disguised as legitimate
through various money laundering schemes. Consequently, U.S.
efforts to combat money laundering rely heavily upon the reporting of
transactions involving large amounts of cash. In March 1994, we
reported that the Customs Service was aware of the impact of currency
smuggling on drug control efforts and at that time had increased
national oversight of and emphasis given to outbound inspection
programs to interdict unreported currency.\33
Experts estimate that most of the cocaine entering the United States
enters from Mexico across the southwest border. For example, it has
been estimated that between 50 and 70 percent of the cocaine smuggled
into the United States transits through Mexico, entering primarily by
land across the southwest border. We concluded that the Immigration
and Naturalization Service's (INS) 1994 national strategy for gaining
control of the nation's borders had affected drug smuggling in that
smugglers began rerouting drugs from San Diego and El Paso to other
southwest border areas.\34
We also examined INS' role in the Organized Crime Drug Enforcement
Task Force program, which is designed to be a comprehensive,
multiagency attack on drug-related and money laundering enterprises.
Nine federal agencies, including INS, and various state and local
organizations comprised individual task forces. The task forces were
to use the special skills and expertise of all participating agencies
and rely on the jurisdictional authority of those agencies. We
reported in July 1994\35 that when carrying out task force
investigations, INS contributed its alien-related expertise and its
jurisdictional authority to apprehend and remove criminal alien drug
traffickers from the country.
--------------------
\33 Money Laundering: U.S. Efforts to Fight It Are Threatened by
Currency Smuggling (GAO/GGD-94-73, Mar. 9, 1994).
\34 Border Control: Revised Strategy Is Showing Some Positive
Results (GAO/GGD-95-30, Dec. 29, 1994).
\35 INS Drug Task Force: Federal Agencies Supportive of INS Efforts
(GAO/GGD-94-143, July 7, 1994).
DIFFICULTIES IN MEASURING
AGENCIES' ANTIDRUG PERFORMANCE
----------------------------------------------------------- Letter :10
In a 1990 report,\36 we pointed out the difficulties in measuring the
effectiveness of drug interdiction activities. For example, we noted
that while agencies generally view the number or amounts of seizures
as an indicator of program success, a decrease in seizures does not
necessarily mean that a program was less effective than it was
previously or less effective than other programs making more
seizures.
We took this concern one step further in our 1993 report on the
reauthorization of ONDCP.\37 We found that national strategies
contained inadequate measures for assessing the contributions of
component programs for reducing the nation's drug problems and
recommended that, as part of its reauthorization of ONDCP, Congress
direct the agency to develop better performance measures. In
reauthorizing ONDCP in 1993, Congress specified that ONDCP's
performance measurement system should assess changes in drug use,
drug availability, the consequences of drug use, drug treatment
capacity, and the adequacy of drug treatment systems.
ONDCP has been working toward this end since our 1993 report. In
1994, ONDCP began efforts to measure the international supply
reduction components of the national drug control strategy. In early
1996, ONDCP decided to expand this effort to all drug control
programs and activities. As of January 1997, ONDCP had convened
working groups composed of representatives from all federal drug
control agencies as well as from state, local, and private entities
to develop national level measures of drug control performance.
ONDCP plans to submit proposed national performance measures to
federal agencies involved in national drug control efforts for
comment by the summer of 1997.
We reported in September 1996 that the Customs Service was developing
some nontraditional measures to use in assessing the effectiveness of
its drug interdiction activities.\38 In addition to the traditional
measures of seizures, arrests, indictments, and convictions, Customs
began measuring the reduction in the number of drug smugglers who
attempt to race a drug-laden vehicle through a port of entry, and the
ratio of seizures to examinations conducted for cargo and passengers.
In addition, Customs is estimating the number of persons violating
U.S. laws at major air and land ports.
The Coast Guard has taken steps toward conforming with certain GPRA
principles. It has defined its performance goal as "reducing the
amount of illegal drugs entering the country through maritime routes
by 25 percent over 5 years." It plans to gather data to compare the
amount of drugs it seizes with estimates of the amount of drugs
produced in source countries and shipped to the United States via
maritime routes.
However, agency officials recognize that challenges remain. The
Coast Guard has developed preliminary performance plans that reflect
a need for additional work in three areas: (1) developing goals and
ways of achieving them, (2) developing data to measure the results of
its actions, and (3) identifying wide variety of constraints that
could influence the effectiveness of its antidrug activities. (See
app. III for more details on the Coast Guard's performance
measures.)
--------------------
\36 Drug Interdiction: Funding Continues to Increase but Program
Effectiveness Is Unknown (GAO/GGD-91-10, Dec. 11, 1990).
\37 Drug Control: Reauthorization of the Office of National Drug
Control Policy (GAO/GGD-93-144, Sept. 29, 1993).
\38 Customs Service: Drug Interdiction Efforts (GAO/GGD-96-189BR,
Sept. 26, 1996).
CONCLUSIONS
----------------------------------------------------------- Letter :11
ONDCP and several other agencies are developing measures of the
results of their antidrug activities. Used together, these measures
could provide information congressional and executive branch
decisionmakers need to assess program performance and make judgments
about future funding levels. It is important to consider both ONDCP
and operational agency data together because results achieved by one
agency in reducing the use of drugs may be offset by less favorable
results by another agency. For example, increased Customs Service
inspections and use of technology to detect drugs being smuggled
through ports of entry may cause smugglers to seek other routes; this
would put more pressure on drug interdiction activities of other
agencies, such as the Coast Guard. Experts say substantiating
outcome results through further research and evaluation is an
important step in advancing promising drug prevention and treatment
approaches. It is also important in helping policymakers to better
focus efforts and resources on proven effective drug abuse prevention
and treatment programs.
It is too soon to tell whether the measures being developed by ONDCP
and each agency participating in implementing the U.S. drug control
strategy will be adequate for assessing results. Congressional and
agency officials will need to review several years of data before
they can assess whether changes in funding or allocation of resources
would improve the results being achieved.
AGENCY COMMENTS
----------------------------------------------------------- Letter :12
On January 31, 1997, we provided a draft of this report for comment
to the Director, Office of National Drug Control Policy; the
Secretary of Transportation; and the Commandant of the U.S. Coast
Guard. Between February 7 and 14, 1997, officials from ONDCP and the
U.S. Coast Guard provided comments on this draft by teleconference.
On February 7, 1997, Department of Transportation officials provided
their comments by electronic mail. Officials from all three
organizations generally agreed with the information presented in the
report and provided technical comments that we incorporated where
appropriate.
--------------------------------------------------------- Letter :12.1
We are sending copies of this report to the Ranking Minority Members
of your Subcommittees, the Director of ONDCP, the Secretary of
Transportation, and the Commandant of the U.S. Coast Guard. We will
also make copies available to others upon request.
The major contributors to this report are listed in appendix IV. If
you or your staffs have any questions on this report, please call me
on (202) 512-8777.
Norman J. Rabkin
Director, Administration
of Justice Issues
BACKGROUND
=========================================================== Appendix I
The United States has developed a multifaceted drug control strategy
intended to reduce the supply and demand for illegal drugs. The 1996
U.S. drug control strategy includes five goals: (1) motivate
America's youth to reject illegal drugs and substance abuse; (2)
increase the safety of U.S. citizens by substantially reducing
drug-related crime and violence; (3) reduce health, welfare, and
crime costs resulting from illegal drug use; (4) shield America's
air, land, and sea frontiers from the drug threat; and (5) break
foreign and domestic drug sources of supply. For fiscal year 1997,
the President requested $15.1 billion for programs designed to attain
the strategy's goals. Table I.1 lists federal drug control spending
by function for fiscal years 1995 to 1997.
Table I.1
Federal Drug Control Spending by
Function, FYs 1995-1997
(Dollars in millions)
FY 1996-1997
change
--------------
FY
FY 1996 President's
1995 estima FY 1997 Percen
actual te\a request Amount t
--------------------------------- ------ ------ ------------- ------ ------
Drug function
Criminal justice system $6,545 $7,105 $7,790.5 $685.4 9.6%
.4 .1
Drug treatment 2,692. 2,679. 2,908.7 229.3 8.6%
0 4
Drug prevention 1,559. 1,430. 1,591.6 161.5 11.3%
1 1
International 295.8 319.5 400.5 81.0 25.4%
Interdiction 1,280. 1,339. 1,437.2 97.8 7.3%
1 4
Research 542.2 569.6 559.2 -10.4 -1.8%
Intelligence 336.6 340.4 375.9 35.4 10.4%
================================================================================
Total $13,25 $13,78 $15,063.5 $1,280 9.3%
1.2 3.5 .0
Function areas
Demand reduction\b $4,691 $4,571 $4,970.6 $398.7 8.7%
.9 .9
Percentage 35% 33% 33%
Domestic law enforcement $6,983 $7,552 $8,255.3 $702.5 9.3%
.3 .8
Percentage 53% 55% 55%
International $295.8 $319.5 $400.5 $81.0 25.4%
Percentage 2% 2% 3%
Interdiction $1,280 $1,339 $1,437.2 $97.8 7.3%
.1 .4
Percentage 10% 10% 10%
================================================================================
Total $13,25 $13,78 $15,063.5 $1,280 9.3%
1.2 3.5 .0
Supply/demand split
Supply $8,559 9,211. $10,093.0 $881.4 9.6%
.2 6
Percentage 65% 67% 67%
Demand $4,691 4,571. $4,970.6 $398.7 8.7
.9 9
Percentage 35% 33% 33%
================================================================================
Total $13,25 13,783 $15,063.5 $1,280 9.3%
1.2 .5 .0
Demand components
Prevention (w/research) $1,738 $1618. $1,783.3 $164.7 10.2%
.7 6
Treatment (w/research) $2,953 $2,953 $3,187.3 $234.0 7.9%
.2 .3
Demand research, total $440.8 $462.4 $470.2 $7.9 1.7%
--------------------------------------------------------------------------------
Note: Detail may not add to totals due to rounding.
\a Includes the administration's proposed adjustments to fiscal year
1996 continuing resolution levels.
\b Demand reduction refers to any activity intended to reduce the
demand for drugs such as through drug abuse treatment, education,
prevention, research, and rehabilitation. Supply reduction refers to
any enforcement activity intended to reduce the supply or use of
drugs, such as through international drug control initiatives,
foreign and domestic drug enforcement intelligence, interdiction of
drugs destined for the United States, and domestic law enforcement,
including enforcement directed at users.
Source: The National Drug Control Strategy: 1996, ONDCP.
Figure I.1 shows the level of federal involvement in drug control
efforts.
Figure I.1: Percentage of Drug
Control Funds by Agency, 1997
(See figure in printed
edition.)
Source: ONDCP.
According to the DEA Administrator, if demand does not change, a
depressed price and elevated purity often signal an increased
availability of a specific drug; on the other hand, increased price
and declining purity indicate decreased availability of that drug.
As can be seen in table I.2, the lower end price of cocaine remained
the same, while the higher range price increased from 1988 to 1992.
But from 1993 to 1995, the price of cocaine declined. Figure I.2
shows that the purity of cocaine has remained relatively constant
since 1988.
Table I.2
U.S. Retail Price Range for 1 Kilogram
of Cocaine, 1988-1995
National price
Year range
-------------------------------------------------- ------------------
1988 $11,000-$34,000
1989 $11,000-$35,000
1990 $11,000-$40,000
1991 $11,000-$40,000
1992 $11,000-$42,000
1993 $10,500-$40,000
1994 $10,500-$40,000
1995 $10,500-$36,000
----------------------------------------------------------------------
Source: DEA and the National Narcotics Intelligence Consumers
Committee.
Figure I.2: Average U.S. Rate
of Purity of Cocaine, 1988-1995
(See figure in printed
edition.)
Source: DEA.
Illegal drug use--particularly the use of cocaine and
heroin--represents a continuing health and safety problem in the
United States. While the level of consumption of illicit drugs has
remained relatively stable during recent years, a great deal of
concern has arisen from the Monitoring the Future, 1996 survey's
findings discussed earlier that drug use by youth in grades 8, 10,
and 12 has increased since 1992. According to ONDCP, an upsurge in
drug use by teens reflects the need to refocus and reinvigorate
prevention efforts.
Figure I.3: Adolescent Illicit
Drug Use, 1991-1996
(See figure in printed
edition.)
Source: Monitoring the Future, National Institute on Drug Abuse,
1996.
DRUG ABUSE PREVENTION AND
TREATMENT
========================================================== Appendix II
INTRODUCTION
-------------------------------------------------------- Appendix II:1
Drug and alcohol abuse continues to be a major problem facing our
society. In 1995, among the general population, about 22.7 million
individuals were estimated to have used at least one illicit drug in
the past year--17.8 million used marijuana, 3.7 million used cocaine,
and 428,000 used heroin.\39 The highest illicit drug use rate among
adolescents continues to be their use of alcohol. In 1995, about 74
percent of high school seniors surveyed had consumed alcohol in the
past year.\40 \41
From 1992 to 1995, the estimated rate of marijuana use in the general
population increased from 7.9 to 8.4 percent. The rate of cocaine
use, although still considered to be of epidemic proportions,
declined from 2.1 to 1.7 percent. There was a pronounced rise in the
drug use rates among school-age youths during this period. The rate
of marijuana use by 8th grade students in the past year more than
doubled, from 7.2 percent to 15.8 percent; use by 10th graders rose
from 15.2 percent to 28.7 percent; and for 12th graders, the rate of
marijuana use increased from 21.9 percent to 34.7 percent. The rate
of alcohol use remained above 70 percent throughout the period for
12th graders. Increases in students' past-year drug use were also
found for 11 other drug types.
To help combat drug abuse and reduce the demand for drugs in the
United States, federal, state, and local governments and the private
sector fund prevention and treatment programs. From fiscal year 1990
through 1994, federal funding for drug prevention and treatment
activities increased from $2.8 billion to $4.4 billion. Combined
state, county, and local expenditures increased from about $1.3
billion to about $1.6 billion. Although data on private sector
funding are very limited, available sources indicate funding of more
than $1 billion for treatment in 1993.\42
In light of the high prevalence of drug use in the United States and
the human and financial investment in fighting drug abuse,
congressional members are interested in knowing what drug prevention
and treatment strategies are being employed to address the drug use
problem. This appendix discusses
-- the nature and objectives of drug prevention and treatment,
-- the types of prevention approaches currently being used and
promising prevention practices for school-age youths,
-- the types of cocaine treatment approaches currently being used
and promising treatment practices for those abusing or addicted
to cocaine, and
-- future research initiatives needed to enhance our knowledge base
of prevention and treatment effectiveness.
--------------------
\39 National Household Survey on Drug Abuse: Population Estimates
1995, Substance Abuse and Mental Health Services Administration,
1996.
\40 In all states, the purchase and public possession of alcohol
beverages by a person who is less than 21 years of age is illegal.
Throughout this report, the use of the term "drug abuse" can also
include alcohol.
\41 Monitoring the Future, National Institute on Drug Abuse, 1996.
\42 Drug and Alcohol Abuse: Billions Spent Annually for Treatment
and Prevention Activities (GAO/HEHS-97-12, Oct. 8, 1996).
SCOPE AND METHODOLOGY
-------------------------------------------------------- Appendix II:2
To determine the objectives of drug prevention and treatment, the
range of prevention and treatment strategies and approaches being
used, and the future research initiatives needed to increase the
knowledge base on the effectiveness of prevention and treatment, we
identified and reviewed selected literature on drug prevention and
treatment research. The documents we reviewed included (1) Institute
of Medicine (IOM) publications, (2) the Secretary of the Department
of Health and Human Services' (HHS) third triennial report to the
Congress on drug abuse research, (3) the National Institute on Drug
Abuse's (NIDA) series of research monographs, (4) Substance Abuse and
Mental Health Services Administration (SAMHSA) monographs, and (5)
relevant government contractor reports as well as journal
publications by major experts in drug prevention and treatment.
To identify promising drug prevention approaches for school-age
youths, we first conducted a literature search of prevention
practices during the period 1990 to 1995, using medical, social,
psychological, and educational reference sources. We extracted and
reviewed from the drug prevention literature 10 syntheses written by
known experts in the field. The authors reviewed and summarized the
evidence of promising prevention approaches used in programs for
youths. We also reviewed the supporting outcome data provided for
each program to determine the level of evidence behind an author's
designation of a program as promising. In the syntheses in which
data either were not provided or were not adequate, we obtained
supplementary information from principal investigators who had
implemented the prevention approach. This supplementary information
was obtained from journal publications, reports, and working drafts.
We cited the drug prevention programs as promising if the approach
met one of the following criteria that we developed:
-- the group receiving the experimental intervention demonstrated
significantly better outcome results than control groups not
receiving the approach;\43 or
-- in cases where the intervention had no comparison or control
group, outcome results were markedly better (by at least 10
percent) than initial baseline scores.
In addition to these criteria, we sought approaches with follow-up
periods of at least 6 months. We combined a standardized statistical
criterion with our professional methodological judgment in developing
the criteria.
To identify promising treatment approaches for cocaine abuse, we used
information from our June 1996 report.\44 For that report, we
identified studies with current reportable data on two major outcome
variables--drug abstinence and treatment retention. We reviewed the
treatment literature published between 1991 and 1995; examined Center
for Substance Abuse Treatment (CSAT) and NIDA agency records of
cocaine-related grants awarded during that time period; and, as
necessary, contacted project investigators for additional
information.
The approximately 65 cocaine-related grants supported by CSAT were
still in progress when the report was being written; neither
abstinence nor retention outcome data were available to judge the
promise of their ongoing work. Many of the NIDA longitudinal
cocaine-supported studies were also in progress. Promising
practices, and their supportive findings, were therefore identified
from available NIDA abstinence and retention study data, cocaine
treatment outcome studies published during the 5-year period, and
documents of unpublished results from federal drug agencies. For
analytical purposes, we classified the treatment intervention types
as either cognitive and behavioral or pharmacological. In making
determinations about which treatment approaches proved promising, we
gave due consideration to the appropriateness of research design.
This appendix is not intended to provide an exhaustive evaluation of
the drug prevention and treatment literature, nor is it to assess the
qualitative methodology of each study we reviewed. Rather, the
primary objective is to identify drug abuse prevention approaches for
school-age youths and cocaine abuse or dependency treatment
approaches that appear promising and provide illustrative examples of
these approaches.
--------------------
\43 To assess whether the experimental intervention group outcome
results were statistically better than those of the control group
participants, we determined whether principal investigators used
"significance" testing and then assessed the results of those tests.
Experimental group findings were judged to be "significantly better"
when the probability of this occurrence by chance alone was less than
5 times in 100 (p < .05).
\44 Cocaine Treatment: Early Results From Various Approaches
(GAO/HEHS-96-80, June 7, 1996).
THE NATURE AND OBJECTIVES OF
DRUG PREVENTION AND TREATMENT
-------------------------------------------------------- Appendix II:3
In October 1996, we reported that federal, state, county, and local
governments and the private sector contribute billions of dollars
annually to support drug prevention and treatment activities. The
latest data available from the Office of National Drug Control Policy
(ONDCP) show that federal funding alone was $4.7 billion in fiscal
year 1995. At least 16 federal departments and agencies provide
funding for drug abuse prevention and treatment programs. Three
departments accounted for 81.9 percent of fiscal year 1995
funding--HHS, the Department of Veterans Affairs (VA), and the
Department of Education--provided approximately $2.3 billion, $967
million, and $584 million, respectively.
The federal agencies fund an array of drug abuse prevention and
treatment programs for a variety of targeted population groups. For
instance, within HHS, SAMHSA's Center for Substance Abuse Prevention
(CSAP) sponsors the Community Partnership program, the Community
Coalition program, and the High Risk Youth program. The Veterans
Health Administration operates a network of substance abuse treatment
programs in its medical centers, domiciliaries, and outpatient
clinics. And within the Department of Education, the Safe and
Drug-Free Schools and Communities Act includes funding to prevent
youth violence as well as drug and alcohol use. These and other
federal programs provide a broad range of drug abuse prevention and
treatment activities and services.
PREVENTION
------------------------------------------------------ Appendix II:3.1
THE NATURE OF PREVENTION
ACTIVITIES
---------------------------------------------------- Appendix II:3.1.1
Drug abuse prevention activities focus on the general population as
well as individuals who may be at risk for alcohol or other drug
problems. These activities include (1) providing information and
education that increase knowledge of drug abuse and alternative
drug-free lifestyles; (2) teaching skills to resist drug influences,
solve problems, and make decisions; (3) developing interventions to
control the sale and distribution of illegal drugs; and (4)
encouraging communities to implement responses to drug use.
Prevention activities can be differentiated, according to NIDA, into
three distinct types commonly referred to as universal, selective,
and indicated. A description of these types follows.
Universal drug abuse prevention interventions are directed at the
general population and employ a variety of integrated activities,
including social resistance education in the schools, antidrug media
campaigns, parent skills training, antidrug coalitions at the
neighborhood level, and antidrug policies at the state and local
levels. The objective of the universal strategy is to alter social,
psychological, and environmental factors that may influence drug
prevalence and drug outcomes at the community level.
Selective drug abuse prevention interventions are directed at
individuals or subgroups who are at risk of developing drug abuse
behaviors. The objective of a selective prevention intervention is
to reduce "risk factors" and enhance "protective factors" related to
drug use onset and the progression to abuse and dependence.
Indicated drug abuse prevention interventions are targeted to
individuals who use one or more drugs but who do not yet meet
diagnostic criteria for a drug disorder. Drug users with mental
health disorders may be targeted as well. The objective of indicated
interventions is to interrupt the progression from drug use to drug
abuse, addiction, and social dysfunctionality.
GOALS AND OBJECTIVES OF
PREVENTION PROGRAMS
---------------------------------------------------- Appendix II:3.1.2
The major goals of drug prevention programs are to prevent or
eliminate drug use and to avert drug-related problems (such as
sexually transmitted diseases and tuberculosis). But many prevention
intervention initiatives also identify and address the "intermediate"
factors, which have been found, or are perceived, to be related to
drug use. These are often referred to as the "risk" and "protective"
factors.
1. Reduction of individual "risk factors" focuses on trying to
minimize the negative effect of factors that impinge on one's life
that have been shown or theorized to be related to drug use. These
factors include availability of drugs, community norms favorable to
drug use, extreme economic deprivation, family history of problem
drug use, favorable parental attitudes and involvement in problem
drug use, early and persistent antisocial behavior, academic failure,
alienation and rebellion, and friends who engage in problem behavior.
2. Enhancement of "protective factors" focuses on increasing an
individual's resilience in dealing with potentially high-risk
situations (such as dysfunctional families, schools, and
communities). The drug prevention research field has hypothesized
that more resilient individuals are less likely to engage in drug
use. Increased resiliency in youths may be described under seven
major factors--optimism, empathy, insight, intellectual competence,
self-esteem, direction or mission, and determination and
perseverance. The coping or life skills associated with these seven
factors are emotional management skills, interpersonal social skills,
intrapersonal reflective skills, academic and job skills, ability to
restore self-esteem, planning and life skills, and problem-solving
ability.
3. Reduction of environmental and societal risk factors focuses on
prevention approaches that seek to reduce the availability illegal
and nonprescriptive legal drugs (for example, higher penalties for
sale and distribution in and around schools).
Prevention programs are conducted in a variety of settings. For
school-age youths, drug prevention activities can occur in the
classroom, peer support groups, the home setting, and the community
(using the media, youth groups, and community leaders), or in a
combination of these settings. For adults, drug prevention can be
extended to the workplace.
TREATMENT
------------------------------------------------------ Appendix II:3.2
THE NATURE OF TREATMENT
ACTIVITIES
---------------------------------------------------- Appendix II:3.2.1
Treatment activities are designed to benefit individuals who have not
been exposed to or dissuaded by drug abuse prevention programs and
have not been able to abstain or control drug use on their own. Drug
treatment traditionally has been reserved for drug abusers, or
individuals dependent on drugs who require more intensive therapy,
and pharmacological medications. The services drug treatment
programs provide may include diagnostic assessment, detoxification,
pharmacological dosing, and medical, psychiatric, and psychological
counseling and psychotherapy.
GOALS AND OBJECTIVES OF
TREATMENT PROGRAMS
---------------------------------------------------- Appendix II:3.2.2
The major goals of drug treatment programs are to achieve initial
client abstinence and then to maintain such abstinence over time.
Individual treatment objectives vary by the type of treatment
intervention sought and the nature and severity of a client's
problem. Common objectives include (1) detoxification, when
necessary; (2) use of self-help groups (for example, Alcoholics
Anonymous and Narcotics Anonymous) throughout treatment and
aftercare; (3) social or personal habilitation or rehabilitation
(including a focus on improved health and a reduction in psychiatric
disorders and psychological problems); (4) better relations with
family and significant others; (5) development of a lifestyle free of
drugs; (6) avoidance of others using drugs; (7) taking steps toward
the attainment of educational and occupational aspirations; (8) a
reduction in criminal behavior and resolution of legal problems; and
(9) improved personal circumstances (including enhanced coping
skills, family and social support systems, and ability to provide for
basic needs). The longer a client remains in treatment, the greater
the possibility of a successful outcome.
Drug treatment can be administered in different ways and in both
inpatient and outpatient settings. IOM and others identify four
types of treatment modalities in the form of programs and
settings.\45 The four modalities--outpatient methadone maintenance,
outpatient nonmethadone and drug-free, chemical dependency, and
residential therapeutic communities are described as follows:
1. Outpatient methadone maintenance is specifically for the group of
clients who are dependent on narcotics, particularly heroin, and who
are able to benefit from the use of methadone as a "substitute" drug.
Methadone is used to ease withdrawal symptoms, reduce heroin craving,
and improve the psychological functioning of the individual.
2. Outpatient nonmethadone and drug-free facilities offer diverse
purposes, programs, and staffing. Generally, clients are seen 1 or 2
days a week for individual and group counseling sessions. Self-help
groups are thought to be an essential program component. Medication
and assistance with educational, vocational, and health and housing
concerns are offered in some programs.
3. Chemical dependency programs represent the type of inpatient
modality most often assumed by the private sector. Treatment
consists of a psychiatric and psychosocial evaluation, a drug
education component, individual and group therapy, self-help group
participation, and aftercare planning in an intensive outpatient or a
residential setting.
4. Residential therapeutic communities incorporate programs that are
designed for the severely dependent clients whose social and
occupational functioning warrant rehabilitative or habilitative care.
Therapeutic communities perceive drug abuse as a deviant behavior
that limits one's personality development and is associated with
chronic deficits in the individual's social, educational, and
economic skills. Reality-oriented group and individual psychotherapy
with definitive client roles and responsibilities are provided in a
very structured living arrangement. Over an approximate 6- to
24-month inpatient stay, therapeutic community programs focus on
preparing an individual for reentry into society.
--------------------
\45 Institute of Medicine, Treating Drug Problems, vol. 1
(Washington, D.C.: National Academy Press, 1990); Research Triangle
Institute, Data Tables Comparing Crack and Cocaine Users to Other
Drug Users Entering Drug Treatment, unpublished manuscript.
THE TYPES OF PREVENTION
APPROACHES CURRENTLY BEING USED
FOR SCHOOL-AGE YOUTHS
-------------------------------------------------------- Appendix II:4
Drug prevention strategies generally include one or more approaches
designed to prevent or reduce drug use, some of which include helping
participants deal with other problems in their lives. The strategies
commonly used have been categorized under five different
approaches--information dissemination, affective education,
alternative approaches, social influence, and personal and social
skills. The social influence and personal and social skills
approaches both address psychosocial factors; therefore, for purposes
of this report, we refer to these as the "psychosocial" approach.
Also, we include another approach--the comprehensive approach--to
categorize multicomponent prevention activities involving the
participation of two or more social institutions. (See table II.1
for a description of each approach.)
Table II.1
Types of Prevention Approaches
Approach Strategy
---------------------------------- ----------------------------------
Information dissemination Provision of factual information
on drugs presented through
instruction, discussion, audio-
visual presentation, display,
posters, pamphlets, or group
programs
Affective education Promotes individual's personal and
social development with focus on
improving one's self-
understanding and acceptance,
enhancing interpersonal
relationships, and attaining
needs-satisfaction through
existing social institutions
Alternative approaches to drugs Engagement in alternative
activities in nondrug surroundings
as a means of limiting one's
probability of drug use--such as
sports, hobbies, and community
service
Psychosocial Teaching specific skills for
resisting drug influences (e.g.,
familial, peer, and media
influences) as well as generic
skills for generally coping with
life (e.g., problem-solving and
decisionmaking skills)
Comprehensive\a A multicomponent intervention
involving the participation of
several social institutions,
including the schools, families,
community organizations, and the
media
----------------------------------------------------------------------
\a The term "comprehensive" has been utilized by IOM, CSAP, and other
experts in the field. Yet it can be defined in different ways. IOM
and CSAP, for example, have used the term when referring to
coordinated, communitywide interventions. The Seattle Social
Development Research Group and Oregon Social Learning Center have
used the term to refer to the cooperation or interaction of multiple
target groups from various social institutions, such as the school,
family and neighborhood. Selected references include: Institute of
Medicine, Pathways of Addiction: Opportunities in Drug Abuse
Research (Washington, D.C. National Academy Press, 1996), p. 141,
and William Hansen, "School-based Substance Abuse Prevention: A
Review of the State of the Art in Curriculum, 1980-1990," Health
Education Research, 7 (1992), 403-40.
Although these prevention approaches or strategies can be used for
all ages, they are most often used with youths because youths are
very susceptible to peer group and media influences that might
encourage negative behaviors. Because youths are apt to experiment
with alcohol and drugs, it is important to introduce prevention
strategies early in their lives.
TWO PREVENTION APPROACHES
SHOW PROMISE AMONG
SCHOOL-AGE YOUTHS
------------------------------------------------------ Appendix II:4.1
Of the five drug prevention approaches described in table II.1, the
psychosocial and comprehensive approaches have shown more promise for
reducing drug use and risk factors and for enhancing protective
factors among school-age youths. While the three other approaches
have not been shown to be consistently effective when used
individually, they have been included in promising comprehensive
approaches.
Our review of selected literature syntheses identified several
prevention programs that had definitive positive outcome results when
using the psychosocial and comprehensive approaches as their core
prevention strategy. Although the two approaches can be applied in a
variety of settings, the programs cited in the research literature we
reviewed were school-based or had a family or community focus. HHS
and the Department of Education also recognize some of these programs
as noteworthy in decreasing drug use and risk factors.
PROGRAMS INCORPORATING
THE PSYCHOSOCIAL APPROACH
SHOW PROMISE
---------------------------------------------------- Appendix II:4.1.1
The psychosocial approach appears to have some promise, as evidenced
by positive outcome data for the five illustrative programs using
this approach in table II.2. Outcome results point to reductions in
drug use and risk factors as well as enhanced protective factors.
Table II. 2
Methodology and Results of Illustrative
School-Age Prevention Programs
Sample design Setting and target Investigator
Study Study description (size) population Prevention outcome affiliation
---------------------------- ---------------------------- ------------------- ------------------ ---------------------------- ------------------
Psychosocial approaches
-----------------------------------------------------------------------------------------------------------------------------------------------------
1. Life Skills Training 3-year school-based Randomized trial (n School-based: 7th- At 12th-grade follow-up, 44% Cornell
Prevention Program\a intervention consisting of = 3,597) 9th graders from fewer treatment students University, New
15 7th-grade sessions, 10 56 New York state used all 3 gateway drugs York, New York
8th-grade sessions, and 5 schools once a month or more
9th-grade sessions compared to controls; 66%
fewer treatment students
used all 3 substances once a
week or more
2. Project ALERT\b In 20 schools receiving the Blocking by School-based: 7th- At 15-month follow-up, RAND, Santa
intervention curriculum, district, and 8th-grade significantly fewer students Monica, California
classes taught by teacher restricted and students from 30 in experimental intervention
alone or by teacher and an randomized diverse California groups anticipated using
older teen; 10 control assignment of and Oregon schools marijuana in the future
schools did not receive the schools (n = more compared to controls;
curriculum; the curriculum than 4,000) experimental subjects also
had 11 lessons, 8 7th-grade were significantly more
sessions, and 3 8th-grade likely to believe that
booster sessions marijuana and cigarette use
can bring immediate and
negative social consequences
and result in drug
dependence
3. Generic Skills 15-session curriculum for Matched assignment School-based: 7th At 9th-grade follow-up, Cornell
Intervention\c grade 7 with 8 8th-grade (n = 757) and 8th graders drinking frequency, amount University, New
booster sessions from 6 New York of alcohol consumed, and York, New York
City schools with intention to drink beer or
more than 85% wine were lower in the 2
minority student experimental groups relative
bodies to controls; students in
experimental groups used
drug-refusal skills more
often than controls
4. Adolescent Alcohol 4 experimental conditions: Random assignment School-based: 7th- At 1-year follow-up, classes Wake Forest
Prevention Trial\d normative education and (n = 3,011) grade students in receiving normative University,
resistance skill training, 12 Los Angeles and education had significantly Winston-Salem,
provided either separately Orange County reduced rates of marijuana North Carolina
or together junior high use and alcohol and
schools cigarette consumption
relative to controls;
average increase in initial
incidence of marijuana use
for normative group was
64.5% less than controls,
22.5% less in the case of
alcohol
5. Interpersonal Relations InterPersonal Relations High-risk students School-based: IPR program participants University of
Program\e (IPR) classes met daily for assigned first come high-risk 9th- demonstrated significantly Washington,
a full semester (55 minutes first served to 12th graders from decreased drug use, fewer Seattle,
per day for 4.5 months) special IPR Northwest urban school disciplinary actions, Washington
experimental high school fewer problems with family
training; control serving and friends, lower dropout
group matched to predominantly rate, and higher grade point
experimental group white, middle- average relative to controls
(n = 146) class students
Comprehensive approaches
-----------------------------------------------------------------------------------------------------------------------------------------------------
6. Seattle Social 6-year elementary school School assignment; School-based: 1st- By 6-year follow-up, group University of
Development Project (SSDP)\f intervention consisting of student 6th graders in receiving intervention Washington,
teacher training each year randomization (n = Seattle public demonstrated significantly Seattle,
and parent training in 598 students schools in high greater school commitment Washington
grades 1, 2, 3, 5, and 6 completing high crime rate areas; and attachment, fewer school
school: the 6th- their teachers and problem behaviors, less
year follow-up) parents alcohol use, less violent
behavior, and fewer sexual
partners compared to
controls
7. Midwestern Prevention Social influence approach Two-group design (n School-and 20%-40% net change in 2 University of
Project, known locally as school-based component plus = 5,400 Kansas community-based: drugs over 3 years for Southern
Project Star or I-Star\g media, parent, and community City, 3,192 6th or 7th graders program participants California, Los
organization programs and Indianapolis) in 50 Kansas City Angeles,
drug use policy changes; 11- schools and 57 California
13-session school program Indianapolis
followed by 5 session schools
boosters
8. Safe Haven Program (a Focus of the intervention Quasi-experimental Family-focused: 6- At follow-up, parents in University of
cultural version of the for the 6 to 12 year old design, to 12-year-old both the high and low Utah, Salt Lake
Strengthening Families children was on risk and nonequivalent children substance substance abuse groups City, Utah;
Program, SFP)\h protective factors. The comparison group (n using parents were reported significant Detroit City
parental and adult family = 88) admitted to a decreases in drug use for Health Department,
intervention targeted both Detroit drug themselves and their Michigan
drug use and family treatment center; families; children in high
management, communication effectiveness of substance abuse group showed
issues in 12 weekly the Safe Haven significant reductions in
structured sessions Program compared school problems, aggression,
families of low delinquency, and
and high substance hyperactivity
use
9. Adolescent Transitions 4 experimental conditions: Random assignment Family-focused and At 1-year follow-up, mothers Oregon Social
Program (ATP)\i parent focus (developing to experimental neighborhood in parent and teen group Learning Center,
effective, noncoercive intervention, based: reported significantly less Eugene, Oregon
family management quasi-experimental 6th-to 8th-grade family conflict than
practices), teen focus control high-risk controls and significant
(enhancing adolescent self- (n = 158) adolescents and reductions in adolescent
regulation, competence), their families problem behavior; teen focus
parent and teen focus, and intervention had negative
self-directed group that effect
received only the materials;
12 weekly 90-minute sessions
10. Project Northland\j Experimental curricula 20 school districts Communitywide: Students in experimental University of
consisting of 3 years of blocked by size and 6th-8th graders intervention districts had Minnesota,
parental involvement and randomized to and their significantly lower Minneapolis,
education programs, either the communities in tendency Minnesota
behavioral curricula, peer experimental or the mostly rural, to use alcohol by the end of
participation, and community control condition lower middle- 8th grade; among baseline
task force activity (n = 1,901) class Minnesota nonusers of alcohol,
percentage of students
reporting marijuana and
cigarette use was also
significantly lower in the
intervention districts at
8th-grade follow-up;
intervention group
significantly more likely to
report being able to resist
alcohol at a party or dance
-----------------------------------------------------------------------------------------------------------------------------------------------------
\a Sources for the Life Skills Training Prevention Program are
Gilbert J. Botvin, "Preventing Adolescent Drug Abuse Through Life
Skills Training: Intervention Approach and Evaluation Results,"
Community Epidemiology Work Group (CEWG), June 1996, 451-459; and
Gilbert J. Botvin et al., "Long-term Follow-up Results of a
Randomized Drug Abuse Prevention Trial in a White Middle-Class
Population," Journal of the American Medical Association, 273:14
(1995), 1106-12.
\b The source for Project ALERT is Phyllis L. Ellickson, Robert M.
Bell, and Ellen R. Harrison, "Changing Adolescent Propensities to
Use Drugs: Results from Project ALERT," Health Education Quarterly,
20:2 (summer 1993), 227-42.
\c The source for the Generic Skills Intervention program is Gilbert
J. Botvin et al., "Effectiveness of Culturally Focused and Generic
Skills Training Approaches to Alcohol and Drug Abuse Prevention Among
Minority Adolescents: Two-Year Follow-Up Results," Psychology of
Addictive Behaviors, 9:3 (1995), 183-94.
\d The source for the Adolescent Alcohol Prevention Trial is William
B. Hansen and John W. Graham, "Preventing Alcohol, Marijuana, and
Cigarette Use Among Adolescents: Peer Pressure Resistance Training
Versus Establishing Conservative Norms," Preventive Medicine, 20
(1991), 414-30.
\e The source for the Interpersonal Relations Program is Leona L.
Eggert et al., "Effects of a School-Based Prevention Program for
Potential High School Dropouts and Drug Abusers," International
Journal of the Addictions, 25:7 (1990), 773-801.
\f The sources for the Seattle Social Development Project are an
unpublished document by J. David Hawkins et al. entitled "Promoting
Academic Success and Preventing Crime in Urban America: Six-Year
Follow-Up Effects of the Seattle Social Development Project" and a
set of unpublished 6-year follow-up documents from Hawkins et al.
provided to GAO on November 28, 1996. The principal investigator of
the SSDP considers this program comprehensive because it is a
cooperative program that targets students, parents, and teachers and
seeks to change the entire school environment.
\g The sources for the Midwestern Prevention Project are an
unpublished draft by Mary Ann Pentz entitled "Preventing Drug Abuse
Through the Community: Multi-component Programs Make the Difference"
and Mary Ann Pentz's "Benefits of Integrating Strategies in Different
Settings."
\h Although the program might not necessarily include several social
institutions, the Safe Haven Program follows a comprehensive,
family-focused curriculum in that it includes three components: (1)
children's skills training; (2) parent training; and (3) if needed,
community support services such as child care, meals, transportation,
and support with basic needs (groceries and clothing). The source
for the Safe Haven Program is G. Aktan, K. L. Kumpfer, and C.
Turner, "The Safe Haven Program: Effectiveness of a Family Skills
Training Program for Substance Abuse Prevention With Inner City
African-American Families," International Journal of the Addictions,
31 (1996), 158-75.
\i While The ATP program does not necessarily involve a multiple of
social institutions, it is a family-focused program that has a
comprehensive strategy because it includes parents and adolescents as
well as community wraparound services if needed, such as family
therapy, case management, transportation, and food services. The
source for the Adolescent Transitions Program is Thomas J. Dishion
and David W. Andrews, "Preventing Escalation Problem Behaviors with
High-Risk Young Adolescents: Immediate and 1-Year Outcomes," Journal
of Consulting and Clinical Psychology, 63:4 (1995), 538-48.
\j The source for Project Northland is Cheryl L. Perry et al.,
"Project Northland: Outcomes of a Communitywide Alcohol Use
Prevention Program During Early Adolescence," American Journal of
Public Health, 86:7 (1996), 956-65.
Illustrations of successful psychosocial programs include the Life
Skills Training Program\46 and the Adolescent Alcohol Prevention
Trial.\47 Three-year follow-up results of a randomized trial of more
than 3,500 7th to 9th grade students showed 66 percent fewer program
participants using three drugs (alcohol, tobacco, and marijuana) at
least once a week, compared with control group participants not
receiving the intervention. A 1-year follow-up of approximately
3,000 California 7th graders participating in the Adolescent Alcohol
Prevention Trial demonstrated that the increase in the initial
incidence of marijuana use for the experimental group was 65-percent
less than control group participants and 23-percent less than control
group participants for initial alcohol use.
Common features of these programs include increasing awareness of the
social influences that promote drug use, modifying normative
expectations concerning drug use, teaching skills for resisting drug
use pressures, and teaching more generic personal and interpersonal
problem-solving skills. All the programs we cite as using the
psychosocial approach are delivered in the school setting and target
students in grades 7 through 12.
--------------------
\46 Gilbert J. Botvin, "Preventing Adolescent Drug Abuse Through
Life Skills Training: Intervention Approach and Evaluation Results,"
Community Epidemiology Work Group (CEWG), June 1996, 451-459; and
Gilbert J. Botvin et al., "Long-term Follow-up Results of a
Randomized Drug Abuse Prevention Trial in a White Middle-Class
Population," Journal of the American Medical Association, 273:14
(1995), 1106-12.
\47 William B. Hansen and John W. Graham, "Preventing Alcohol,
Marijuana, and Cigarette Use Among Adolescents: Peer Pressure
Resistance Training Versus Establishing Conservative Norms,"
Preventive Medicine, 20 (1991), 414-30.
PROGRAMS INCORPORATING
THE COMPREHENSIVE
APPROACH SHOW PROMISE
---------------------------------------------------- Appendix II:4.1.2
The comprehensive approach also appears to show some promise, as
illustrated by the five programs using this approach (see table
II.2). In one program, the Seattle Social Development Project,\48
6-year follow-up results demonstrated that elementary school students
participating in the full parent-teacher intervention had
significantly fewer annual school problem behaviors than control
group participants (4.77 problems versus 3.36 problems), drank less
alcohol (15 percent of experimental subjects drank 10 times per year
or more compared with 25 percent for control group participants), had
a lower lifetime prevalence of violent delinquency (60 percent versus
48 percent), and had fewer sexual partners (50 percent versus 62
percent.) Likewise, in the Midwestern Prevention Project (also known
as Project Star or I-Star)\49 3-year follow-up results demonstrated a
20-to 40-percent net change in two drugs for program participants.
While some of the multicomponent interventions are centered on a
school setting, others tend to be family focused and address both
parent and child behaviors. For example, the Safe Haven Program
achieved reductions in family drug use as well as significant student
reductions in school problem behavior, aggression, and delinquency.
Common features of programs using a comprehensive approach included
multistrategies to target multiple aspects of youths' lives, such as
the individual, family, peer group, school, and community. We
discussed the importance of comprehensive approaches in
community-based adolescent drug prevention programs in our January
1992 report.\50 Although no definitive evidence was available at the
time to demonstrate the effectiveness of the community prevention
programs we reviewed, we reported that the comprehensive strategy was
a feature present in the most promising programs or at least those
that appeared to be making more headway than others.\51 The
comprehensive approaches addressed multiple dimensions of youths'
lives (such as the individual, family, peer group, school, and
community) and used a variety of services.
--------------------
\48 J. David Hawkins and others, "Promoting Academic Success and
Preventing Crime in Urban America: Six-Year Follow-Up Effects of the
Seattle Social Development Project" and a set of unpublished 6-year
follow-up documents from Hawkins and others provided to us on
November 28, 1996.
\49 Mary Ann Pentz,"Preventing Drug Abuse Through the Community:
Multi-Component Programs Make the Difference" and Mary Ann Pentz
"Benefits of Integrating Strategies in Different Settings," in
A. Elster, S. Panzarine, and K. Holt (eds.). American Medical
Association State of the Art Conference on Adolescent Health
Promotion Proceedings: National Center for Education in Maternal and
Child Health, Arlington, VA, 1993, pp. 15-34.
\50 Adolescent Drug Use Prevention: Common Features of Promising
Community Programs (GAO/PEMD-92-2, Jan. 16, 1992).
\51 CSAP is currently conducting a national evaluation of the
Community Partnership Demonstration Program the agency supports.
According to CSAP, national results of this effort should be
available in 1998.
FEDERAL AGENCIES RECOGNIZE
PROGRAMS AS NOTEWORTHY
------------------------------------------------------ Appendix II:4.2
NIDA and CSAP, within HHS, and the Department of Education recognized
as noteworthy several of the drug prevention programs we cite from
the literature as having positive outcome results (for example, the
Adolescent Alcohol Prevention Trial, Life Skills Training, the
Midwestern Prevention Project, and the Seattle Social Development
Project). The agencies recognized these programs because they have
either demonstrated decreases in drug use and the risk factors that
lead to drug use or they have shown an increase in the protective
factors promoting drug-free lifestyles. In addition to the programs
we cite in table II.2, numerous other programs (such as Project
PRIDE, GAPS, and the Youth Gang Drug Prevention Program) have been
cited as effective or exemplary in reducing risks for drug use among
adolescents. However, according to NIDA, some of these science-based
drug abuse prevention interventions and principles are not being
widely used in schools and communities across the country.
THE TYPES OF APPROACHES
CURRENTLY BEING USED TO TREAT
COCAINE ADDICTION
-------------------------------------------------------- Appendix II:5
Drug treatment strategies have a common goal of eliminating, or at
least reducing, an individual's drug abuse. The strategies in use
incorporate various approaches and modalities as a means of treating
drug abusers or drug-dependent individuals. Although different
approaches have been used, IOM has adopted a paradigm that
distinguishes drug abuse treatment approaches as falling under the
rubric of pharmacotherapy or psychosocial treatment.
Pharmacotherapies involve the use of medications to deal with client
overdose, detoxification, dependence, and relapse prevention.
Methadone, for example, is the prime pharmacotherapy determined to be
useful in the treatment of heroin. However, none of the major
medications tested have proven effective consistently in the
treatment of cocaine.
Psychosocial treatment includes counseling, different forms of
psychotherapy, cognitive skill development, and contingency
management. Counseling is oriented toward the effective management
of specific, concrete problems, while psychotherapy attempts to help
a client deal with more dysfunctional cognitive and behavioral
processes. The use of acupuncture represents a new strategy in the
treatment of drug addiction.
Research suggests that psychosocial treatment offers a promising
approach to treating cocaine abuse and dependency. Within the
psychosocial treatment rubric, cognitive and behavioral therapies are
showing promise in cocaine treatment research. As we reported in
June 1996, data from a review of the literature show positive results
in the use of three cognitive and behavioral approaches to cocaine
treatment.\52 Because cocaine therapies are still in their early
stages of development, treatment outcome results cannot be
generalized to all cocaine users.
--------------------
\52 Cocaine Treatment: Early Results From Various Approaches
(GAO/HEHS-96-80, June 7, 1996).
THREE COGNITIVE-BEHAVIORAL
TREATMENTS SHOW PROMISE IN
OUTPATIENT SETTINGS
------------------------------------------------------ Appendix II:5.1
Early research indicates that relapse prevention, community
reinforcement and contingency management, and neurobehavioral therapy
are potentially promising cocaine-addiction treatment approaches for
cocaine abusers and cocaine-dependent clients. These approaches
appear to promote extended periods of client abstinence and treatment
retention in outpatient treatment settings. Table II.3 provides an
overview of cognitive and behavioral study methodologies and results.
Table II.3
Methodology and Results of Illustrative
Cognitive-Behavioral Studies
Study group (publication Sample design Client diagnosis/ Investigator
date) Study period (size) demographics Treatment outcome affiliation
---------------------------- ---------------------------- -------------- --------------------------- -------------------------- ----------------
Relapse prevention
-----------------------------------------------------------------------------------------------------------------------------------------------------
1. Carroll and others 12 weeks Random (n = Clients met criteria for Cocaine-abstinent at least Yale
(1994)\a 121) cocaine dependence 70% of the time in University,
treatment New Haven,
average age: 29 Connecticut
male: 79%
white: about 50%
unemployed: about 40%
single/divorced: about 70%
at least high school
graduate: about 80%
2. Carroll and others 12 weeks Random (n = Clients met criteria for 54% of high-severity Yale
(1991)\b 42) both cocaine abuse and cocaine users were able to University,
dependence attain at least 3 weeks of New Haven,
continuous abstinence; Connecticut
average age: 27 only 9% of high-severity
male: 67% cocaine users receiving
white: 67% standard psychotherapy
average years of education: could achieve this
13
3. Washton and Stone- About 28 weeks Consecutive Clients met criteria for More than 60% abstinent Washton
Washton (1993)\c admissions (n severe psychoactive drug from cocaine during 6-to- Institute,
= 60) dependence (85% were 24-month follow-up period New York, New
cocaine addicts) York
average age: about 35
male: about 80%
white: about 70%
employed: about 90%
4. Wells and others (1994)\d 24 weeks Alternative Cocaine was primary drug of Average number of days of University of
assignment (n choice cocaine use cut by 71% Washington,
= 110) within 6 months Seattle,
average age: 29 Washington
male: 64%
white: 84%
employed full time for past
3 years: 68%
average years of education:
13
Community reinforcement and contingency management
-----------------------------------------------------------------------------------------------------------------------------------------------------
5. Higgins and others 12 weeks Consecutive Clients met criteria for 46% were continuously University of
(1991)\e admissions (n cocaine dependence abstinent from cocaine for Vermont,
= 25) 8 treatment weeks Burlington,
average age: 29 Vermont
education �12 years: 46%
employed: 62%
single: 54%
6. Higgins and others 24 weeks Random (n = Clients met criteria for 42% were continuously University of
(1993)\f 38) cocaine dependence abstinent from cocaine for Vermont,
16 treatment weeks Burlington,
average age: 29 Vermont
male: 89%
white: 100%
unmarried: 89%
completed high school: 63%
employed: 42%
Contingency management only
-----------------------------------------------------------------------------------------------------------------------------------------------------
7. Silverman and others 12 weeks Frequency Clients met criteria for Nearly 50% of the clients Johns Hopkins
(1994, 1995)\g of cocaine- heroin and cocaine receiving vouchers for University,
positive urine dependence cocaine-free urine Baltimore,
during initial remained continuously Maryland
5 weeks of average age: 36 abstinent from cocaine for
methadone black: 26% 7 to 12 weeks
therapy (n = married: 16%
37) completed at least high
school: 74%
employed full time: 47%
Neurobehavioral therapy
-----------------------------------------------------------------------------------------------------------------------------------------------------
8. Shoptaw and others 12 months Random (n = Clients met criteria for 36% remained continuously Matrix
(1994)\h 146) stimulant abuse or abstinent from cocaine for Institute,
dependence at least 8 treatment Los Angeles,
weeks; 38% were abstinent California
average age: 31 from cocaine at 6-month
male: 84% follow-up
white: 63%
Hispanic: 25%
average years of education:
13
unmarried: 78%
9. Rawson and others 6 months Open trial (n Cocaine-using clients At least 40% at two Matrix
(1993)\i = 486) treatment sites remained Institute,
average age: 30 continuously abstinent Los Angeles,
male: 74% from cocaine through 6 California
white: 76% months of treatment
average years of education:
14
single: 54%
10. Rosenblum and others 6 months Random (n = Methadone clients who met Clients attending 3 to 19 National
(1994)\j 77) criteria for cocaine sessions reduced past- Development and
dependence month cocaine use by 5%; Research
those attending 85 to 133 Institutes,
age 24 to 43: 87% sessions reduced past- Inc.,
Hispanic: 64% month cocaine use by 60% New York, New
black: 31% York
unemployed: 77%
married/common law: 38%
completed at least high
school: 42%
11. Magura and others 6 months Random Methadone clients who met Group demonstrated National
(1994)\k (n = 62) criteria for cocaine significant decrease in Development and
dependence cocaine use between Research
entering treatment and 6- Institutes,
average age: 36 month follow-up; clients Inc.,
male: 56% not receiving New York, New
Hispanic: 72% neurobehavioral therapy York
black: 23% showed no significant
married/common law: 49% decrease
completed at least high
school: 38%
-----------------------------------------------------------------------------------------------------------------------------------------------------
\a The source for Carroll and others is Kathleen Carroll et al.,
"Psychotherapy and Pharmacotherapy for Ambulatory Cocaine Abusers,"
Archives of General Psychiatry, 51 (1994), 177-87.
\b The source for Carroll and others is Kathleen Carroll et al., "A
Comparative Trial of Psychotherapies for Ambulatory Cocaine Abusers:
Relapse Prevention and Interpersonal Psychotherapy," American Journal
of Drug and Alcohol Abuse, 17:3 (1991), 229-47.
\c The source for Washton and Stone-Washton is Arnold Washton and
Nannette Stone-Washton, "Outpatient Treatment of Cocaine and Crack
Addiction: A Clinical Perspective," National Institute on Drug Abuse
Research Monograph #135 (Rockville, Md.: National Institute on Drug
Abuse, 1993), pp. 15-30.
\d The source for Wells and others is Elizabeth Wells et al.,
"Outpatient Treatment for Cocaine Abuse: A Controlled Comparison of
Relapse Prevention and Twelve-Step Approaches," American Journal of
Drug and Alcohol Abuse, 20:1 (1994), 1-17.
\e The source for Higgins and others is Stephen Higgins et al., "A
Behavioral Approach to Achieving Initial Cocaine Abstinence,"
American Journal of Psychiatry, 148:9 (1991), 1218-24. To test the
accuracy of self-reported client data, researchers at the University
of Vermont compared self-reports to urine test results. In 98
percent of the cases in which a client indicated nonuse, urinalysis
data confirmed the report.
\f The source for Higgins and others is Stephen Higgins et al.,
"Achieving Cocaine Abstinence With a Behavioral Approach," American
Journal of Psychiatry, 150:5 (1993), 763-69.
\g The sources for Silverman and others are K. Silverman et al.,
"Differential Reinforcement of Sustained Cocaine Abstinence in
Intravenous Polydrug Abusers," in L. S. Harris (ed.), Problems of
Drug Dependence 1994: Proceedings of the 56th Annual Scientific
Meeting, The College on Problems of Drug Dependence. National
Institute on Drug Abuse Research Monograph 153 (Rockville, Md.:
National Institute on Drug Abuse Research, 1995), p. 212, and K.
Silverman et al., "Voucher-Based Reinforcement of Cocaine Abstinence:
Effects of Reinforcement Schedule," in
L. S. Harris (ed.), Problems of Drug Dependence 1995: Proceedings
of the 57th Annual Scientific Meeting, The College on Problems of
Drug Dependence. National Institute on Drug Abuse Research
Monograph, in press. Also cited in NIDA Notes, 10:5
(September-October 1995), 10 and 14.
\h The source for Shoptaw and others is Steven Shoptaw et al., "The
Matrix Model of Outpatient Stimulant Abuse Treatment: Evidence of
Efficacy," Journal of Addictive Diseases, 13:4 (1994), 129-41.
\i The source for Rawson and others is Richard Rawson et al.,
"Neurobehavioral Treatment for Cocaine Dependency: A Preliminary
Evaluation," Cocaine Treatment: Research and Clinical Perspectives.
National Institute on Drug Abuse Research Monograph #135 (Rockville,
Md.: National Institute on Drug Abuse, 1993), pp. 92-115.
\j The source for Rosenblum and others is Andrew Rosenblum et al.,
"Treatment Intensity and Reduction in Drug Use for Cocaine-Dependent
Methadone Patients: A Dose Response Relationship." A prior version
of this paper was presented at the American Society of Addiction
Medicine Annual Conference, New York, N.Y., April 1994.
\k The source for Magura and others is Stephen Magura et al.,
"Neurobehavioral Treatment for Cocaine-Using Methadone Patients: A
Preliminary Report," Journal of Addictive Diseases, 13:4 (1994),
143-60.
RELAPSE PREVENTION
------------------------------------------------------ Appendix II:5.2
Relapse prevention provides users with the ability to recognize
triggering events, places, people, and situations, and it develops
alternative coping strategies that help the user resist those
specific triggers. Clients who received relapse prevention treatment
have demonstrated favorable abstinence rates not only during the
period of treatment but also during follow-up periods as well.
Client retention results also appear to be favorable. For example,
cocaine-dependent clients participating in a 12-week Yale University
program\53 focusing on relapse prevention were able to remain
abstinent from cocaine at least 70 percent of the time while in
treatment. A year after treatment, gains were still evident:
clients receiving relapse prevention treatment and a placebo
medication were reported to have used cocaine, on average, fewer than
3 days in the past month.
Positive outcome results were also found in a program conducted by
the Washton Institute in New York:\54 more than 60 percent of the
primarily middle-class, cocaine-addicted clients attending the
program were abstinent from cocaine during the 6- to 24-month
follow-up period. Similarly, in the Seattle area,\55
cocaine-using clients cut their average number of days of cocaine use
by 71 percent within 6 months.
Among high-severity cocaine addicts participating in another Yale
program,\56 54 percent receiving relapse prevention therapy were able
to attain at least 3 weeks of continuous abstinence, while only 9
percent of those receiving the interpersonal psychotherapy could
remain abstinent for that period of time.
Retention rates of clients in programs were also favorable: 67
percent of the relapse prevention clients completed the entire
12-week Yale program, and more than 70 percent completed the Washton
program.
--------------------
\53 Kathleen Carroll et al., "Psychotherapy and Pharmacotherapy for
Ambulatory Cocaine Abusers," Archives of General Psychiatry, 51
(1994), 177-87.
\54 Arnold Washton and Nannette Stone-Washton, "Outpatient Treatment
of Cocaine and Crack Addiction: A Clinical Perspective," National
Institute on Drug Abuse Research Monograph #135 (Rockville, Md.:
National Institute on Drug Abuse, 1993), pp. 15-30.
\55 Elizabeth Wells et al., "Outpatient Treatment for Cocaine Abuse:
A Controlled Comparison of Relapse Prevention and Twelve-Step
Approaches," American Journal of Drug and Alcohol Abuse, 20:1 (1994),
1-17.
\56 Kathleen Carroll et al., "A Comparative Trial of Psychotherapies
for Ambulatory Cocaine Abusers: Relapse Prevention and Interpersonal
Psychotherapy," American Journal of Drug and Alcohol Abuse, 17:3
(1991), 229-47.
COMMUNITY REINFORCEMENT AND
CONTINGENCY MANAGEMENT
------------------------------------------------------ Appendix II:5.3
Community reinforcement and contingency management programs are
intended to help the client achieve initial abstinence as well as an
extended drug-free lifestyle. The therapy consists of several key
community-oriented components, including the participation of a
client's family member or friend in the treatment process; management
incentives or rewards for drug abstinence; employment counseling when
needed; and the encouragement of client participation in recreational
activities as pleasurable, healthy alternatives to drug use.
Community reinforcement and contingency management therapy teaches
clients about the consequences of their actions and aims to
strengthen family and social ties.
Almost half (46 percent) of the cocaine-dependent clients
participating in a 12-week community reinforcement and contingency
management program at the University of Vermont\57
were able to remain continuously abstinent from cocaine through 2
months of treatment. When the program was extended to 24 weeks,\58
42 percent of the participating cocaine-dependent subjects were able
to achieve 4 months of continuous abstinence. By comparison, only 5
percent of those in the control group receiving drug abuse counseling
alone could remain continuously abstinent for the entire 4 months.
A year after clients began treatment, community reinforcement and
contingency management effects were still evident--65 to 74 percent
of those in the community reinforcement group reported 2 or fewer
days of cocaine use in the past month. Only 45 percent of those in
the control group achieved such gains.
Contingency management was also studied independently in an
inner-city Baltimore program.\59 Positive results were found when
tying the 12-week voucher reward system to cocaine drug testing.
Nearly half of the cocaine-abusing and cocaine-dependent clients (who
were also heroin users) given vouchers for cocaine-free urine test
results were able to remain continuously abstinent for 7 to 12 weeks.
Among clients receiving vouchers unpredictably--not tied to urine
test results--only one client achieved abstinence for more than 2
weeks.
Client retention in treatment programs was also high. Within the
Vermont community reinforcement and contingency management group, 85
percent of the clients completed the 12-week program, compared with
only 42 percent of those in the 12-step drug counseling control
group. The 24-week program was completed by about five times as many
clients in the community reinforcement group as those receiving drug
counseling therapy (58 percent versus 11 percent).
--------------------
\57 Stephen Higgins et al., "A Behavioral Approach to Achieving
Initial Cocaine Abstinence," American Journal of Psychiatry, 148:9
(1991), 1218-24.
\58 Stephen Higgins et al., "Achieving Cocaine Abstinence With a
Behavioral Approach," American Journal of Psychiatry, 150:5 (1993),
763-69.
\59 K. Silverman et al., "Differential Reinforcement of Sustained
Cocaine Abstinence in Intravenous Polydrug Abusers," in L. S.
Harris (ed.), Problems of Drug Dependence 1994: Proceedings of the
56th Annual Scientific Meeting, The College on Problems of Drug
Dependence. National Institute on Drug Abuse Research Monograph 153
(Rockville, Md.: National Institute on Drug Abuse Research, 1995),
p. 212, and K. Silverman et al., "Voucher-Based Reinforcement of
Cocaine Abstinence: Effects of Reinforcement Schedule," in L. S.
Harris (ed.), Problems of Drug Dependence 1995: Proceedings of the
57th Annual Scientific Meeting, The College on Problems of Drug
Dependence. National Institute on Drug Abuse Research Monograph, in
press. Also cited in NIDA Notes, 10:5 (September-October 1995), 10
and 14.
NEUROBEHAVIORAL THERAPY
------------------------------------------------------ Appendix II:5.4
Neurobehavioral therapy is a comprehensive, 12-month outpatient
treatment approach that includes individual therapy, drug education,
client stabilization, and self-help group involvement. Five major
stages of recovery are distinguished during the treatment process
with emphasis on addressing the client's behavioral, emotional,
cognitive, and relational problems at each stage of recovery.
Several programs have demonstrated that a neurobehavioral therapeutic
approach can also be effective in promoting cocaine abstinence and
treatment retention. Thirty-six percent of the cocaine-abusing and
cocaine-dependent clients participating in a neurobehavioral therapy
program through the Matrix Institute in California\60 succeeded in
remaining continuously abstinent from cocaine for at least 8
consecutive weeks while in treatment. Follow-up results obtained 6
months after treatment entry showed that 38 percent of these clients
still tested drug free. In a separate examination of two
neurobehavioral outpatient treatment sites,\61 at least 40 percent of
the cocaine clients in each site remained continuously abstinent
through the entire 6-month course of therapy.
Given the high rate of cocaine use among methadone clients, the
neurobehavioral model was adapted in New York for use among methadone
clients meeting the diagnostic criteria for cocaine dependence. In
an intensive 6-month program,\62 a strong relationship was found
between the number of sessions attended and cocaine use reduction.
Clients attending 3 to 19 sessions experienced a 5-percent reduction
in cocaine use during the previous month. Those attending 85 to 133
sessions experienced a 60-percent reduction in their past 30-day use
of cocaine. In another New York study\63 with cocaine-addicted
methadone clients, individuals receiving neurobehavioral treatment
demonstrated a significant decrease in cocaine use between entering
treatment and 6-month follow-up; the control group showed no
statistically significant decrease.
Neurobehavioral retention rates also proved favorable. In the
California study of two treatment sites, clients were retained an
average of about 5 months and 3 months; in the other California
study, the average length of stay for cocaine users was about 4-1/2
months. For the first New York study, a total of 61 percent of the
cocaine-dependent methadone clients completed the initial 6-month
cocaine treatment regimen.
--------------------
\60 Steven Shoptaw et al., "The Matrix Model of Outpatient Stimulant
Abuse Treatment: Evidence of Efficacy," Journal of Addictive
Diseases, 13:4 (1994), 129-41.
\61 Richard Rawson et al., "Neurobehavioral Treatment for Cocaine
Dependency: A Preliminary Evaluation," Cocaine Treatment: Research
and Clinical Perspectives. National Institute on Drug Abuse Research
Monograph #135 (Rockville, Md.: National Institute on Drug Abuse,
1993), pp. 92-115.
\62 Andrew Rosenblum et al., "Treatment Intensity and Reduction in
Drug Use for Cocaine-Dependent Methadone Patients: A Dose Response
Relationship." A prior version of this paper was presented at the
American Society of Addiction Medicine Annual Conference, New York,
New York, April 1994.
\63 Stephen Magura et al., "Neurobehavioral Treatment for
Cocaine-Using Methadone Patients: A Preliminary Report," Journal of
Addictive Diseases, 13:4 (1994), 143-60.
ADDITIONAL RESEARCH INITIATIVES
IDENTIFIED FOR PREVENTION AND
TREATMENT EFFECTIVENESS
-------------------------------------------------------- Appendix II:6
In our literature search, we found that early research has
demonstrated that psychosocial and comprehensive approaches to drug
prevention have led to decreased use of drugs among school-age youths
as well as reductions in risk factors and the enhancement of
protective factors. Relapse prevention, community reinforcement and
contingency management, and neurobehavioral therapy have resulted in
increased abstinence and extended periods of treatment retention
among cocaine-abusing and dependent clients. Although these research
results in the 1990s demonstrate promising approaches to drug
prevention for school-age youths and treatment for cocaine abuse and
dependence, some of these strategies have not been tried, tested, and
evaluated in different settings, for different target populations, in
various combinations, and over long periods of time. Therefore,
there is still a wide array of research initiatives that can be
pursued to better understand what promise these approaches hold for
effectively preventing, reducing, or treating drug problems. Some of
the prevention initiatives suggested by IOM and cocaine treatment
initiatives recommended by cocaine abuse experts follow. Additional
treatment initiatives can be found in our 1996 cocaine treatment
report.\64
--------------------
\64 Cocaine Treatment: Early Results From Various Approaches
(GAO/HEHS-96-80, June 7, 1996).
PREVENTION
------------------------------------------------------ Appendix II:6.1
Testing the utility of booster sessions. Prevention training
programs frequently take place over the course of only one or two
grades (for example, Project ALERT takes place in the 7th and 8th
grades). While we have seen that immediate, or short-term, outcome
results can be quite promising, positive successes can begin to fade
as other negative stimuli and pressures confront the individual.
Booster sessions have been shown in limited trials to reinforce
initial training sessions and help maintain positive outcome
findings. However, because boosters are infrequently used, there is
limited supporting evidence on the appropriate content of booster
sessions for different age groups. Such knowledge is important for
maintaining positive prevention and treatment outcome gains over
time.
Determining the mix of program components that yield the most
significant outcome results. Outcome results of various promising
practices have shown that sizable percentages of the intervention
group had not become drug users at the time of the follow-up.
Whether these results can be substantially improved with a different
mix of prevention approaches and program components remains to be
demonstrated.
Evaluating how best to disseminate positive findings to the larger
community. In many instances, the promising practice prevention
programs supported by the federal government are not being adopted at
the local level. Further research is, therefore, necessary to
determine how best to market the more effective prevention programs
to the user community.
Assessing the types of program approaches that work best for
different target populations, in diverse environmental settings, with
varying trainers. Many prevention programs have been evaluated only
with restricted target audiences (for example, 7th graders in a
limited geographic area) by the principal investigator and staff.
The extent to which one can generalize from these prevention
approaches remains to be determined. Also, further research directed
at how these programs can be modified for various target groups,
while maintaining the essential components of the intervention
program, is needed. In addition, the effect that trainers other than
the principal investigator will have on the outcome results will
broaden the knowledge base of the widespread applicability of these
approaches.
TREATMENT
------------------------------------------------------ Appendix II:6.2
Identifying improved additional cognitive/behavioral strategies to
reduce relapse. Additional study of the promising treatment
approaches is warranted to (1) identify optimal sanction systems to
be used in contingency management practices, (2) obtain a more
in-depth understanding of the triggers that promote drug use, and (3)
identify the appropriate intensities and durations of treatment
necessary for the successful implementation of each of the promising
practices. The results of this research could lead to increasing a
client's ability to avoid relapse and, thereby, minimize substance
abuse third-party payments.
Testing the effectiveness and safety of new medications to prevent or
reduce drug intake. Advancement in the pharmacological area rests on
a better understanding of brain functioning, the immune system, and
actions of the specific illicit drugs. This requires further
development and testing of medications to (1) block a drug's toxicity
and aid in the withdrawal process, (2) reduce craving for the drug,
and (3) inhibit the euphoric "high" induced by the drug. With the
craving reduced and the euphoric high diminished, it follows that the
use of the drug will decline.
Identifying the necessary components of promising
cognitive/behavioral strategies and medications that lead to
successful outcomes. This is of particular importance when
disseminating these model cocaine treatment practices to the local
practitioner. The practitioner may have little time to be trained,
may need to streamline use of the approach down to its bare
essentials to fit in with other schedule requirements, and may need
to know where local adaptations can be incorporated.
Substantiating outcome results through further research and
evaluation is an important step in advancing promising drug
prevention and treatment approaches. It is also important in helping
policymakers to better focus efforts and resources on proven
effective drug abuse prevention and treatment programs. In light of
federal efforts to establish national goals in an overall drug
strategy and to assess results through program performance measures
and evaluation, definitive research can be an important prerequisite
to focusing and maximizing the use of federal resources.
COAST GUARD HAS MADE PROGRESS, BUT
CHALLENGES REMAIN IN DEVELOPING
ANTIDRUG STRATEGIC AND PERFORMANCE
PLANS
========================================================= Appendix III
A component of the Department of Transportation, the Coast Guard is
the federal agency primarily responsible for providing many maritime
services and enforcing related laws and regulations. Its staff and
equipment are involved in multimissions that range from national
security to environmental protection. For fiscal year 1997, the
Coast Guard's budget is about $3.84 billion.
The Coast Guard is the lead federal agency for maritime drug
interdiction. It shares lead responsibility with the U.S. Customs
Service for air interdiction. The Coast Guard's antidrug authority
covers domestic waters (12 miles from U.S. shores), including
navigable waters of the United States and international waters.
Where bilateral agreements permit, the Coast Guard has special
jurisdiction in foreign waters. For fiscal year 1997, the Coast
Guard estimated that its budget for antidrug activities is about $336
million.
The Coast Guard has made progress in developing antidrug performance
measures that conform with GPRA requirements; however, challenges
remain. Government Performance and Results Act (GPRA) requires
federal agencies\65 to develop two types of plans--a strategic
plan\66 by the end of fiscal year 1997 and annual performance
plans,\67 the first of which is to cover fiscal year 1999. The Coast
Guard's preliminary plans represent a start at incorporating a
results-oriented approach to drug interdiction, but as could be
expected at this early date, they also reflect a need for additional
work. The Coast Guard has recognized three areas that require more
attention:
-- developing data to measure the results of antidrug actions,
-- developing goals and ways of achieving them, and
-- identifying the wide variety of constraints that could influence
the Coast Guard's ability to deter the flow of drugs into the
United States via maritime routes.
--------------------
\65 Under GPRA, "agency" is defined as an executive department, a
government corporation, and an independent establishment. The Coast
Guard is implementing GPRA in support of the Department of
Transportation.
\66 Under GPRA, a strategic plan is the starting point for agencies
to set annual goals for programs and to measure the performance of
the programs in achieving those goals. GPRA requires each federal
agency to develop strategic plans that cover a period of at least 5
years and include the agency's missions statement; identify the
agency's long-term strategic goals; and describe how the agency
intends to achieve those goals through its activities and though its
human, capital, information, and other resources.
\67 The annual performance plan provides the direct linkage between
the strategic goals outlined in the agency's strategic plan and what
managers and employees do day-to-day. The plan is to contain the
performance goals the agency will use to gauge its progress toward
accomplishing its strategic goals and identify the performance
measures the agency will use to assess its progress.
COAST GUARD HAS MADE PROGRESS
TOWARD IMPLEMENTING GPRA
PRINCIPLES
------------------------------------------------------- Appendix III:1
The Coast Guard has taken action toward implementing the principles
of GPRA for its antidrug activities. Under GPRA, the Coast Guard has
defined its results-oriented performance goal as "reducing the amount
of illegal drugs entering the country through maritime routes by 25
percent over five years." The primary indicator it plans to use in
measuring progress toward achieving this goal is data comparing the
amount of drugs seized and deterred with the amount bound for the
United States via maritime routes. The Coast Guard also plans to use
a variety of secondary indicators, such as surveillance coverage and
intercept rates.\68
The preliminary goal and indicators show progress in conforming with
certain GPRA principles in that the goal covers a period of 5 years,
is results oriented, and is potentially measurable. However, as the
next sections discuss, Coast Guard efforts at conforming with the
full extent of GPRA is a work in progress.
--------------------
\68 The Coast Guard defines "surveillance coverage" as the area
covered divided by the area assigned per 24-hour period. It defines
"intercept" as directing the movement of a Coast Guard asset to the
scene of an identified target to support the collection of additional
information and to take further action, if appropriate. The
"interception rate" is defined as the number of intercepts divided by
the number of intercepts attempted.
MEASURING RESULTS OF DRUG
INTERDICTION PRESENTS
CHALLENGES
------------------------------------------------------- Appendix III:2
GPRA requires agencies to measure the results of their programs.
Measuring the results of drug-control actions is difficult because
data on illegal drugs entering the country are more difficult to
develop than data on most legal commodities. Without knowing how
much was shipped or what got through, the amount of contraband seized
does not yield a meaningful measure of effectiveness. The
ONDCP-sponsored Semiannual Interagency Assessment of Cocaine Movement
has made some progress in developing estimates on the amount of
cocaine entering the United States via surface, air, and maritime
routes. The Coast Guard is using these data as a primary indicator
of its antidrug activities. If reasonably accurate, these data could
aid the Coast Guard in measuring the results of its cocaine
interdiction program. According to an ONDCP official, ONDCP is
working with the intelligence components of federal agencies involved
in foreign and domestic drug control programs to develop a
comprehensive baseline on heroin production and trafficking.
Developing a heroin flow model will be part of this project.
A second factor that makes the measurement of results difficult is
that of separating the impact of the Coast Guard's actions from those
of other agencies. For example, a decrease in the amount of drugs
entering the United States via maritime routes could be the result of
greater efforts by other federal agencies to control drugs in the
source country, lower domestic demand due to demand-reduction
efforts, or better intelligence rather than Coast Guard interdiction
efforts. In this regard, Coast Guard officials recognize that
measures showing the overall result of the U.S. drug control effort
are needed. For example, they stated that placing additional
resources in key choke points could result in reduced smuggling
activity in one area; however, smugglers may still ship drugs to the
United States through other transportation means or routes. Thus,
while the actions of one agency may result in success in its area of
responsibility, only interagency measures of effectiveness and the
attendant data would provide a basis to gauge the success of the
total U.S. effort.
COAST GUARD OFFICIALS
ACKNOWLEDGE THAT DEVELOPING
GOALS AND METHODS FOR
ACHIEVING THEM STILL NEED TO
BE REFINED
----------------------------------------------------- Appendix III:2.1
Coast Guard officials acknowledge that complying with the GPRA
requirements to develop results-oriented performance goals and to
identify methods of achieving them is a work-in-progress. Coast
Guard officials indicated that the extent to which they reduce
illegal drugs entering the United States via maritime routes over the
next 5 years is largely dependent on additional resources. Coast
Guard officials expect that additional resources and assets will
deter smugglers from using a particular route, cause them to stop
smuggling entirely, or result in interdiction of about 90 percent of
all maritime smuggling traffic in high-risk areas (if the Coast Guard
has a "contact rate" of 40 percent with the smuggling community).\69
The officials base this expectation on a 1989 study that collected
opinions from convicted smugglers on their view of the risk level
that would stop them from smuggling drugs.\70 Coast Guard officials
believe that a greater presence and interdiction actions in targeted
areas will result in smugglers' perception that the chances of being
caught are high, contributing to the deterrence or interdiction of
about 90 percent of smuggling traffic in target areas.
Information from another study suggests that more resources make a
difference in reducing the supply of illegal drugs coming into the
United States, but the difference may not be significant. A recent
study conducted for ONDCP examined the impact of more resources in
disrupting the flow of drugs in the transit zone.\71
The study estimated that smugglers successfully moved about 560 tons
of cocaine in the transit zone in 1994, and it evaluated the
potential impact of committing an additional $200 million and $500
million to the transit zone. It projected that smugglers would
successfully move 470 metric tons (11-percent reduction) in the
transit zone under the $200 million option and that they would
successfully move 430 metric tons (16-percent reduction) under the
$500 million option. According to the study, "given that annual U.S.
cocaine consumption is less than 300 tons, the impact of the
additional resources in the transit zone does not seem significant
enough to affect U.S. drug use."
On the basis of this analysis, the study concluded that "[i]t does
not appear that the potential benefit of decreased trafficker
smuggling success rate in the transit zone is significant enough to
warrant additional resources." The study noted that the federal
policy challenge is not only to determine the benefits from direct
investment in the transit zone but also to consider whether the
investment of a similar level of resources elsewhere in the drug
strategy might produce even more benefits.\72 The study, however,
contained several methodological limitations, including a low level
of confidence in its predictions and a limited scope, such as not
analyzing the potential benefits of investing resources in the source
countries.
Coast Guard officials generally agreed with the analysis in the study
but disagreed with the conclusions. Officials agreed that the amount
of cocaine deterred in the transit zone would total about 90 metric
tons, or an 11-percent reduction, if an additional $200 million were
to be committed to the transit zone. Unlike the study, Coast Guard
officials believe that this level of reduction would be a good return
on the investment. Officials pointed out that at the time of the
study, the additional resources ($200 million) needed for this level
of reduction was only about 1.6 percent of the total federal antidrug
budget.
--------------------
\69 According to Coast Guard officials, they have not developed an
estimate of the amount of additional resources needed to achieve a
40-percent "contact rate"; however, they plan to determine this
amount in the future. The Coast Guard defines "contact rate" as the
frequency with which Coast Guard assets make contact with maritime
traffic in targeted areas, including interdiction and boarding known
or suspected smugglers. According to the Coast Guard, it currently
has a contact rate of 12 percent, which results in deterrence or
interdiction of 29 percent of smugglers using maritime routes.
\70 Measuring Deterrence - Approach and Methodology, Rockwell
International Special Investigations, Inc., Decisions Science
Applications, Sumner Associates, Oct. 27, 1989.
\71 The National Drug Control Strategy, 1996: Program, Resources,
and Evaluation. Office of National Drug Control Policy, Washington,
D.C., pp. 48-51.
\72 The study suggested the following order of priority if funding is
increased: (1) increase intelligence, which because of its relative
low cost has the greatest leverage and is critical for responding to
the maritime threat; (2) improve disruption capability because,
without it, law enforcement would be unable to respond to the targets
identified by increased and improved intelligence; and (3) increase
detection and monitoring to fill geographic gaps and ensure an
ability to link intelligence and disruption capability.
COAST GUARD OFFICIALS
IDENTIFY CONSTRAINTS OTHER
THAN FUNDING THAT AFFECT
THEIR ANTIDRUG EFFORTS
----------------------------------------------------- Appendix III:2.2
GPRA requires an identification of key factors external to the agency
and beyond its control that could significantly affect the
achievement of its goals and objectives. In developing its
preliminary plans, the Coast Guard has identified the level of
resources as a primary factor that influences its ability to achieve
the goal that it ultimately establishes. However, identifying and
interdicting maritime drug smuggling is affected by other constraints
as well. Following are several constraints that the Coast Guard says
also affect its antidrug efforts:
-- Covering large geographic areas is problematic. When smugglers
use maritime routes, they may not ship the drugs directly to the
United States, but instead they may ship the drugs to Mexico or
Central American countries and then to the United States via
land or air routes. An estimated 180 metric tons of cocaine are
transported annually from Colombia to Mexico or other Central
American countries via maritime routes in the eastern Pacific
Ocean, according to the ONDCP-sponsored Semiannual Interagency
Assessment of Cocaine Movement. Coast Guard officials stated
that this is an area of concern because success in deterring
drugs in the Caribbean could result in more smuggling activity
in the Pacific. Coast Guard officials noted that unlike the
Caribbean, where specific routes and choke points have been
identified, interdiction and deterrence in the eastern Pacific
presents greater challenges because of the size of the area.
-- Sovereignty constraints. Coast Guard officials cited
sovereignty issues with foreign-flag vessels as another factor
that complicates their antidrug efforts. Coast Guard officials
stated that bilateral maritime counternarcotic agreements are
being sought with countries such as Colombia, Jamaica, Mexico,
Barbados, and Nicaragua.\73 According to Coast Guard officials,
these agreements provide them with greater flexibility to carry
out their antidrug activities. Such agreements outline the
criteria for boarding and pursuing foreign-flag vessels. Also,
they may authorize the Coast Guard to fly over foreign airspace,
to order suspect aircraft to land in the host nation, to
investigate suspect vessels in foreign waters, or authorize the
Coast Guard to conduct other law enforcement activities, such as
boardings, in foreign waters.
-- Increasing use of technology by smugglers. Coast Guard
officials also noted that smugglers are using more sophisticated
means to conceal and transport drugs, such as the use of global
positioning systems and camouflaged vessels to avoid detection.
According to Coast Guard officials, the use of the positioning
systems allows traffickers to determine airdrop coordinates
prior to departure, thus reducing the amount of radio
communication needed. Officials noted that the increasing use
of technology makes it more difficult to gather the information
needed to track and interdict the shipment of illegal drugs
through the Caribbean because traffickers can detect whether
they are being followed.
--------------------
\73 By December 1996, antidrug bilateral agreements had been signed
with 16 countries: Antigua and Barbuda, Bahamas, Belize, Dominica,
Dominican Republic, Grenada, Haiti, Netherlands Antilles, Panama, St.
Kitts and Nevis, St. Lucia, St. Vincent/Grenadines, Trinidad and
Tobago, Turks and Caicos, United Kingdom, and Venezuela.
MAJOR CONTRIBUTORS TO THIS REPORT
========================================================== Appendix IV
GENERAL GOVERNMENT DIVISION,
WASHINGTON, D.C.
Weldon McPhail, Assistant Director, Administration of Justice
Issues
Richard B. Groskin, Evaluator-in-Charge
Carolyn S. Ikeda, Senior Evaluator
Dennise R. Stickley, Evaluator
David P. Alexander, Senior Social Science Analyst
Pamela V. Williams, Communications Analyst
HEALTH, EDUCATION, AND HUMAN
SERVICES DIVISION, WASHINGTON,
D.C.
Bernice Steinhardt, Director, Health Financing and
Public Health Issues
James O. McClyde, Assistant Director, Health Financing
and Public Health Issues
Jared Hermalin, Senior Evaluator
NATIONAL SECURITY AND
INTERNATIONAL AFFAIRS DIVISION,
WASHINGTON, D.C.
Jess T. Ford, Associate Director, International Relations and
Trade
Allen C. Fleener, Senior Evaluator
RESOURCES, COMMUNITY, AND ECONOMIC
DEVELOPMENT DIVISION, WASHINGTON,
D.C.
John H. Anderson, Jr., Director, Transportation and
Telecommunications Issues
SEATTLE FIELD OFFICE
Randall B. Williamson, Assistant Director,
Transportation and Telecommunications Issues
Neil T. Asaba, Senior Evaluator
OFFICE OF THE GENERAL COUNSEL,
WASHINGTON, D.C.
Nancy Finley, Senior Attorney
RELATED GAO PRODUCTS\74
1996
Substance Abuse Treatment: VA Programs Serve Psychologically and
Economically Disadvantaged Veterans (GAO/HEHS-97-6, Nov. 5, 1996).
Drug and Alcohol Abuse: Billions Spent Annually for Treatment and
Prevention Activities (GAO/HEHS-97-12, Oct. 8, 1996).
Customs Service: Drug Interdiction Efforts (GAO/GGD-96-189BR, Sept.
26, 1996).
Drug Control: U.S. Heroin Control Efforts in Southeast Asia
(GAO/T-NSIAD-96-240, Sept. 19, 1996).
Drug Control: Observations on Counternarcotics Activities in Mexico
(GAO/T-NSIAD-96-239, Sept. 12, 1996.)
Terrorism and Drug Trafficking: Technologies for Detecting
Explosives and Narcotics (GAO/NSIAD/RCED-96-252, Sept. 4, 1996).
Substance Abuse Surveys (GAO/HEHS-96-179R, July 19, 1996).
Drug Control: Observations on Counternarcotics Efforts in Mexico
(GAO/T-NSIAD-96-182, June 12, 1996).
Drug Control: Counternarcotics Efforts in Mexico (GAO/NSIAD-96-163,
June 12, 1996).
Cocaine Treatment: Early Results From Various Approaches
(GAO/HEHS-96-80, June 7, 1996).
Drug Control Observations on U.S. Interdiction in the Caribbean
(GAO/T-NSIAD-96-171, May 23, 1996).
Drug Control: U.S. Interdiction Efforts in the Caribbean Decline
(GAO/NSIAD-96-119, Apr. 17, 1996).
Terrorism and Drug Trafficking: Threats and Roles of Explosives and
Narcotics Detection Technology (GAO/NSIAD/RCED-96-76BR, Mar. 27,
1996).
At-Risk and Delinquent Youth: Multiple Federal Programs Raise
Efficiency Questions (GAO/HEHS-96-34, Mar. 6, 1996).
Drug Control: U.S. Heroin Program Encounters Many Obstacles in
Southeast Asia (GAO/NSIAD-96-83, Mar. 1, 1996).
1995
Review of Assistance to Colombia (GAO/NSIAD-96-62R, Dec. 12, 1995).
Drug War: Observations on U.S. International Drug Control Efforts
(GAO/T-NSIAD-95-194, Aug. 1, 1995)
Treatment of Hardcore Cocaine Users (GAO/HEHS-95-179R, July 31,
1995).
Drug War: Observations on the U.S. International Drug Control
Strategy (GAO/T-NSIAD-95-182, June 27, 1995).
Drug Courts: Information on a New Approach to Address Drug-Related
Crime (GAO/GGD-95-159BR, May 22, 1995).
Honduras: Continuing U.S. Military Presence at Soto Cano Base Is
Not Critical (GAO/NSIAD-95-39, Feb. 8, 1995).
1994
Border Control: Revised Strategy Is Showing Some Positive Results
(GAO/GGD-95-30, Dec. 29, 1994).
Drug Activity in Haiti (GAO/OSI-95-6R, Dec. 28, 1994).
Drug Control: U.S. Antidrug Efforts in Peru's Upper Huallaga Valley
(GAO/NSIAD-95-11, Dec. 7, 1994).
U.S. Postal Service: Drug Investigation Data (GAO/GGD-95-29FS, Dec.
6, 1994).
Drug Control: U.S. Drug Interdiction Issues in Latin America
(GAO/T-NSIAD-95-32, Oct. 7, 1994).
Drug Control in Peru (GAO/NSIAD-94-186R, Aug. 16, 1994).
Drug Control: U.S. Counterdrug Activities in Central America
(GAO/T-NSIAD-94-251, Aug. 2, 1994).
Drug Control: Interdiction Efforts in Central America Have Had
Little Impact on the Flow of Drugs (GAO/NSIAD-94-233, Aug. 2, 1994).
INS Drug Task Force Activities: Federal Agencies Supportive of INS
Efforts (GAO/GGD-94-143, July 7, 1994).
Disability Benefits for Addicts (GAO/HEHS-94-178R, June 8, 1994).
Social Security: Major Changes Needed for Disability Benefits for
Addicts (GAO/HEHS-94-128, May 13, 1994).
Weed and Seed: Program Objectives (GAO/GGD-94-128R, May 10, 1994).
Foster Care: Parental Drug Abuse Has Alarming Impact on Young
Children (GAO/HEHS-94-89, Apr. 4, 1994).
Money Laundering: The Volume of Currency Transaction Reports Filed
Can and Should Be Reduced (GAO/GGD-94-113, Mar. 15, 1994).
Money Laundering: U.S. Efforts to Fight It Are Threatened by
Currency Smuggling (GAO/GGD-94-73, Mar. 9, 1994).
Money Laundering: Project Gateway (GAO/GGD-94-91R, Feb. 15, 1994).
Social Security: Disability Benefits for Drug Addicts and Alcoholics
Are Out of Control (GAO/HEHS-94-101, Feb. 10, 1994).
Residential Care: Some High-Risk Youth Benefit, but More Study
Needed (GAO/HEHS-94-56, Jan. 28, 1994).
1993
Drug Use Among Youth: No Simple Answers to Guide Prevention
(GAO/HRD-94-24, Dec. 29, 1993).
Border Management: Dual Management Structure at Entry Ports Should
End (GAO/T-GGD-94-34, Dec. 10, 1993).
Illicit Drugs: Recent Efforts to Control Chemical Diversion and
Money Laundering (GAO/NSIAD-94-34, Dec. 8, 1993).
Financial Management: Customs' Accountability for Seized Property
and Special Operations Advances Was Weak (GAO/AIMD-94-6, Nov. 22,
1993).
Drug Control: The Office of National Drug Control Policy--
Strategies Need Performance Measures (GAO/T-GGD-94-49, Nov. 15,
1993).
Money Laundering: Characteristics of Currency Transaction Reports
Filed in Calendar Year 1992 (GGD-94-45FS, Nov. 10, 1993).
Money Laundering: Progress Report on Treasury's Financial Crimes
Enforcement Network (GAO/GGD-94-30, Nov. 8, 1993).
Mandatory Minimum Sentences: Are They Being Imposed and Who Is
Receiving Them? (GAO/GGD-94-13, Nov. 4, 1993).
Drug Control: Expanded Military Surveillance Not Justified by
Measurable Goals or Results (GAO/T-NSIAD-94-14, Oct. 5, 1993).
The Drug War: Colombia Is Implementing Antidrug Efforts, but Impact
Is Uncertain (GAO/T-NSIAD-94-53, Oct. 5, 1993).
Drug Control: Reauthorization of the Office of National Drug Control
Policy (GAO/GGD-93-144, Sept. 29, 1993).
Drug Control: DOD Operated Aerostat Ship Although Conferees Denied
Funds (GAO/NSIAD-93-213, Sept. 10, 1993).
Drug Control: Heavy Investment in Military Surveillance Is Not
Paying Off (GAO/NSIAD-93-220, Sept. 1, 1993).
The Drug War: Colombia Is Undertaking Antidrug Programs, But Impact
Is Uncertain (GAO/NSIAD-93-158, Aug. 10, 1993).
Confronting the Drug Problem: Debate Persists on Enforcement and
Alternative Approaches (GAO/GGD-93-82, July 1, 1993).
Customs Service and INS: Dual Management Structure for Border
Inspections Should Be Ended (GAO/GGD-93-111, June 30, 1993).
Drug Use Measurement: Strengths, Limitations, and Recommendations
for Improvement (GAO/PEMD-93-18, June 25, 1993).
Drugs: International Efforts to Attack a Global Problem
(GAO/NSIAD-93-165, June 23, 1993).
Money Laundering: The Use of the Bank Secrecy Act Reports by Law
Enforcement Could Be Increased (GAO/T-GGD-93-31, May 26, 1993).
Drug Control: Revised Drug Interdiction Approach Is Needed in Mexico
(GAO/NSIAD-93-152, May 10, 1993).
War on Drugs: Federal Assistance to State and Local Drug Enforcement
(GAO/GGD-93-86, Apr. 29, 1993).
Indian Health Service: Basic Services Mostly Available; Substance
Abuse Problems Need Attention (GAO/HRD-93-48, Apr. 9, 1993).
Drug Control: Coordination of Intelligence Activities
(GAO/GGD-93-83BR, Apr. 2, 1993).
Drug Education: Limited Progress in Program Evaluation
(GAO/T-PEMD-93-2, Mar. 31, 1993).
Community-Based Drug Prevention: Comprehensive Evaluations of
Efforts Are Needed (GAO/GGD-93-75, Mar. 24, 1993).
Needle Exchange Programs: Research Suggests Promise as an AIDS
Prevention Strategy (GAO/HRD-93-60, Mar. 23, 1993).
U.S. Customs Service Performance Indicators (GAO/AFMD-93-47R, Mar.
10, 1993).
Drug Control: Increased Interdiction and Its Contribution to the War
on Drugs (GAO/T-NSIAD-93-4, Feb. 25, 1993).
Drug Control: Treatment Alternatives to Street Crime (GAO/GGD-93-61,
Feb. 11, 1993).
Drug Control: Status Report on Counterdrug Technology Development
(GAO/NSIAD-93-104, Jan. 28, 1993).
--------------------
\74 For a list of GAO's federal drug control products issued before
January 1, 1993 (covering fiscal years 1988 through 1993), see Drug
Control: Reauthorization of the Office of National Drug Control
Policy (GAO/GGD-93-144, Sept. 29, 1993).
*** End of document. ***