Drug Abuse Treatment: Efforts Under Way to Determine Effectiveness of
State Programs (Letter Report, 02/15/2000, GAO/HEHS-00-50).

Pursuant to a congressional request, GAO reviewed the efforts by the
Substance Abuse and Mental Health Services Administration (SAMHSA) and
states to provide effective drug abuse treatment programs, focusing on:
(1) activities supported by SAMHSA's Substance Abuse Prevention and
Treatment (SAPT) block grant and Knowledge Development and Application
(KDA) grant funds for drug abuse treatment; (2) SAMHSA and state
mechanisms for monitoring fund use; and (3) SAMHSA and state efforts to
determine the effectiveness of drug abuse treatment supported with SAPT
block grant funds.

GAO noted that: (1) about $581 million in SAMHSA's fiscal year (FY) 1996
grant funds was spent on drug abuse treatment activities; (2) more than
$478 million was spent by all states for treatment services funded
through the SAPT block grant program; (3) the 16 states GAO surveyed
reported that SAPT funds supported both residential and outpatient drug
abuse treatment services, including detoxification and methadone
maintenance; (4) for half of the states in GAO's survey, outpatient drug
abuse treatment services accounted for 57 to 85 percent of their block
grant expenditures; (5) all of the states GAO surveyed reported
providing methadone treatment services almost exclusively on an
outpatient basis; (6) SAMHSA spent another $25 million of the SAPT block
grant for technical assistance and evaluation activities related to drug
abuse treatment; (7) the remaining $78 million of SAMHSA's FY 1996
grants were KDA funds provided to community-based organizations,
universities, and state and local government agencies to develop and
disseminate information on promising drug abuse treatment practices; (8)
to monitor grantees' use of SAPT and KDA program funds, SAMHSA uses
on-site reviews, reviews of independent financial audit reports, and
application reviews; (9) these mechanisms are primarily used to monitor
grantees' compliance with program requirements, identify grantees'
technical assistance needs, and provide grantees guidance for improving
program operations; (10) the accountability system for the SAPT block
grant is mostly based on a review of state expenditures; (11) SAMHSA
primarily monitors states' compliance with certain statutory
requirements for use of funds; (12) the states also monitor SAPT block
grant funds using mechanisms similar to SAMHSA's; (13) they used the
results of their monitoring efforts, in part, to make drug abuse
treatment funding allocation decisions and determine technical
assistance needs; (14) several state and SAMHSA efforts are under way to
determine the effectiveness of drug abuse treatment programs using
client outcome measures, such as drug use, employment, criminal activity
and living status; (15) nine of the 16 states that GAO surveyed have
conducted such assessments, but the results vary from state to state;
(16) SAMHSA officials believe that collecting uniform state-level client
outcome and other performance data are critical to determining the
effectiveness of state programs supported with SAPT block grant funds;
and (17) however, this effort is not likely to result in uniform state
data because some of the states reported that they would not be able to
submit all of the requested data.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-00-50
     TITLE:  Drug Abuse Treatment: Efforts Under Way to Determine
	     Effectiveness of State Programs
      DATE:  02/15/2000
   SUBJECT:  Drug treatment
	     Grant monitoring
	     Drug abuse
	     Block grants
	     Federal/state relations
	     State-administered programs
	     Methadone maintenance
	     Reporting requirements
	     Discretionary grants
	     Funds management
IDENTIFIER:  HHS Knowledge Development and Application Program
	     SAMHSA Substance Abuse Prevention and Treatment Block
	     Grant Program
	     SAMHSA State Treatment Needs Assessment Program
	     SAMHSA Services Research Outcome Study
	     SAMHSA Treatment Outcomes and Performance Pilot Studies
	     Enhancement Grant Program
	     SAMHSA National Treatment Improvement Evaluation Study
	     SAMHSA National Household Survey on Drug Abuse
	     SAMHSA Drug Abuse Warning Network
	     SAMHSA Drug Abuse Services Information System

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GAO/HEHS-00-50

Appendix I: Objectives, Scope, and Methodology

28

Appendix II: History and Administration of SAMHSA

30

Appendix III: KDA Grant Programs and Funding for Drug Abuse
Treatment

37

Appendix IV: State Program Assessments

40

Table 1: Characteristics of SAMHSA's Major Drug Abuse
Treatment Studies 20

Table 2: States' Client Outcome Assessment Activities 22

Table 3: SAMHSA's Administrative Expenses, Fiscal Year 1999 Appropriation 31

Table 4: Selected SAMHSA Contracts for Technical Assistance
and Program Evaluation, Fiscal Year 1999, by Agency and
Program 32

Table 5: SAMHSA's Staffing Levels by Program, as of
December 1999 35

Figure 1: Percentage of SAMHSA's Drug Abuse Treatment
Expenditures for SAPT Block Grant and KDA Grant Programs,
Fiscal Year 1996 9

Figure 2: Percentage of Surveyed State Agencies' Total
Expenditures for Drug Abuse Treatment Services by
Funding Source, Fiscal Year 1996 10

Figure 3: Percent of SAPT Block Grant Expenditures for
Methadone Services, Fiscal Year 1996 12

ADATSA Alcoholism and Drug Addiction Treatment and Support Act

HHS Department of Health and Human Services

KDA Knowledge Development and Application

NIDA National Institute on Drug Abuse

SAMHSA Substance Abuse and Mental Health Services Administration

SAPT Substance Abuse Prevention and Treatment

TASC Treatment Alternatives to Street Crime

TOPPS Treatment Outcomes and Performance Pilot Studies

TOPPS II Treatment Outcomes and Performance Pilot Studies Enhancement

Health, Education, and
Human Services Division

B-281927

February 15, 2000

The Honorable John L. Mica
Chairman
The Honorable Patsy Mink
Ranking Minority Member
Subcommittee on Criminal Justice, Drug Policy
and Human Resources
Committee on Government Reform
House of Representatives

Drug abuse continues to be a major national problem and concern. National
survey data show that in 1998, 13.6 million Americans reported that they had
used an illicit drug in the past month. The cost of drug abuse to
society--which includes costs for health care, drug addiction prevention and
treatment, drug-related crime prevention, and lost resources resulting from
reduced worker productivity or death--is estimated at $67 billion annually.
For treatment-related programs, the federal government spent more than $3.2
billion in fiscal year 1998.1 To better understand how federal funds are
used, you asked us to describe efforts by the Substance Abuse and Mental
Health Services Administration (SAMHSA) and states to provide effective drug
abuse treatment programs. Specifically, you asked us to describe (1)
activities supported by SAMHSA's Substance Abuse Prevention and Treatment
(SAPT) block grant and Knowledge Development and Application (KDA) grant
funds for drug abuse treatment; (2) SAMHSA and state mechanisms for
monitoring fund use; and (3) SAMHSA and state efforts to determine the
effectiveness of drug abuse treatment supported with SAPT block grant funds.

Our work on SAPT program activities included a survey of the 16 states that
received at least $25 million for their fiscal year 1996 SAPT block grant
award: California, Florida, Georgia, Illinois, Indiana, Maryland,
Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Texas, Virginia, and Washington. We interviewed selected
respondents on their use of these funds for residential and outpatient drug
abuse treatment services, including detoxification and methadone
maintenance. We asked states to exclude their use of SAPT block grant funds
for activities other than drug abuse treatment, such as alcohol treatment
and prevention from their survey responses. We also interviewed officials in
SAMHSA's Center for Substance Abuse Treatment, Office of Program Services,
and Office of Applied Studies, and reviewed documents they provided on SAPT
and KDA activities funded with drug abuse treatment dollars.

Although the 16 states we surveyed represented about 60 percent of SAPT
block grant drug abuse treatment expenditures for services, the results of
our survey are not necessarily generalizable to all states. Our review
focused on expenditures of fiscal year 1996 drug abuse treatment funds
because, at the time of our review, it was the latest year for which
complete expenditure data from SAMHSA and the states on the SAPT block grant
were available. Also, some survey states provided estimates of drug abuse
treatment expenditures because they could not separate drug from alcohol
abuse treatment services or could not isolate SAPT block grant expenditures
from their total drug abuse treatment expenditures. (See app. I for a
detailed description of our scope and methodology.) We did our work from
January 1999 to January 2000 in accordance with generally accepted
government auditing standards.

The federal government has made a considerable investment in states' drug
abuse treatment programs, and although there is currently little information
on their effectiveness, SAMHSA and some states have efforts under way to
measure these programs' outcomes. About $581 million in SAMHSA's fiscal year
1996 grant funds was spent on drug abuse treatment activities. Of these
funds, more than 80 percent ($478 million) was spent by all states for
treatment services funded through the SAPT block grant program. The 16
states we surveyed reported that SAPT funds supported both residential and
outpatient drug abuse treatment services, including detoxification and
methadone maintenance. For half of the states in our survey, outpatient drug
abuse treatment services accounted for 57 to 85 percent of their block grant
expenditures; the average of the remaining states' expenditures for
outpatient services was 31 percent. All of the states we surveyed reported
providing methadone treatment services almost exclusively on an outpatient
basis. SAMHSA spent another $25 million of the SAPT block grant for
technical assistance and evaluation activities related to drug abuse
treatment. The remaining $78 million of SAMHSA's fiscal year 1996 grants
were KDA funds provided to community-based organizations, universities, and
state and local government agencies to develop and disseminate information
on promising drug abuse treatment practices.

To monitor grantees' use of SAPT and KDA program funds, SAMHSA uses on-site
reviews, reviews of independent financial audit reports, and application
reviews. These mechanisms are primarily used to monitor grantees' compliance
with program requirements, identify grantees' technical assistance needs,
and provide grantees guidance for improving program operations. The current
accountability system for the SAPT block grant is mostly based on a review
of state expenditures. As a result, SAMHSA primarily monitors states'
compliance with certain statutory requirements for use of funds, such as
those that stipulate that a certain percentage be used to treat special
populations. The states we surveyed also reported that they monitor SAPT
block grant funds provided to third parties, including counties and
providers, using mechanisms similar to SAMHSA's. They used the results of
their monitoring efforts, in part, to make drug abuse treatment funding
allocation decisions and determine technical assistance needs.

Several state and SAMHSA efforts are under way to determine the
effectiveness of drug abuse treatment programs using client outcome
measures, such as drug use, employment, criminal activity, and living
arrangement. Nine of the 16 states that we surveyed have conducted such
assessments, but the outcomes measured, populations assessed, methodologies
used, and availability of results vary from state to state. SAMHSA officials
believe that collecting uniform state-level client outcome and other
performance data is critical to determining the effectiveness of state
programs supported with SAPT block grant funds. Consequently, SAMHSA is
funding a pilot effort to help 19 states develop and uniformly report on a
core set of client outcomes. SAMHSA has also asked all states to voluntarily
report client outcome data in their fiscal year 2000 block grant
application. However, this effort is not likely to result in uniform state
data because some of the states we surveyed reported that they would not be
able to submit all of the requested data because they are not currently
collecting it.

In 1995, SAMHSA estimated that about 8.9 million people in the United States
needed treatment for serious drug abuse problems, including drug dependence,
heavy drug use, or injection drug use. Drug abuse treatment is typically
provided in residential or outpatient settings and uses pharmacotherapy,
psychosocial/behavioral therapy, or both. Pharmacotherapy relies on
medications to interfere with the euphoric effects or manage the withdrawal
symptoms and cravings experienced with illicit drug use. One widely used
medication is methadone, an opioid agonist that blocks or interferes with
the euphoria of heroin, morphine, and other opiate drugs and suppresses
withdrawal symptoms and cravings between treatment doses.
Psychosocial/behavioral therapy may include skills training and a variety of
counseling approaches, including individual, family, or group counseling.

SAMHSA, an agency within the Department of Health and Human Services (HHS),
has primary responsibility for supporting substance abuse treatment and
prevention activities. (See app. II for a detailed description of SAMHSA's
role, program staffing, and budget authority.) SAMHSA awards 95 percent of
SAPT block grant funds to states and U.S. territories to fund local drug and
alcohol abuse treatment and prevention programs and retains 5 percent for
program evaluation and other administrative purposes. State awards are
determined by a statutory formula based on several factors, including a
state's personal income data, taxable resources, population estimates, and
service costs. To obtain a block grant, a state must submit to SAMHSA for
review and approval an annual application that includes a discussion of how
the state intends to comply with the various block grant requirements.

States have broad discretion in how they distribute SAPT block grant funds
to cities, counties, and service providers; the services they support; and
the specific amount allocated to drug abuse treatment. SAPT block grant
legislation specifies that at least 35 percent of the state block grant
award be used for alcohol prevention and treatment activities and 35 percent
be used for other drug abuse prevention and treatment activities. The
remaining 30 percent can be used at the state's discretion for drug
programs, alcohol programs, or both. Further, states are required to satisfy
certain statutory set-aside requirements for allocating a portion of SAPT
funds for special populations, such as pregnant and postpartum women and
their children, and, in certain states, to provide early intervention
services for those with HIV.

SAPT block grant legislation requires that 5 percent of the SAPT block grant
be set aside at the federal level to support data collection, program
evaluation, and technical assistance to the states. For example, this
set-aside funds four major surveys required by the Public Health Service
Act: the National Household Survey on Drug Abuse, the Drug Abuse Warning
Network, the Drug Abuse Services Information System, and the Alcohol and
Drug Services Survey. These surveys are intended to provide information for
formulating substance abuse policy and evaluating the performance of
programs and activities supported with federal funds. Another study
supported by the set-aside, the Services Research Outcome Study, is a
national study that used client outcome measures to assess the effectiveness
of drug abuse treatment.

The KDA program is SAMHSA's discretionary grant program that replaced the
demonstration grant program in 1996.2 KDA program grants are designed to
bridge the gap between knowledge and practice in order to transfer research
findings to community practitioners and to provide new, more efficient ways
to deliver services. Funds are provided to community-based organizations,
universities, and state and local government agencies for developing and
promoting effective approaches to providing substance abuse treatment
services as well as prevention and mental health services. The KDA program
is also used to expand the availability of treatment services for specific
locations and populations. KDA topics are determined based on assessments of
research and needs in the field as well as input from drug abuse experts,
providers, clinicians, and congressional offices. Grant proposals are
screened, peer reviewed, and scored based on criteria that include the
proposed methodology for addressing the KDA topic as well as the populations
to be researched.

The Government Performance and Results Act of 1993 (Results Act)--enacted to
increase federal program effectiveness and accountability--requires federal
agencies to set program goals, measure performance, and report to the
Congress on their accomplishments. SAMHSA develops performance goals for the
SAPT block grant program as part of HHS' Results Act reporting. In 1995, HHS
requested that the National Academy of Science's National Research Council
convene an expert panel to examine and report on the technical issues
involved in establishing performance measures in 10 program areas, including
substance abuse treatment. The conclusions and recommendations from the
report that resulted from this effort were used to support SAMHSA's current
efforts to develop and collect state-level client outcome data.3

and Evaluation

Fiscal year 1996 expenditures for drug abuse treatment activities funded by
SAMHSA's SAPT block grant and KDA grant programs totaled $581 million. About
82 percent of these expenditures supported outpatient and residential
treatment services and methadone maintenance--the pharmacotherapy treatment
most widely used for heroin and other opiate addictions. For the 16 states
we surveyed, outpatient services accounted for almost half of their SAPT
block grant drug abuse treatment expenditures. The remaining 18 percent of
SAMHSA's grant funds for drug abuse treatment activities supported technical
assistance and program evaluation funded by the SAPT block grant set-aside
and the development and dissemination of information on promising treatment
practices funded by the KDA grant program.

Drug Abuse Treatment

In fiscal year 1996, about $581 million in SAMHSA grant funds supported
activities related to drug abuse treatment. State SAPT block grant
expenditures accounted for about $478 million,4 and the SAPT set-aside for
technical assistance contracts and program evaluation efforts accounted for
another $25 million. The remaining $78 million supported KDA grants for
programs designed to develop promising treatment practices that can be used
to improve the provision of substance abuse treatment services and
disseminate information to the public and treatment community.
(See fig. 1.)

Figure 1: Percentage of SAMHSA's Drug Abuse Treatment Expenditures for SAPT
Block Grant and KDA Grant Programs, Fiscal Year 1996

In addition to block grant funds, states use other revenue sources to fund
drug abuse treatment services, including state funds; other federal funds,
such as Medicaid; and county funds and insurance payments. The proportion of
total drug abuse treatment expenditures accounted for by SAPT block grant
expenditures varied considerably among the states we surveyed (see fig. 2).
For example, New York reported that SAPT block grant expenditures accounted
for 18 percent of its total reported funds for drug abuse treatment compared
with 76 percent reported by Indiana. Expenditure data reported by the states
we surveyed result from drug abuse treatment funds that flow through the
state agency responsible for administering the SAPT block grant. In some
states, other agencies also fund drug abuse treatment.

Figure 2: Percentage of Surveyed State Agencies' Total Expenditures for Drug
Abuse Treatment Services by Funding Source, Fiscal Year 1996

Note: Florida, Illinois, Massachusetts, Michigan, North Carolina, Ohio, and
Washington provided estimates of fiscal year 1996 drug abuse treatment
expenditures by funding source. Pennsylvania is not included. Pennsylvania
officials reported that drug abuse treatment expenditure information was not
available for other federal, state, and other funding sources because, aside
from the SAPT block grant, they do not track drug abuse treatment
expenditures separately from alcohol treatment expenditures. The officials
stated that estimates could be constructed using client information but that
such estimates would not take into consideration potential variations in the
cost of treating alcohol versus drug abuse.

a"Other" refers to funds other than state and federal funds, such as county
funds and insurance payments.

b "Other federal" refers to federal funds other than SAPT block grant funds,
such as Medicaid.

Used for Outpatient Services

The 16 states we surveyed reported spending a total of about $300 million of
SAPT block grant funding on drug abuse treatment, which included, for
example, detoxification and methadone maintenance in residential and
outpatient settings. The largest portion of reported drug abuse treatment
expenditures was for services in outpatient settings, which can vary from
psychotherapy to group counseling and may include pharmacological treatment.
Of the 16 states surveyed, 14 reported spending SAPT block grant funds on
outpatient services: 8 states spent between 57 and 85 percent of funds on
these services; the average of the 6 remaining states' expenditures for
outpatient services was 31 percent.5

All of the states we surveyed reported that SAPT block grant expenditures
supported methadone treatment, which is the pharmacotherapy treatment most
widely used for heroin addiction. Methadone maintenance generally requires
clients to receive daily methadone dosages that can continue for several
years and, in some cases, may last a lifetime. The states we surveyed
reported providing methadone maintenance almost exclusively as an outpatient
service. Of the 16 states surveyed, 14 reported spending a total of $42.7
million of fiscal year 1996 SAPT block grant funds for methadone provided on
an outpatient basis.6 SAPT block grant expenditures for methadone services
ranged from 2 percent to about 50 percent of total block grant expenditures
for drug abuse treatment (see fig. 3). This range in expenditures is an
example of the flexibility states have in determining the services supported
by SAPT block grant funds.

Figure 3: Percent of SAPT Block Grant Expenditures for Methadone Services,
Fiscal Year 1996

Note: Illinois, New Jersey, Ohio, Pennsylvania, and Washington officials
provided estimates of SAPT block grant expenditures for methadone services.
Michigan and North Carolina did not provide data on these expenditures and
were, therefore, not included.

Assistance

SAMHSA spent about $25 million of the fiscal year 1996 SAPT block grant
set-aside to provide technical assistance to states and for program
evaluation activities related to drug abuse treatment. About 93 percent of
these funds supported technical assistance activities, including $11 million
for technical assistance contracts and $12 million for the State Treatment
Needs Assessment Program; the remaining $2 million supported program
evaluation activities. At the request of states, SAMHSA uses technical
assistance contracts to provide a wide range of activities, which include
conducting training seminars, redesigning treatment policies and procedures,
and assisting states in establishing cost-effective treatment models. SAMHSA
developed the State Treatment Needs Assessment Program to help states better
allocate treatment funds, enhance and sustain states' capabilities to assess
treatment need, and improve states' reporting of their needs assessments in
block grant applications. In September 1998, we reported that some state
officials have found this program useful for targeting resources and
enhancing service delivery. However, states have been slow in developing the
capacity to assess need and to report results developed from the program in
their SAPT block grant applications.7

Practices

SAMHSA awarded $78 million of fiscal year 1996 KDA discretionary grants to
determine the effectiveness of selected treatment practices, expand the
availability of treatment services for specific locations and populations,
and promote the adoption of best practices and treatment techniques. KDA
funds supported grants and cooperative agreements to 111 community-based
organizations, universities, and state and local government agencies in
support of 13 specific drug abuse treatment programs in fiscal year 1996. In
fiscal year 1998, KDA treatment expenditures increased to about $98 million
supporting 27 specific programs.8 (See app. III for a description of KDA
programs funded in fiscal years 1996 and 1998.) KDA programs funded in these
years include the following:

ï¿½ Wraparound Services to evaluate the effect that services such as child
care, vocational training, and transportation have on the effectiveness of
treatment services.

ï¿½ Marijuana −Adults to evaluate the effectiveness of brief treatment
interventions for marijuana dependence and relapse and determine whether
these interventions are effective for individuals from differing
socioeconomic, racial, and ethnic backgrounds.

ï¿½ Pregnant and Postpartum Women to expand the availability of comprehensive
treatment services for pregnant and postpartum women and their children.

ï¿½ Rural Remote and Culturally Distinct Populations to provide treatment
services for harder-to-reach populations and serve as a model program for
Alaskan Natives, American Indians, and Native Hawaiians.

ï¿½ Addiction Technology Transfer Centers to promote the transfer of promising
treatment practices to drug abuse treatment providers.

To help improve the overall quality of substance abuse treatment and
facilitate the adoption of practices that have been identified as effective
treatment approaches, SAMHSA develops and publishes best practice
guidelines. For example, SAMHSA developed treatment improvement protocols by
bringing together clinicians, researchers, policymakers, and other federal
and nonfederal experts to identify and reach consensus on promising
treatment practices. The published protocols recommend strategies to enhance
treatment services for individuals with coexisting mental health and
substance abuse disorders; offer guidelines for the design and delivery of
effective treatment services for adolescents; and offer guidelines for
planning, providing, and evaluating detoxification services. SAMHSA also
developed a protocol to assist state agencies in developing, implementing,
and managing outcome monitoring systems for increasing accountability for
treatment expenditures. The treatment improvement protocols are being
evaluated by an independent contractor to determine their effectiveness.
SAMHSA also publishes technical assistance publications, which compile
materials gathered from various federal, state, programmatic, and clinical
sources that provide guidance and information related to providing substance
abuse treatment services.

SAMHSA coordinates its KDA efforts with the National Institutes of Health's
National Institute on Drug Abuse (NIDA). Coordination activities include
periodic meetings to ensure that NIDA research is considered in the
development, application, and dissemination of KDA information on promising
treatment practices. For example, the KDA programs related to adolescent
treatment, methamphetamine abuse treatment, and interventions for marijuana
abusers reflect clinical research originally funded by NIDA. These KDA
programs test NIDA research to establish the effectiveness of treatment
approaches and to identify and address barriers to the use of these
approaches in different communities and with different populations. SAMHSA
and NIDA also use interagency agreements to draw on each other's expertise
and avoid duplication of effort. SAMHSA also routinely involves NIDA in
selecting treatment improvement protocol topics to ensure that they do not
duplicate activities funded by the National Institutes of Health and in
reviewing the protocols before publication. Further, NIDA grantees
participate on the consensus panels for the development of the treatment
improvement protocols. SAMHSA officials said that they also coordinate with
the National Institute on Alcohol Abuse and Alcoholism.

Grant Funds

SAMHSA uses on-site reviews, reviews of independent financial audit reports
required by the Single Audit Act, and reviews of grant applications to
monitor grantees' use of SAPT and KDA funds and their compliance with
program requirements. The accountability system for SAPT block grant funds
is primarily based on whether states spend SAPT funds as required by federal
law. SAMHSA is statutorily mandated to use on-site reviews to ensure states
comply with requirements for the use of funds, such as the "maintenance of
effort" requirement, which stipulates that states must maintain a certain
level of expenditures for drug abuse treatment. On-site reviews are also
used to identify grantees' technical assistance needs and provide guidance
and recommendations to grantees for improving program operations. States,
which distribute SAPT block grant funds to third parties such as treatment
providers, reported using a variety of mechanisms to monitor third-party use
of SAPT block grant funds. These mechanisms include site visits, management
information systems, cost and activity reports, fiscal audits, and
independent peer reviews. Most of the surveyed states reported using the
results of their monitoring activities to, in part, make funding allocations
and determine technical assistance needs.

and Identify Technical Assistance Needs

SAMHSA is statutorily required to conduct on-site reviews to monitor SAPT
block grant expenditures in at least 10 states each fiscal year. SAMHSA
contracts with an independent firm to conduct these on-site reviews at the
state and local levels. These reviews examine grantees' fiscal monitoring of
providers and compliance with SAPT block grant requirements that include
maintaining a certain level of state expenditures for drug abuse treatment
and spending a certain percentage of funds on services for pregnant and
postpartum women and their children. In practice, each state receives a
review on average once every 3 years, and the review is generally conducted
by one or two persons over a 5-day period. Although the on-site review
process includes collecting and reviewing documents describing agency and
program operations, the primary component of the review is a series of
interviews conducted with state and local program officials. After the
on-site review, the contractor works with SAMHSA program staff and state
officials to develop a report detailing the contractor's findings. SAMHSA
does not currently collect corrective action plans from states or track
states' responses to identified deficiencies to determine if deficiencies
are resolved. SAMHSA officials said that corrective action plans and
SAMHSA's monitoring of them are needed, but the agency has not yet decided
how it will address this issue.

SAMHSA uses the results from the on-site reviews to identify states'
technical assistance needs. For example, Ohio's 1999 review resulted in two
technical assistance recommendations: (1) develop utilization review
guidelines for monitoring grantees and (2) provide training on SAPT block
grant set-aside requirements for funding tuberculosis and HIV services.
States must initiate requests for technical assistance, which SAMHSA
provides through contractors that include experts who specialize in
treatment service issues. In addition to on-site compliance reviews, SAMHSA
project officers periodically conduct site visits to states and local
treatment providers, identifying technical assistance needs and providing
program guidance.

For the KDA program, SAMHSA officials told us that project officers monitor
grantees through site visits as well as conference calls and other regular
meetings. The goal of monitoring KDA programs is to provide technical
assistance and to ensure achievement of program goals. Project officers will
conduct a site visit if a grantee is not making adequate progress toward
meeting KDA project goals. Project officers discuss difficulties that the
grantee is encountering and assist in determining a plan of action for
addressing problems, which may include a recommendation for technical
assistance. Project officers also work collaboratively with study sites to
oversee project design, analysis, and reporting of results.

Monitor Compliance

SAMHSA also reviews grantees' annual financial audits and grant applications
to ensure compliance with program requirements. According to SAMSHA
officials, the agency's primary fiscal monitoring mechanism for grantees is
the agency's review of annual financial audit reports required by the Single
Audit Act. In general, the single audit is designed to determine if a
grantee's financial statements are fairly presented and grant funds are
managed in accordance with applicable laws and program requirements. Under
criteria established in the act, independent auditors use expenditure limits
and risk-based guidelines to identify the programs that will be audited.9
Therefore, if a grantee's SAPT or KDA program expenditures in a given year
fall below the audit threshold of $300,000--or 3 percent of total federal
expenditures--the program is generally not audited in that year. In 1997, 13
SAPT block grantees were not audited.

SAMHSA officials reported using their reviews of independent financial audit
reports to identify grantees that need to take corrective actions to come
into compliance with program requirements. For example, if an audit report
includes recommendations for resolving findings related to grantee
noncompliance, SAMHSA will request a corrective action plan from the grantee
for each recommendation and review grantee submissions for adequate
responses. If a grantee does not submit an audit report or correct audit
findings in a timely manner, or material accounting and financial weaknesses
are repeated in audit reports, SAMHSA has the authority to suspend or
terminate the grant award, or require the grantee to submit additional
financial reports as a condition of receiving additional grant funds.

SAMHSA also uses its review of grantee applications to monitor SAPT block
grant program compliance. SAMHSA project officers are responsible for
reviewing SAPT block grant applications to determine if states have complied
with statutory requirements, such as set-asides for special populations and
maintenance of effort. SAMHSA, however, has approved some states'
applications without addressing their reported maintenance of effort
shortfalls.10 Audit report and on-site review findings as well as a
subsequent internal review of grantees' fiscal years 1994 through 1996 block
grant applications identified seven states that reported noncompliance with
maintenance of effort requirements. If a state fails to comply with the
maintenance of effort requirement, SAMHSA can reduce the state's block grant
award by the amount of the shortfall or request a determination of material
compliance from the Secretary of HHS. SAMHSA can also grant a waiver if the
state has experienced a financial crisis. SAMHSA, however, did not follow
appropriate procedures when states reported maintenance of effort shortfalls
in their block grant applications. In August 1998, SAMHSA developed a plan
to improve its oversight of maintenance of effort issues, which includes
making maintenance of effort compliance the highest priority for initial
staff review, initiating weekly status reports on states with compliance
issues, and conducting internal quarterly assurance meetings to review SAPT
block grant documentation.

Similar to SAMHSA's

The states we surveyed reported using a variety of mechanisms to monitor the
use of SAPT block grant funds provided to third parties, such as counties
and treatment providers. Many of these mechanisms were similar to those used
by SAMHSA. Of the 16 states surveyed, 12 reported using on-site visits,
financial audits of providers, management information systems, and cost and
activity reports. The remaining four states used at least two of these
mechanisms. Some states reported that these mechanisms were used
specifically to monitor provider billing procedures, quality of care, and
providers' compliance with SAPT block grant program requirements.

Most of the surveyed states reported that the results of their monitoring
were used to determine provider and service contracting, funding
allocations, and technical assistance needs. For example, Texas reported
delaying funding or suspending contracts for providers who were not
compliant with program requirements. Washington state officials reported
that monitoring results have been used to identify priority populations for
receiving treatment services. Georgia officials reported that monitoring
results have been used to establish policies for staff training and a
process for allocating treatment funds.

Effectiveness of Drug Abuse Treatment Services

Several efforts are under way to determine whether states receiving SAPT
block grant funds are supporting effective drug abuse treatment programs.
Some states are conducting studies using client outcome measures to assess
the effectiveness of their programs. While SAMHSA has supported national
studies that suggest drug abuse treatment is beneficial in reducing drug
use, increasing employment, and reducing criminal activity, SAMHSA does not
currently know the outcomes of states' drug abuse treatment programs
supported with SAPT block grant funds. To determine the effect states'
programs are having on drug abuse, SAMHSA believes it is critical to collect
uniform state-level client outcome data. Therefore, the agency is currently
conducting a pilot study with 19 states to collect such data. SAMHSA has
also initiated an effort to have states voluntarily report client outcome
data in their block grant applications. However, this effort has limitations
because states do not collect data in the same way; some states do not
collect the data SAMHSA requested; and, according to SAMHSA officials, some
states lack the capacity to collect and report the data.

Treatment

SAMHSA has funded two national studies that suggest drug abuse treatment is
effective at improving outcomes, such as decreasing drug use, criminal
activity, and unemployment. The Services Research Outcome Study is the first
national study of substance abuse treatment outcomes to include a
representative sample of drug abuse treatment programs in rural, suburban,
and urban locations.11 The National Treatment Improvement Evaluation Study,
a 5-year study, examined the effectiveness of treatment provided in public
programs supported by SAMHSA. While these two studies relied on
self-reported data as the primary data collection method, they also used
methods to validate study results. Table 1 summarizes the characteristics of
the two studies and the results of selected outcome measures.

Table 1: Characteristics of SAMHSA's Major Drug Abuse Treatment Studies

                                                     National Treatment
                       Services Research Outcome   Improvement Evaluation
                                 Study
                                                           Study
 Study characteristics
                      1,799 people, representing
                      a 65-percent simple        4,411 people, representing
 Population           response rate and a        67 percent of the total
                      38-percent cumulative      number of clients in the
                      response ratea             study sample
                                                 1 month or 1 year before
 Measurement time     5 years before treatment   treatment compared to 1
 frame                compared to 5 years after  month or 1 year after
                      treatment
                                                 treatment
                      Hospital inpatient,        Methadone, drug-free
 Treatment service    residential, outpatient    outpatient, short- and
                      methadone, outpatient      long-term residential,
                      nonmethadone               correctional
 Outcome measures and
 results
                      A 21-percent overall       Drug use declined by about
 Drug use             reduction in the number of 50 percent for as long as
                      people using any illicit   1 year following
                      drug following treatment.  treatment.
                                                 Significant decreases in
                      Between 23- and 38-percent multiple indicators of
                      reduction for most crimes, criminal involvement, such
 Criminal activity    including theft, drug      as a 64-percent decrease
                      sales, prostitution, drunk in arrests and a
                      driving, and weapon use.   78-percent decrease in
                                                 selling drugs.

                      No appreciable change in   Rate of employment
                                                 increased by 19 percent,
 Employment           the rate of full-time      and those on welfare
                      employment for clients
                      discharged from treatment. decreased by almost 11
                                                 percent.
                      Improved housing was
 Living arrangement   secured and custody of     Homelessness decreased by
                      children regained after    43 percent.
                      treatment.
                                                 Alcohol and drug-related
 Physical health      (Not measured.)            medical visits declined by
                                                 53 percent.
                                                 Mental health problems
                                                 declined by 35 percent,
 Mental health        Suicide attempts declined  and inpatient mental
                      following treatment.
                                                 health declined by 28
                                                 percent.
                                                 Sex for money or drugs
                                                 decreased by 56 percent,
 Sexual activity      (Not measured.)            and sex with an
                                                 intravenous drug user
                                                 decreased by 51 percent.

aThe Services Research Outcome Study's client sample was derived from a
sample of treatment facilities identified in the Drug Services Research
Survey, a prior study. Therefore, when the Services Research Outcome Study
is viewed as a longitudinal study (that captures the facilities sample from
the Drug Services Research Survey as well as its completed cases), its
cumulative response rate is 38 percent--the product of the studies' response
rates.

In addition to national studies, SAMHSA is trying to develop state-level
data about drug abuse treatment effectiveness. The results of this effort
will be used to monitor and report to the Congress the performance and
success of individual states' drug abuse treatment programs supported with
SAPT funds. While there is no specific statutory requirement for states to
collect and report outcome data on the results of their treatment programs
supported with SAPT block grant funds, SAMHSA officials stated that having
such data is essential in determining the effect state programs have on the
agency's mission of improving health and reducing illness, death,
disability, and costs to society.

Drug Abuse Treatment

Most states we surveyed have conducted outcome assessments of drug abuse
treatment since 1994, including special studies and ongoing performance
measurement, but their assessments vary in the outcomes measured,
populations assessed, methodologies used, and availability of results. Seven
of the 16 states we surveyed--Florida, Maryland, New York, North Carolina,
Ohio, Texas, and Washington--reported that they have been mandated by state
legislation to assess the outcomes of their drug abuse treatment activities.
For example, North Carolina is required to establish and report performance
outcomes that include abstinence from drug use. In Washington, the governor
holds the Secretary of the state's Department of Social and Health Services
accountable for achieving drug abuse treatment outcomes that are
specifically outlined in the performance contract of the state's director
for alcohol and substance abuse. All states we surveyed plan to begin
assessing treatment programs using outcome measures by the year 2002.

Of the 16 states surveyed, 9 reported having completed at least one outcome
assessment and of them, 7 reported they had completed specific client
outcome studies (see table 2). Seven of the nine states reported they use
performance measurement data to assess drug abuse treatment effectiveness on
an ongoing basis.

Table 2: States' Client Outcome Assessment Activities

    States reporting      Conducted specific     Continually assess client
   completed outcome     client outcome study   outcomes using performance
      assessments        (number of studies)         measurement data
 California             X (1)
 Florida                X (1)                  X
 Georgia                X (3)                  X
 New York                                      X
 North Carolina         X (3)                  X
 Ohio                   X (5)
 Texas                  X (1)                  X
 Virginia                                      X
 Washington             X (11)                 X

These states generally use a number of outcome measures to assess their drug
abuse treatment efforts, including abstinence, drug use, employment, mental
and physical health, living arrangement, and criminal activity. However, the
indicators for measuring these outcomes varied. For example, Ohio measures
criminal activity in terms of rearrests, incarcerations, and probation
violations. California measures criminal activity using several indicators
that include the number of times a drug abuser sold or helped sell drugs,
had sex for money or drugs, broke into a house or vehicle, or used a weapon.
In addition, the surveyed states' assessments varied in terms of target
populations, purpose, time frames, or other methodological issues.

Of the nine states that reported conducting outcome assessments,
six−California, Florida, North Carolina, Ohio, Texas, and
Washington−reported benefits as a result of drug abuse treatment.12
(See app. IV for details of the six states' outcome assessments.) For
example, California has conducted a large-scale study that showed treatment
reduced drug use by about 40 percent and criminal activity by about 66
percent. Washington reported that its study of treatment for impoverished
populations showed that quarterly earnings of clients receiving treatment
were more than twice the earnings of clients not receiving treatment and
that health care costs for clients receiving treatment decreased by nearly
50 percent. According to SAMHSA, the National Association of State Alcohol
and Drug Abuse Directors, and substance abuse experts, Washington and New
York are examples of states from which lessons could be learned about
measuring the effectiveness of drug abuse treatment using client outcomes.
For example, Washington's data system uses Social Security numbers to track
clients, enabling the state to integrate self-reported data with secondary
databases, including state employment and welfare rolls, to provide
objective data for measuring client outcomes.13 Washington reported
conducting 12 outcome assessment activities since 1994 and using client
identifiers and integrative techniques for the past 7 to 8 years. New York
officials reported using an integrated program monitoring and evaluation
system since 1995 to assess the performance of all drug abuse treatment
providers. This system uses 12 performance measures, including abstinence
and employment, and has an established set of minimum performance standards.
Drug abuse treatment providers who do not meet the standards are required to
develop an action plan to meet the minimum performance standards.

Uniform State Outcome Data

SAMHSA has initiated efforts to improve existing state data systems to make
them comparable for performance measurement. Specifically, in 1997, SAMHSA
developed the Treatment Outcomes and Performance Pilot Studies (TOPPS) to
help states develop or enhance their management information systems and
outcome monitoring systems for evaluating clients receiving treatment. In
1998, SAMHSA created a grant program to further this effort--the Treatment
Outcomes and Performance Pilot Studies Enhancement (TOPPS II)--which is
being conducted under cooperative agreements with 19 states,14 including 9
that we surveyed. TOPPS II aims to help the pilot states collect information
on SAPT-funded treatment services and monitor a core set of substance abuse
treatment effectiveness measures. Several of the states we surveyed reported
this program as part of their assessment efforts to measure drug abuse
treatment effectiveness.

While the TOPPS initiative supported individually designed state studies to
assess treatment effectiveness, TOPPS II supports a consensus-developed set
of common client outcome measures of treatment effectiveness and
incorporation of these measures into the databases of participating states.
Both SAMHSA and the states participating in TOPPS II agreed on a core set of
outcome measures that include substance abuse, health services utilization,
self-help participation, pregnancy and status of children, employment
status, living arrangements, and criminal behavior. As a condition of
receiving funding through TOPPS II, each of the 19 participating states is
required to report to SAMHSA on each of these measures of treatment
effectiveness. The TOPPS II study will issue interim and final reports that
summarize developments and findings in the state and interstate evaluations.
States are to report final results to SAMHSA in September 2001.

Provide Uniform Data

SAMHSA is asking states to voluntarily report on a core set of outcome
measures--drug use, criminal activity, employment status, and living
arrangements--in the fiscal year 2000 SAPT block grant application.15 For
programs supported with SAPT block grant funds, SAMHSA is asking states to
report the percent change in each measure that has occurred between
admission and discharge for clients completing treatment, by age and
race/ethnicity, using specific indicators such as arrests and
homelessness.16 Further, SAMHSA is asking states to report the source of the
data, reasons for not being able to report the data, and whether information
is available to measure outcomes after treatment is completed.

SAMHSA's effort to have all states voluntarily report outcome data in their
fiscal year 2000 SAPT block grant application, however, will not yield
consistent and uniform data across states because some states reported that
they are not currently collecting all the outcome data that SAMHSA is
requesting. Of the 16 states we surveyed, 8 plan to report data on some of
the outcome measures; 4 of these states--California, Maryland, New York, and
Washington--are participating in SAMHSA's TOPPS II program. For example,
Georgia officials stated that they will report outcome information to SAMHSA
in the fiscal year 2000 block grant application but do not have the data
needed to report outcomes by race and age as requested by SAMHSA. The
remaining eight states we surveyed reported that they will not or are unsure
whether they will report the outcome information because they are not
currently collecting much of the data SAMHSA requested.

SAMHSA officials are still reviewing applications and said that they are
unsure of the extent to which states will report complete and consistent
client outcome information in their SAPT block grant applications. SAMHSA
plans to use the information it collects to identify states' ability to
report outcome data, such as the availability of state outcome data, the
complexities of measuring client outcomes, and states' infrastructure needs
for measuring outcomes. SAMHSA officials stated that improving states'
ability to collect client outcomes and requiring them to report on a uniform
set of measures would enhance SAMHSA's ability to obtain uniform and
consistent client outcome data across states. In November 1999, HHS' general
counsel, together with SAMHSA officials, determined that the Secretary of
HHS has the authority to require such information for administering the
program. However, according to SAMHSA officials, it is highly unlikely that
the states could currently report the quality of data needed to make
accurate program assessments.

The federal government invests hundreds of millions of dollars for drug
abuse treatment through the SAPT block grant program. While SAMHSA monitors
state expenditures to determine whether block grant funds are used in
accordance with statutory requirements, this type of monitoring is not
designed to determine the effect state drug abuse treatment programs are
having on client outcomes. Assessing the effectiveness of drug abuse
treatment is important in ensuring federal and state accountability for
program results. Some states are assessing the effectiveness of their
treatment programs using various outcome indicators. SAMHSA officials
believe that the collection of uniform state-level client outcome data is
essential for determining the effectiveness of drug abuse treatment programs
supported with federal funds and for reporting the information to the
Congress. SAMHSA is trying to determine the availability of client outcome
data from all states and has awarded grants to some states to help improve
their data collection systems. These efforts should help identify states'
views about and some of the complexities associated with collecting and
reporting client outcome data. SAMHSA's efforts should also help to
determine what additional actions are needed to get uniform state reporting
on the results of drug abuse treatment programs supported with SAPT block
grant funds.

We provided a draft of this report to SAMHSA and the 16 states we surveyed.
SAMHSA officials said that the report provided an accurate and thorough
review of the agency's SAPT block grant and KDA grant programs. SAMHSA and
some of the 14 states that responded to our request for comments had
additional information, clarifications, and technical comments, which we
incorporated where appropriate.

As agreed with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 5 days from
the date of this letter. At that time, we will send copies to the Honorable
Donna E. Shalala, Secretary of HHS; the Honorable Nelba Chavez,
Administrator of SAMHSA; officials of the state substance abuse agencies we
surveyed; appropriate congressional committees; and other interested
parties. We will also make copies available to others upon request.

Please contact me at (202) 512-7119 or James O. McClyde, Assistant Director,
at (202) 512-7152, if you or your staff have any questions. Other major
contributors to this report were Veronica Henry and Janina Johnson.

Janet Heinrich
Associate Director, Health Financing
and Public Health Issues

Objectives, Scope, and Methodology

In response to congressional concern about how federal drug abuse treatment
funds are accounted for and whether they support effective drug abuse
treatment programs, we were asked to describe the activities supported by
SAMHSA's SAPT block grant and KDA grant funds for drug abuse treatment, the
mechanisms SAMHSA and states have in place to monitor fund use, and SAMHSA
and state efforts to determine the effectiveness of drug abuse treatment
supported with SAPT block grant funds.

To conduct our work on SAMHSA's SAPT block grant program, we surveyed 16
states--California, Florida, Georgia, Illinois, Indiana, Maryland,
Massachusetts, Michigan, New Jersey, New York, North Carolina, Ohio,
Pennsylvania, Texas, Virginia, and Washington--and conducted follow-up
interviews with selected respondents. We selected these states because they
received at least $25 million for their fiscal year 1996 SAPT block grant
award; further, substance abuse experts and knowledgeable officials
identified some of these states as having well-established systems for
collecting outcome data and assessing their drug abuse treatment programs.
Our review focused on expenditures of fiscal year 1996 drug abuse treatment
funds because it is the most recent year for which complete expenditure data
are available on the SAPT block grant from SAMHSA and the states. States
have 2 years to spend their SAPT block grant award and generally report
expenditures in the third year.

Through our survey and interviews, we collected information on (1) grantees'
expenditures for the different categories of drug abuse treatment services
states report in their annual SAPT block grant applications--residential,
outpatient, detoxification, and methadone; (2) the mechanisms used to
monitor the use of these grant expenditures; and (3) assessments of drug
abuse treatment effectiveness conducted since 1994 using client outcomes,
including measuring performance on an ongoing basis or through periodic
special studies. We asked states to exclude their use of SAPT block grant
funds for other activities, such as alcohol treatment and prevention, from
their survey responses.

We also interviewed officials in SAMHSA's Center for Substance Abuse
Treatment, Office of Program Services, and Office of Applied Studies, and
reviewed documents they provided on (1) SAPT block grant and KDA grant
activities funded with drug abuse treatment dollars; (2) mechanisms SAMHSA
uses to monitor grantees' use of funds and compliance with program
requirements; (3) efforts to assess the effectiveness of treatment using
client outcomes; and (4) SAMHSA's administrative expenses, including
contracts and staffing levels. In addition, we obtained the views of
officials at the National Association of State Alcohol and Drug Abuse
Directors and experts in the substance abuse research community on assessing
the effectiveness of drug abuse treatment using client outcomes.

Although the 16 states we selected to survey represented about 70 percent of
fiscal year 1996 SAPT block grant awards and 60 percent of SAPT block grant
drug abuse treatment expenditures for services, the results of our survey
are not necessarily generalizable to the nation. Also, some survey states
provided estimates of drug abuse treatment expenditures because they could
not separate drug from alcohol abuse treatment services or could not isolate
SAPT block grant expenditures from their total drug abuse treatment
expenditures. We did not independently verify the accuracy of grantees' drug
abuse treatment expenditures. However, we compared some of the expenditure
data reported in our survey with grantee expenditures reported to SAMHSA in
their approved SAPT block grant applications and found no material
differences. We did our work from January 1999 to January 2000 in accordance
with generally accepted government auditing standards.

History and Administration of SAMHSA

In October 1992, the Congress established SAMHSA under Public Law 102-321 to
strengthen the nation's health care delivery system for prevention and
treatment of substance abuse and mental illnesses. Specifically, SAMHSA was
to develop national goals and model programs; coordinate federal policy
related to providing prevention and treatment services; and evaluate the
process, outcomes, and community impact of prevention and treatment
services. Before 1992, the major federal substance abuse and mental health
delivery services and research activities were combined under one agency,
the Alcohol, Drug Abuse, and Mental Health Administration. In the 1992
legislation, the Congress created SAMHSA to administer the services portion
of the former agency and transferred its research components to the National
Institutes of Health to be carried out by the National Institute on Alcohol
Abuse and Alcoholism, NIDA, and the National Institute of Mental Health.

Since 1992, SAMHSA's budget has remained relatively stable at about $2
billion each year. SAMHSA's fiscal year 1999 budget was about $2.5 billion
for substance abuse treatment and prevention and mental health services.
About $1.6 billion was for the SAPT block grant program--95 percent of which
is allocated to states and local governments. SAMHSA allocated another $329
million to fund prevention and treatment discretionary grant programs. A
portion of SAMHSA's budget is appropriated for administrative
expenses--about 6 percent ($155 million) for fiscal year 1999. The majority
of the administrative expense appropriation supports contractual services
that include technical assistance and program evaluation activities.
Administrative expenses also support personnel compensation. As of December
1999, SAMHSA employed a total of 538 people, who are centrally located in
the Washington, D.C., metropolitan area. The remaining administrative funds
support costs related to travel, communications, printing, supplies, and
rental payments. Table 3 lists SAMHSA's fiscal year 1999 appropriated
amounts for administrative expenses; table 4 describes selected SAMHSA
fiscal year 1999 contracts for technical assistance and program evaluation;
and table 5 lists SAMHSA's staffing levels by program as of December 1999.

Table 3: SAMHSA's Administrative Expenses, Fiscal Year 1999 Appropriation

          Administrative expenses           Fiscal year 1999 appropriation
 Personnel compensation and benefits        $47,031,000
 Printing and reproduction                  3,608,000
 Communications, utilities, and
 miscellaneous charges                      1,401,000
 Travel                                     1,199,000
 Supplies and materials                     392,000
 Transportation of things                   105,000
 Rental payments                            40,000
 Other contractual servicesa                101,576,000
 Total                                      $155,352,000

aExcludes about $62 million in contractual services related to SAMHSA's
block grant set-asides, drug surveys, and program evaluation; includes
indirect costs estimated at 19.5 percent, with contractor fees of 5.1
percent.

Source: HHS Fiscal Year 2000 Substance Abuse and Mental Health Services
Administration Justification of Estimates for Appropriations Committees.

Table 4: Selected SAMHSA Contracts for Technical Assistance and Program
Evaluation, Fiscal Year 1999, by Agency and Program

Continued

         Contractor                      Description              Amount
 Center for Substance Abuse Treatment
 SAPT Block Grant
                              Help states prepare technical
                              assistance plans to resolve
 Johnson, Bassin & Shaw,      deficiencies identified in
 Inc., Silver Spring, Md.     on-site technical reviews, and    $5,686,113
                              improve linkages between the drug
                              abuse treatment system and other
                              social service systems.
                              Provide technical assistance to
                              maintain the Treatment
 Health Systems Research,     Improvement Exchange database,
 Inc. Washington, D.C.        logistical assistance for         1,088,632
                              meetings, and editorial expertise
                              for reports and documents.
 KDA/Targeted Capacity Expansion
                              Provide technical assistance and
                              support of KDA grants funded in
                              fiscal years 1996 through 1998
 R.O.W. Sciences, Inc.,       and 2000 through 2002, and
 Rockville, Md.               ongoing demonstration programs of 3,635,571
                              the Center for Substance Abuse
                              Treatment's Division of Practice
                              and Systems Development.
                              Establish a program to ensure
                              that knowledge developed by
 CDM/JBS Joint Venture, Chevy projects funded by the Center for
 Chase, Md.                   Substance Abuse Treatment is      3,504,201
                              disseminated to substance abuse
                              treatment and related fields.
                              Provide support for a
                              coordinating center to facilitate
 Johnson, Bassin & Shaw,      transfer of business and
 Inc., Silver Spring, Md.     management technology to          3,298,997
                              organizations and entities that
                              make up the public sector
                              treatment system.
                              Primarily provide support for the
                              Residential Women and Children,
                              Pregnant and Postpartum Women and
 Caliber Associates, Fairfax, Children, and HIV Outreach
 Va.                          programs' cross-site evaluation   3,234,270
                              initiatives, and provide selected
                              technical assistance to KDA
                              grantees.
                              Provide a wide array of data
                              management and scientific support
 Caliber Associates, Fairfax, across various programmatic and
 Va.                          evaluation activities, including  2,767,868
                              grants, cooperative agreements,
                              and contracts.
                              Provide technical assistance for
                              the Targeted Capacity Expansion
 Birch & Davis Associates,    cross-site evaluation, including
 Inc., Silver Spring, Md.     support for implementing data     1,970,758
                              collection systems, conducting
                              data analyses, and preparing
                              reports.
                              Develop a field evaluation of the
                              treatment improvement protocols
                              in order to assess treatment
 Johnson, Bassin & Shaw,      provider awareness and
 Inc., Silver Spring, Md.     implementation, and to evaluate   1,597,259
                              the effects of the protocols on
                              the process and outcomes of
                              addiction treatment.
                              Develop an integrated database of
                              mental health and substance abuse
 The Medstat Group, Inc.,     treatment services spending
 Washington, D.C.             estimates that will allow for     1,379,585
                              comparisons to national health
                              expenditures.
 Center for Substance Abuse Prevention
 SAPT Block Grant
                              Provide technical assistance to
                              states on complying with SAPT
                              block grant requirements and
 Johnson, Bassin & Shaw,      developing systems to administer
 Inc., Silver Spring, Md.     successful and cost-effective     3,584,997
                              prevention services, and support
                              on-site monitoring of states'
                              block grant funds and programs.
                              Assist with developing and
                              disseminating knowledge about
                              what works in prevention and
                              making available to states and
 Research Foundation, John    the field useful tools for
 Jay College, CUNY, New York, developing prevention plans,      3,469,057
 N.Y.                         making resource allocation
                              decisions, implementing
                              appropriate and effective
                              prevention programs, and
                              satisfying demands for public
                              accountability.
                              Assist states in the development
 Macro International, Inc.,   of data systems designed to
 Calverton, Md.               monitor prevention service        1,333,586
                              delivery.
 KDA
                              This contract carries out the
                              Corporate Alliance on Drug
                              Education earmark, which has been
                              included within the center's
 CRP, Inc., Washington, D.C.  budget for the past several       1,703,145
                              years. It also provides SAMHSA
                              logistical support, including
                              training and technical assistance
                              on evaluating prevention
                              programs.
                              Assist the Center for Substance
                              Abuse Prevention with
 Caliber Associates, Fairfax, coordinating program data and
 Va.                          producing analytic reports.       1,498,708
                              Contract also includes monitoring
                              and analyzing performance
                              measurements.
                              Conduct a process and outcome
 EMT Associates Inc., Folsom, evaluation of 47 high-risk
 Calif.                       substance abuse prevention        1,168,057
                              programs for youth, funded in
                              1994 and 1995.
                              Assist with developing,
                              collecting, and analyzing outcome
                              measures across Workplace Managed
 The CDM Group, Inc., Chevy   Care program grantees; support
 Chase, Md.                   the planning, development, and    1,086,895
                              implementation of a series of
                              specialized work groups and
                              meetings on workplace issues.
 Center for Mental Health Services
 Children's Programs
                              Provide grantees of the
                              Comprehensive Community Mental
                              Health Services for Children and
                              Their Families Program with
 American Institute for       training and technical assistance
 Research, Washington, D.C.   for developing community-based    3,947,394
                              and family-focused services and
                              integrating child and family
                              services into local comprehensive
                              systems of care.
                              Assess the effectiveness of the
                              systems of care created by the
                              Comprehensive Community Mental
 Macro International, Inc.,   Health Services Program for
 Calverton, Md.               Children and Adolescents, as      3,127,160
                              required by statute. This funding
                              was for evaluations of 26
                              grantees.
                              Assess the effectiveness of the
                              systems of care created by the
                              Comprehensive Community Mental
 Macro International, Inc.,   Health Services Program for
 Calverton, Md.               Children and Adolescents, as      2,274,583
                              required by statute. This funding
                              was for evaluations of 20
                              grantees.
                              Develop and implement a
 Vanguard Communications of   community-based, local and
 Falls Church, Washington,    national marketing campaign, and  2,091,988
 D.C.                         disseminate campaign messages and
                              products to reduce the mental
                              health stigma.
                              Continue the evaluation of the
                              Comprehensive Community Mental
 Macro International, Inc.,   Health Services Program for
 Calverton, Md.               Children and Adolescents focusing 1,346,466
                              on services for children and
                              adolescents with serious
                              emotional disturbances.
                              Evaluate children's mental health
                              in urban communities, including
 American Institute for       state commitments to mental
 Research, Washington, D.C.   health services programs and      1,064,853
                              integration of family-centered
                              concepts and teaching strategies
                              in medical education.
 KDA
                              Provide support for the School
                              Violence Prevention grantee sites
                              by developing products and
                              activities to communicate with
 The Gallup Organization,     primary and secondary target
 Rockville, Md.               audiences, and enhance awareness, 2,006,000
                              understanding, and application of
                              strategies aimed at school
                              violence prevention and healthy
                              child development.
                              Evaluate the Access to Community
 R.O.W. Sciences, Inc.,       Care and Effective Services and
 Rockville, Md.               Support Demonstration Program for 1,399,880
                              Homeless Persons with Serious
                              Mental Health Illnesses.
 Mental Health Block Grant
                              Provide support for the Mental
                              Health Statistical Improvement
 Masimax Resources, Inc.,     Program, specifically the policy
 Rockville, Md.               group, operations of task forces, 1,196,093
                              regional and decision application
                              groups, and further development
                              of the managed care data system.
 Office of Program Services
                              Provide support for local area
 Orkand Corporation, Falls    network operation, microcomputer
 Church, Va.                  technical services, software      1,449,921
                              training, ADP technical studies,
                              and database administration.
 Office of Applied Studies
                              Assess the value of the Drug
                              Abuse Warning Network in relation
 Westat, Inc., Rockville, Md. to the needs of its users and     1,000,000
                              make recommendations for an
                              alternative design.
 Office of Planning and Program Coordination
                              Provide technical,
 MayaTech Corporation, Silver administrative, and logistical
 Spring, Md.                  support for peer review meetings  1,000,000
                              that evaluate grant applications
                              and contract proposals.

Note: These contracts represent $64 million, or 64 percent, of contracts
SAMHSA specifically identified for technical assistance and program
evaluation and account for those contracts in fiscal year 1999 whose dollar
values are $1 million or greater. There were 95 other contracts with values
less than $1 million funded in fiscal year 1999.

Table 5: SAMHSA's Staffing Levels by Program, as of December 1999

Continued

                                         Grade-level
                            Executive                   Commissioned
                                            staff                    Total
   Program and activity       staff    (GS-1 to GS-15)   officers
 Center for Substance Abuse
 Treatment
 KDA/targeted capacity
 expansion                 0          55               4             59
 SAPT block granta         0          21               5             26
 Public communicationsb    0          7                0             7
 Program support           0          6                0             6
 Program planning/advisory
 councils                  0          10               1             11
 Center management         2          4                0             6
                                      103

                                      (16 GS-15s; 26
 Total staffing            2          GS-14s; 32       10            115
                                      GS-13s; and 29
                                      GS-12s or
                                      lower)
 Center for Substance Abuse
 Prevention
 KDA/targeted capacity
 expansion/high-risk youth 1          33               2             36
 SAPT block granta         0          19               1             20
 Other substance abuse
 programsc                 0          17               0             17
 Public communicationsb    0          21               1             22
 Program support           0          4                0             4
 Program planning/advisory
 councils                  0          11               1             12
 Center management         1          5                1             7
                                      110

                                      (11 GS-15s; 29
 Total staffing            2          GS-14s; 36       6             118
                                      GS-13s; and 34
                                      GS-12s or
                                      lower)
 Center for Mental Health
 Services
 KDA                       0          42               2             44
 Mental health block granta1          12               0             13
 Children's program        0          10               0             10
 Homeless programsd        0          2                0             2
 Protection advocacy       0          1                0             1
 Other mental health
 programse                 0          11               1             12
 Public communicationsb    0          10               3             13
 Program support           0          8                1             9
 Center management         1          7                1             9
                                      103

                                      (12 GS-15s; 27
 Total staffing            2          GS-14s; 29       8             113
                                      GS-13s; and 35
                                      GS-12s or
                                      lower)
 Office of the
 Administrator
 Operating division/public
 communicationsb           0          12               0             12
 Grants/contract reviewf   0          10               3             13
 Other operating
 division/crosscutting     0          19               1             20
 programsg
 Program
 planning/coordination     1          8                0             9
 Operating division
 managementh               3          16               0             19
                                      65

                                      (13 GS-15s; 14
 Total staffing            4          GS-14s; 14       4             73
                                      GS-13s; and 24
                                      GS-12s or
                                      lower)
 Other SAMHSA Offices
                                      91

 Office of Program                    (7 GS-15s; 14
 Servicesi                 1          GS-14s; 26       0             92
                                      GS-13s; and 44
                                      GS-12s or
                                      lower)
                                      26

                                      (6 GS-15s; 11
 Office of Applied Studies 1          GS-14s; 5        0             27
                                      GS-13s; and 4
                                      GS-12s or
                                      lower)
 Total                     12         498              28            538

aThe number of staff assigned to block grant programs represents only those
staff who work directly on the programs in the centers' divisions of state
programs. However, numerous other staff support block grant programs
directly or indirectly, including statistical staff who calculate state
allocations and budget support, grants management, and audit staff.

bIncludes development of program materials, prevention communications,
public information clearinghouses, public service messages.

cIncludes minority health concerns, workplace programs, and managed care
programs.

dIncludes Projects for Assistance in Transition From Homelessness Program, a
formula grant program.

e Includes emergency programs, clinical training pay back, monitoring,
managed care, surgeon general's report, and bioterrorism.

fConducted within the Division of Extramural Activities, Policy, and Review.

gIncludes minority health program, women's health program, HIV/AIDS program,
managed care program, and alcohol program.

hIncludes equal employment programs.

i Includes grants management, contracts management, financial management,
information resources management, human resources management, and
administrative services.

KDA Grant Programs and Funding for Drug Abuse Treatment

Continued

                                                   Fiscal year 1996    Fiscal year 1998
          Program               Description      Grantees  Funding    Grantees  Funding
                            Help metropolitan
                            areas increase the
                            effectiveness of
                            treatment delivery
                            by developing a
                            model infrastructure
 Target Cities              to expand and        10       $20,340,000 7       $1,526,448
                            coordinate local
                            health care and
                            social service
                            delivery systems
                            with specialized
                            addiction treatment
                            networks.
                            Address gaps in
                            treatment capacity
                            by supporting rapid
 Targeted Capacity Expansionand strategic        a        a           41      23,731,977
                            responses to demands
                            for substance abuse
                            treatment services.
                            Foster participation
                            of those who are
                            recovering from
                            substance abuse in
                            the development of
                            substance abuse
 Recovery Community Support treatment services   a        a           19      3,661,892
                            and programs,
                            policies, and
                            quality assurance
                            activities at the
                            state and local
                            levels.
                            Evaluate the
                            benefits and
                            cost-effectiveness
                            of these services as
                            they relate to
 Wraparound Services        substance abuse      1        1,196,733   1       2,004,823
                            treatment given
                            changes in health
                            care financing,
                            including managed
                            care.
                            Study the
                            effectiveness of a
                            program for
                            substance-busing
                            women eligible for
 Welfare-to-Work            Temporary Assistance a        a           1       300,000
                            to Needy Families to
                            receive treatment
                            for alcohol and/or
                            drug addiction and
                            to become employed.
                            Establish a more
                            effective continuum
                            of care by
                            integrating
                            substance abuse
 Residential Women and      services with
 Children                   general health care, 26       16,524,873  15      13,804,411
                            providing
                            comprehensive
                            services for
                            addicted women and
                            their children.
                            Expand the
                            availability of
                            comprehensive
 Pregnant and Postpartum    treatment services
 Women                      for pregnant and     17       14,875,127  4       2,893,776
                            postpartum women and
                            their children with
                            alcohol and other
                            drug use problems.
                            Generate and apply
                            empirical knowledge
                            about the
                            development and
                            effectiveness of an
 Violence Against Women     integrated systems   a        a           9       5,229,228
                            approach for
                            assisting women with
                            co-occurring
                            disorders and their
                            children.
                            Test the
                            effectiveness of
                            integrating mental
                            health and substance
                            abuse prevention and
 Starting Early Starting    treatment services
 Smart                      with primary health  a        a           12      2,575,567
                            care or early
                            childhood service
                            settings for
                            children from birth
                            to age 7 and their
                            families.
                            Adjunct to the
                            Criminal Justice
                            Networks Program to
                            provide supplemental
                            funds to existing
                            Center for Mental
 Children's Mental Health   Health Services'
 Services                   programs that        a        a           1       99,749
                            support
                            community-based
                            substance abuse and
                            mental health
                            services for
                            children and
                            families.
                            Network of centers
                            to ensure that
                            treatment
 Addiction Technology       professionals have
 Transfer Centers           the latest           11       7,148,339   15      7,565,505
                            information on best
                            practices and
                            treatment
                            techniques.
                            Link metropolitan
                            justice agencies
                            with substance abuse
 Criminal Justice Treatment treatment networks
 Networks                   and related health,  7        6,074,987   7       8,148,230
                            mental health, and
                            social services
                            agencies.
                            Support the
                            evaluation of the
                            relative
                            effectiveness of a
                            variety of pre- and
 Criminal Justice Jail      post-booking police
 Diversion                  diversion and        a        a           7       2,999,999
                            criminal justice
                            intervention models
                            for individuals with
                            co-occurring
                            disorders.
                            Modify behavior and
                            reduce the incidence
                            of HIV and related
 HIV Outreach               diseases by          11       3,406,999   a       a
                            targeting high-risk
                            substance abusers
                            and their partners.
                            Collaboration among
                            six federal agencies
                            to study integrated
 HIV/AIDS Cost Study        mental health,       a        a           9       950,000
                            substance abuse, and
                            primary medical HIV
                            treatment
                            interventions.
                            Enhance knowledge
                            about how managed
 Managed                    care in the public
 Care−Vulnerable      sector affects the   7        3,234,846   6       3,357,520
 Populations                provision of
                            substance abuse and
                            mental health
                            services.
                            Examine the effects
                            on cost,
                            utilization, and
 Managed                    outcomes of
 Care−Adolescents     different models of  a        a           7       4,177,676
                            managed care for
                            adolescents with
                            substance abuse
                            problems.
                            Evaluate the
                            effectiveness of
 Managed Care−Alcohol alcoholism services
 Services                   delivery in a        a        a           1       199,999
                            managed care
                            environment.
                            Deliver treatment
                            services in
                            innovative ways to
                            hard-to-reach
                            populations and to
 Rural Remote and Culturallyserve as a model
 Distinct Populations       program to be        3        1,765,000   3       2,018,782
                            replicated for
                            Alaskan Natives,
                            Native Americans,
                            and Native
                            Hawaiians.
                            Supplemental funding
                            to the Center for
                            Mental Health
                            Services to continue
                            and augment mental
                            health and substance
                            abuse treatment
                            services and enhance
 Farm Resource Center       outreach to rural,   a        a           1       50,000
                            coal mining, and
                            farm populations in
                            West Virginia and
                            Illinois, especially
                            to those who are
                            poor, disabled, or
                            elderly and to
                            child-bearing women.
                            Examine the efficacy
                            of brief treatment
                            interventions for
                            marijuana dependence
                            and whether these
 Marijuana−Adults     treatments are       4        1,288,805   4       1,844,311
                            effective in diverse
                            populations with a
                            higher proportion of
                            minority
                            representation.
                            Examine the
                            effectiveness of
                            treatment for
                            marijuana-dependent
 Marijuana−Adolescentsyouth, comparing     a        a           5       3,219,164
                            five promising
                            approaches that vary
                            in orientation,
                            duration, mode of
                            delivery, and cost.
                            Test the
                            replicability of
                            specific
                            nonresidential
 Methamphetamine Treatment  programs for the     a        a           8       3,024,100
                            treatment of
                            methamphetamine
                            abuse and their
                            cost-effectiveness.
                            Document
                            homelessness
                            prevention models
                            for individuals with
                            serious mental
                            illness and
                            substance abuse
 Homelessness Prevention    disorders who are    12       1,040,695   8       1,826,921
                            homeless, formerly
                            homeless, or at risk
                            for homelessness and
                            who have had contact
                            with the mental
                            health or substance
                            abuse treatment
                            system.
                            Provide expanded
                            substance abuse
 Disaster Assistance        treatment services   1        663,708     a       a
                            during a natural
                            disaster.
                            Develop a model
                            comprehensive
                            program for the
 Campus                     treatment of         1        600,000     a       a
                            substance abuse in
                            the national capital
                            area.
                            Provide
                            doctoral-level
                            training to increase
                            the number of
                            professionals
                            qualified to develop
 Minority Fellowship        and implement        a        a           4       340,000
                            services for
                            underserved ethnic
                            populations with
                            mental health and
                            substance abuse
                            problems.
                            Identify those
                            regimens for
                            treating adolescent
 Exemplary                  heroin abusers that
 Programs−Adolescents appear to be         a        a           5       2,116,079
                            exemplary and may be
                            useful for further
                            replication and
                            dissemination.
                            Support the adoption
                            of exemplary
                            practices for
 Community Action Grants    Hispanic adults and  a        a           3       442,944
                            adolescents with
                            mental health or
                            substance abuse
                            problems.
                            Support domestic
 Conference Grant           conferences for      a        a           7       309,066
                            knowledge synthesis
                            and dissemination.
 Total                                           111      $78,160,112 210     $98,418,167

aProgram not funded.

State Program Assessments

Continued from Previous Page

                                                          Selected outcome
 State and program        Client          Treatment         measures and
                       populations        services
                                                              results
 California
                                                        Drug use declined
                                                        by 40 percent.

                                                        Employment results
                                                        not conclusive.
 California Drug and
 Alcohol Treatment  All clients       All services      Hospital admissions
 Assessment                                             reduced by 33
                                                        percent.

                                                        Criminal activity
                                                        declined by 66
                                                        percent.
 Florida
                                                        Abstinence for 65
                                                        percent of children
 Ongoing performance                                    and 61 percent of
 measurement system All clients       All services      adults.
                                                        Employment achieved
                                                        by 63.4 percent.
                                                        11 percent of
                                                        clients completing
                                                        treatment who were
                                                        drug free at
                                                        discharge reported
                                                        a substance abuse
                                                        problem, compared
                                                        to 26 percent of
 Evaluation of                                          clients who did not
 Substance Abuse    Adults            Residential,      complete treatment.
 Treatment Outcomes                   outpatient
                                                        70 percent of
                                                        clients who
                                                        completed treatment
                                                        were employed,
                                                        compared to 58
                                                        percent of clients
                                                        who did not
                                                        complete treatment.
 North Carolina
                                                        Declines in drug
                                                        use improved
                                                        significantly.

                                                        Abstinence improved
                                                        significantly.

 Ongoing performance                  Outpatient, case  Employment modestly
 measurement system All clients       management        improved.

                                                        Mental health
                                                        moderately
                                                        improved.

                                                        Living arrangement
                                                        modestly improved.
                                                        Drug use declined
                                                        substantially for
                                                        each type of
                                                        substance.

                                                        Medical overnight
                                                        stays reduced by 4
 TOPPS              All clients       Outpatient        percent, and
                                                        emergency room
                                                        visits reduced by
                                                        18 percent.

                                                        Psychiatric
                                                        overnight stays
                                                        reduced by 16
                                                        percent.
                                                        73 percent of
 Perinatal and                                          clients had
 Maternal Substance Pregnant and      Prenatal          full-term births;
 Abuse Treatment    postpartum women  treatment         13 percent of
 Initiative         and adolescents                     births born at very
                                                        low birth weight.
                                                        Abstinence occurred
                                                        for 48 percent at
                                                        discharge.

 Treatment                                              Drug use for those
 Alternatives to    Criminal justice  All services      still using drugs
 Street Crime (TASC)                                    was less often.

                                                        82 percent had no
                                                        arrests while in
                                                        the program.
                                                        Abstinence from
                                                        injected drug use
                                                        for 94 percent.

                                                        Drug use urine
                                                        screens for opiates
                                                        negative for 79
                                                        percent; for
                                                        cocaine, 88
                                                        percent.

 Methadone Treatment                                    Employment
 Quality Assurance  Narcotic          Methadone         full-time for 54
 System             addicted                            percent.

                                                        No medical
                                                        overnight stays for
                                                        93 percent, and no
                                                        emergency room
                                                        visits for 82
                                                        percent.

                                                        No arrests in the
                                                        past 12 months for
                                                        95 percent.
 Ohio
                                                        Abstinence occurred
                                                        for 76 percent of
                                                        discharges.

 TASC               Court-referred    All treatment     Drug use testing
                    juveniles                           negative for 92
                                                        percent.

                                                        Rearrest rate: 7
                                                        percent.
                                                        Abstinence occurred
                                                        for 47 percent of
                                                        discharges.

                                                        Drug use urine
                                                        testing negative
                                                        for 88 percent; for
                                                        breath testing, 91
                                                        percent.
 TASC               Court-referred    All treatment
                    adults                              Employment obtained
                                                        and improved for
                                                        1,017 clients, or
                                                        46 percent of
                                                        discharges.

                                                        Living arrangement
                                                        stable for 1,132,
                                                        or 51 percent of
                                                        discharges
                                                        Criminal activity
 Analysis of Adult  Court-referred    Counseling,       significantly lower
 TASC               adults            urinalysis        for clients
                                                        completing the
                                                        program.
 Arrest and
 Reincarceration    Adult male        Therapeutic       Rearrests were
 Following Prison   felons            community         slightly reduced
 Release                                                among participants.
 Tapestry
 Therapeutic
 Community; Our     Female and male   Residential,      Women had lower
 Awareness of Self  incarcerated      other drug abuse  rearrests; males,
 Increases Success  felons            treatment         no difference.
 Therapeutic
 Community
 Texas
                                                        Abstinence achieved
                                                        by 56 to 61 percent
                                                        for alcohol and
 Treatment Research                   Residential,      other drugs.
 Institute          Adults            outpatient
                                                        Employment achieved
                                                        by 51 to 64
                                                        percent.
 Treatment                                              Criminal activity
 Alternatives to                                        decreased the
 Incarceration      Adult criminals   Outpatient        longer the stay in
 Program                                                treatment.
                                                        Abstinence occurred
                                                        for 72 percent of
                                                        clients.

                                      Detoxification,   Drug use reduced
 Statewide Treatment                  residential,      for 64 percent.
 Outcome Data       Adults            outpatient,
                                      methadone         Employment gained
                                                        by 33 percent.

                                                        Arrest rate at
                                                        followup was 5
                                                        percent.
 Washington
                                                        Physical health
 Cost Savings in                      Intensive         costs $4,500 less
 Medicaid Medical   Indigents         inpatient,        than for untreated
 Expenses                             outpatient        clients over 5-year
                                                        period.
                                                        Employment earnings
                                                        more than double
 Alcoholism and Drug                                    that of untreated
 Addiction Treatment                  Intensive         clients.
 and Support Act    Indigents         inpatient,
 (ADATSA): Economic                   outpatient,       Physical health
 Benefits and Costs                   residential       costs decreased by
                                                        nearly 50 percent
                                                        for treated
                                                        clients.
                                                        Employment earnings
                                                        for those who
 ADATSA Treatment                     Intensive         completed training
 Outcomes:                            inpatient,        nearly doubled.
 Employment and CostIndigents         outpatient,
 Avoidance                            vocational        Physical health
                                      training          costs were less
                                                        than half that of
                                                        nontreated clients.
                                                        Employment earnings
 Employment Outcomes                  Intensive         increased on
 of Indigent Clients                  inpatient,        average by $1.30
 Receiving Alcohol  Indigents         outpatient,       for every day of
 and Drug Treatment                   recovery house    inpatient care
                                                        received.
 Employment Outcomes                                    Employment earnings
 of Chemical                          Intensive         were higher for 46
 Dependency                           inpatient,        percent of clients
 Treatment and      Indigent          outpatient,       who completed
 Additional                           vocational        vocational
 Vocational Services                  training          services.

 Substance Abuse,                     Prenatal          Overall rate of low
 Treatment, and                       treatment,        birth weights for
 Birth Outcomes for Pregnant and      prenatal and      infants whose
 Pregnant and       postpartum women  postpartum        mothers were
 Postpartum Women                     diagnosis,        treated was lowered
                                      Medicaid          by 2.9 percent.
                                                        Mental health
                                                        services declined
                    Mentally ill,                       after treatment 7
                    chemically                          to 25 percent.
 Evaluation of      addicted, and
 Pioneer Center     involuntary       Residential       Physical health
 North              chemical          (nonhospital)     costs decreased
                    dependency                          between $2.2
                    treatment                           million and $1.1
                                                        million for those
                                                        who received
                                                        treatment.
                                                        Abstinence achieved
                                                        for 6 months on
                                                        average by about 40
                                                        percent of clients.

                                                        Number of drug
                                                        substances used
                                                        dropped by about 3.

                                                        Mental health
                                                        problems decreased
                                                        from 42 percent to
                                                        29 percent in
                                                        psychiatric
                                                        symptoms.
 Division of Alcohol                  Intensive
 and Substance Abuse                  inpatient         Physical health
 One-year AdolescentAdolescents       (nonhospital),    problems decreased
 Outcomes Report                      outpatient        from 17 percent to
                                                        11 percent in
                                                        medical
                                                        hospitalization and
                                                        42 percent to 28
                                                        percent in
                                                        emergency room
                                                        visits.

                                                        Criminal activity
                                                        decreased in arrest
                                                        for misdemeanors by
                                                        25 percent,
                                                        felonies by 23
                                                        percent, and drug
                                                        violations by 24
                                                        percent.
                                                        Abstinence was
                                                        achieved for 6
                                                        months on average
                                                        by about 45 percent
                                                        of the clients.

                                                        Employment
                                                        absenteeism or
                                                        tardiness dropped
                                                        by 33 percent.

                                                        Mental health
 Division of Alcohol                  Intensive         problems decreased
 and Substance Abuse                  inpatient         by 17 percent in
 18-Month AdolescentAdolescents       (nonhospital),    major depressive
 Outcomes Report                      outpatient        syndromes and by 14
                                                        percent in suicide
                                                        attempts.

                                                        Physical health
                                                        problems decreased
                                                        in emergency room
                                                        visits.

                                                        Criminal activity
                                                        decreased in drug
                                                        dealing, theft, and
                                                        prostitution by 48
                                                        percent.
                                                        Abstinence was
                                                        achieved for 40
                                                        percent 3 months
                                                        after treatment.
 Treatment Outcome
 Evaluation: Youth                                      Drug use prevalence
 Admitted to                                            decreased by 46
 Residential                          Intensive         percent for
 Chemical DependencyYouth             inpatient         marijuana.
 Treatment Under the                  (nonhospital)
 Provisions of the                                      Criminal activity
 "Becca" Bill                                           decreased in
                                                        selling drugs by 51
                                                        percent, breaking
                                                        and entering by 39
                                                        percent.
                                                        Abstinence occurred
                                                        for two-thirds of
                                                        the sample at 6
 Adolescent                           Intensive         months.
 Treatment Outcome  Adolescents       inpatient
 Study Report                         (nonhospital)     Criminal activity
                                                        decreased fourfold
                                                        for felony arrests
                                                        after 1 year.
 Adolescent                                             Abstinence occurred
 Treatment Outcome                                      for 5 percent more
 Study Report:                                          court-referred
 Six-Month Follow-up                                    clients than
 of Clients ReferredAdolescents                         others.
 by the Juvenile    referred by       Intensive
 Justice System,    court or          inpatient         Criminal activity
 Those Served by    juvenile justice  (nonhospital)     decreased
 Schools, as Well assystem                              significantly for
 Those Whose Parents                                    abstinent clients
 Currently Abuse                                        compared to
 Substances                                             relapsed clients.

(108394)

Table 1: Characteristics of SAMHSA's Major Drug Abuse
Treatment Studies 20

Table 2: States' Client Outcome Assessment Activities 22

Table 3: SAMHSA's Administrative Expenses, Fiscal Year 1999 Appropriation 31

Table 4: Selected SAMHSA Contracts for Technical Assistance
and Program Evaluation, Fiscal Year 1999, by Agency and
Program 32

Table 5: SAMHSA's Staffing Levels by Program, as of
December 1999 35

Figure 1: Percentage of SAMHSA's Drug Abuse Treatment
Expenditures for SAPT Block Grant and KDA Grant Programs,
Fiscal Year 1996 9

Figure 2: Percentage of Surveyed State Agencies' Total
Expenditures for Drug Abuse Treatment Services by
Funding Source, Fiscal Year 1996 10

Figure 3: Percent of SAPT Block Grant Expenditures for
Methadone Services, Fiscal Year 1996 12
  

1. The $3.2 billion represents funding from eight federal agencies: the
Federal Judiciary; the Departments of Health and Human Services, Veterans
Affairs, Defense, Education, Housing and Urban Development, and Justice; and
the Office of National Drug Control Policy.

2. SAMHSA's demonstration grant program was part of an effort to establish a
system for developing, documenting, and disseminating successful approaches
to prevent and treat substance abuse and mental illness. The KDA effort
emerged from the demonstration grant program and, according to SAMHSA
officials, uses more rigorous evaluation methods and focuses on developing
findings that can be adopted in other treatment settings.

3. Assessment of Performance Measures for Public Health, Substance Abuse,
and Mental Health , National Research Council, 1997.

4. In addition to state expenditures for drug abuse treatment, states spent
about $681 million in SAPT block grant awards to support alcohol treatment,
primary prevention, tuberculosis and HIV early intervention services, and
administration.

5. The remaining two states did not report the portion of SAPT block grant
funds spent on outpatient services.

6. Michigan and North Carolina state officials reported that they could not
provide information on methadone expenditures supported with SAPT block
grant funds because methadone expenditures could not be disaggregated from
other SAPT block grant expenditures for drug abuse treatment.

7. Drug Abuse Treatment: Data Limitations Affect the Accuracy of National
and State Estimates of Need (GAO/HEHS-98-229, Sept. 15, 1998).

8. Final results have not been reported on the effectiveness of selected
treatment practices for specific KDA programs.

9. These guidelines, which took effect for fiscal years ending on or after
June 30, 1997, include a review of a program's oversight, including
monitoring or other reviews conducted by oversight entities, current and
prior audit experience, and the inherent risk of the program.

10. The state's principal agency for drug abuse treatment is required to
maintain aggregate drug abuse treatment expenditures at a level that is not
less than the average level of such expenditures for the 2-year period
preceding the fiscal year for which the state is applying for the grant.

11. SAMHSA also funded the Alcohol and Drug Services Study, a national study
to obtain information on substance abuse treatment facilities and patients.
This study is a continuation of the Services Research Outcome Study and
provides more detailed information on the organization of the national
treatment system and the effectiveness and cost-effectiveness of treatment.
However, final results from this study are not yet available.

12. Georgia and New York did not provide results from their assessments;
Virginia officials stated that the results from their performance outcome
measurement system were ambiguous due to inconsistent data elements across
programs and problems with linking the information with the state's
management information system.

13. Washington law allows the use of Social Security numbers to track
clients; however, some states prohibit the use of these identifiers because
of privacy and access concerns.

14. The 19 states that applied and were selected to participate in TOPPS II
are Arizona, Arkansas, California, Connecticut, Illinois, Iowa, Kentucky,
Maryland, Massachusetts, Missouri, New Hampshire, New Jersey, New York,
Oklahoma, Rhode Island, Texas, Utah, Virginia, and Washington.

15. SAMHSA's core set of outcome measures also include alcohol use.

16. One expert we spoke with stated that it is also important to collect a
core set of clinical data at client admissions to help establish an
evaluation database and that such a database could be helpful in
standardizing treatment approaches and training of personnel in the drug
abuse treatment field.
*** End of document. ***