Emerging Drug Problems: Despite Changes in Detection and Response
Capability, Concerns Remain (Letter Report, 07/20/98, GAO/HEHS-98-130).
Pursuant to a congressional request, GAO reviewed the efforts of the
federal public health agencies to detect the spread of drug use in the
United States and their ability to respond to potential drug crises,
focusing on: (1) how the public health service agencies have detected
and responded to the crack cocaine epidemic; (2) any changes made to
improve the nation's drug detection and response capability; and (3) any
remaining issues that could compromise the nation's ability to detect
and respond to emerging drug problems.
GAO noted that: (1) despite certain limitations in its sources of
information, the National Institute on Drug Abuse (NIDA) was able to
track the use of a number of illicit drugs, including cocaine, during
the late 1970s and early 1980s; (2) two drug detection mechanisms NIDA
used as a part of that effort helped detect the emergence of crack--a
smokable form of cocaine; (3) NIDA had become aware of the rapid spread
of crack in 17 metropolitan areas by 1986, but the prevalence of crack
use in the national household population was not known until the late
1980s; (4) federal public health agencies primarily directed their
response efforts to the problem of cocaine and drug abuse in general,
rather than to crack specifically; (5) the response, orchestrated
largely by NIDA, focused primarily on drug abuse research and education;
(6) the Alcohol, Drug Abuse, and Mental Health Administration provided
funding to state and local entities for substance abuse prevention and
treatment services through the federal block grant program during the
1980s; (7) following the height of the crack epidemic around 1985,
concerns were raised in Congress about efforts to detect and respond to
the problem--in particular about the timeliness and accuracy of drug use
data, lack of data on certain populations and geographic areas, limited
availability of certain treatment programs, limited monitoring of the
block grant program, and lack of a coordinated national drug control
strategy; (8) in response, the responsible federal agencies made changes
to improve drug detection capability--changes that included adding new
detection mechanisms; (9) also, to help strengthen the federal response
to drug problems, Congress legislated changes in the organization of the
Department of Health and Human Services' major drug control agencies:
the Substance Abuse and Mental Health Services Administration was
created as a separate agency to focus on prevention and treatment
services, and, to emphasize its research focus, NIDA was moved to the
National Institutes of Health; (10) in addition, Congress created the
Office of National Drug Control Policy (ONDCP) to develop a national
drug control strategy and coordinate the national drug control effort;
(11) despite these changes, concerns remain about the nation's ability
to detect and respond to emerging drug problems; (12) ONDCP established
a group to study the use of drug data that has recommended ways to
improve the nation's drug data collection system; and (13) in addition,
experts agree on the need for an overall strategy among key drug control
agencies for managing emerging drug problems.
--------------------------- Indexing Terms -----------------------------
REPORTNUM: HEHS-98-130
TITLE: Emerging Drug Problems: Despite Changes in Detection and
Response Capability, Concerns Remain
DATE: 07/20/98
SUBJECT: Drug abuse
Narcotics
Interagency relations
Alcohol or drug abuse problems
Controlled substances
Drug treatment
Public health research
Data collection
Surveys
IDENTIFIER: Alcohol, Drug Abuse, and Mental Health Block Grant
NIDA Drug Abuse Warning Network
NIDA National Household Survey on Drug Abuse
NIDA Monitoring the Future Survey
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Cover
================================================================ COVER
Report to the Honorable Daniel Patrick Moynihan and the Honorable
James M. Jeffords, U.S. Senate
July 1998
EMERGING DRUG PROBLEMS - DESPITE
CHANGES IN DETECTION AND RESPONSE
CAPABILITY, CONCERNS REMAIN
GAO/HEHS-98-130
Emerging Drug Use Problems
(108321)
Abbreviations
=============================================================== ABBREV
ADAM - Arrestee Drug Abuse Monitoring
ADAMHA - Alcohol, Drug Abuse, and Mental Health Administration
ADMS - Alcohol, Drug Abuse, and Mental Health Services
BJS - Bureau of Justice Statistics
BLS - Bureau of Labor Statistics
BOP - Bureau of Prisons
CDC - Centers for Disease Control and Prevention
CEWG - Community Epidemiology Work Group
CSAP - Center for Substance Abuse Prevention
CSAT - Center for Substance Abuse Treatment
DAWN - Drug Abuse Warning Network
DEA - Drug Enforcement Agency
DOD - Department of Defense
FBI - Federal Bureau of Investigation
HHS - Department of Health and Human Services
KD&A - Knowledge Development and Application
MTF - Monitoring the Future
NHSDA - National Household Survey on Drug Abuse
NIDA - National Institute on Drug Abuse
NIH - National Institutes of Health
NIMH - National Institute of Mental Health
ONDCP - Office of National Drug Control Policy
OSAP - Office of Substance Abuse Prevention
OTI - Office for Treatment Improvement
SAMHSA - Substance Abuse and Mental Health Services Administration
SAPT - Substance Abuse Prevention and Treatment
SIG - State Incentive Grant
STRIDE - System to Retrieve Information From Drug Evidence
TEDS - Treatment Episode Data Set
UCR - Uniform Crime Reports
VDET - Violence Data Exchange Teams
Letter
=============================================================== LETTER
B-277159
July 20, 1998
The Honorable Daniel Patrick Moynihan
The Honorable James M. Jeffords
United States Senate
In the mid-1980s, crack cocaine use in the United States was reported
to have reached epidemic proportions. While the prevalence of
illicit drug use in the past year has declined overall since the
1980s, drug use remains a serious national public health problem. In
1996, an estimated 13 million Americans aged 12 and older had used an
illicit drug in the past month. In addition, national survey data
indicate that the recent downward trend in illicit drug use among
youth has reversed. From 1992 to 1995, for example, past-month
prevalence of marijuana use by 12- to 17-year-olds more than doubled.
The costs of drug abuse to society--which include costs for health
care related to drug use, drug addiction prevention and treatment
services, and fighting drug-related crime, as well as the cost of
lost earnings due to premature death--were estimated at about $110
billion in 1995.
Each year since the mid-1980s, the Congress has appropriated billions
of dollars for federal agencies to reduce the supply of and demand
for illicit drugs. In general, federal law enforcement agencies
focus on reducing the supply of illicit drugs through activities such
as interdiction and enforcement, while public health service agencies
focus on reducing the demand for drugs by funding drug abuse
prevention and education programs, treatment and rehabilitation, and
research on drug use.
Given the continuing concerns about the demand for drugs and emerging
drug use problems, you asked us to review the efforts of the federal
public health agencies to detect the spread of drug use in this
country and their ability to respond to potential drug crises.
Specifically, you asked us to (1) describe how the public health
service agencies have detected and responded to the crack cocaine
epidemic,\1 (2) identify any changes made to improve our nation's
drug detection and response capability, and (3) identify any
remaining issues that could compromise our nation's ability to detect
and respond to emerging drug problems.
To conduct our work, we obtained written responses to survey
questions from the Office of National Drug Control Policy (ONDCP),
the National Institute on Drug Abuse (NIDA), and the Substance Abuse
and Mental Health Services Administration (SAMHSA) and interviewed
government officials from these agencies as well as from the Centers
for Disease Control and Prevention (CDC). We also reviewed documents
related to these agencies' operations and programs and legislation
that describes these agencies' roles and responsibilities. In
addition, we interviewed government officials and experts in the drug
abuse field in three states--California, Maryland, and New York--and
three cities in these states--San Francisco, Baltimore, and New York
City. These sites were selected on the basis of their high drug use
rates, location, and importance as transport points in the U.S. drug
trade. Finally, we convened a panel of seven experts to obtain their
views on the objectives of our review. (See app. I for more
information about our expert panel.)
While this report discusses some limitations in and changes to drug
use detection mechanisms--methods for identifying and measuring
illicit drug use--we did not assess the overall effectiveness of drug
detection mechanisms available to and used by the public health
service agencies. This report also discusses the agencies' response
to the crack cocaine problem and changes made to address illicit drug
use in the United States;\2 however, we did not assess the
effectiveness of these actions. Our work was performed between March
1997 and May 1998 in accordance with generally accepted government
auditing standards.
--------------------
\1 The term "epidemic" has been used to describe a rapid rise in the
use of a new drug or a sharp increase in the use of a known drug in a
given area over a specified period of time. However, no single
definition has been consistently used by the various drug control
agencies.
\2 The Congressional Research Service is preparing a report at your
request that provides a chronology of events surrounding the
emergence of the crack cocaine problem in the United States.
RESULTS IN BRIEF
------------------------------------------------------------ Letter :1
Despite certain limitations in its sources of information, NIDA was
able to track the use of a number of illicit drugs, including
cocaine, during the late 1970s and early 1980s. Two drug detection
mechanisms NIDA used as part of that effort helped detect the
emergence of crack--a smokable form of cocaine. NIDA had become
aware of the rapid spread of crack in 17 metropolitan areas by 1986,
but the prevalence of crack use in the national household population
was not known until the late 1980s. Federal public health agencies
primarily directed their response efforts to the problem of cocaine
and drug abuse in general, rather than to crack specifically. The
response, orchestrated largely by NIDA, focused primarily on drug
abuse research and education. The Alcohol, Drug Abuse, and Mental
Health Administration (ADAMHA)--the umbrella agency of which NIDA was
a part--provided funding to state and local entities for substance
abuse prevention and treatment services through the federal block
grant program during the 1980s.
Following the height of the crack epidemic around 1985, concerns were
raised in the Congress about efforts to detect and respond to the
problem--in particular about the timeliness and accuracy of drug use
data, lack of data on certain populations and geographic areas,
limited availability of certain treatment programs, limited
monitoring of the block grant program, and lack of a coordinated
national drug control strategy. In response, the responsible federal
agencies made changes to improve drug detection capability--changes
that included adding new detection mechanisms. Also, to help
strengthen the federal response to drug problems, the Congress
legislated changes in the organization of the Department of Health
and Human Services' (HHS) major drug control agencies: SAMHSA was
created as a separate agency to focus on prevention and treatment
services, and, to emphasize its research focus, NIDA was moved to the
National Institutes of Health (NIH). In addition, the Congress
created ONDCP to develop a national drug control strategy and
coordinate the national drug control effort.
Despite these changes, concerns remain about the nation's ability to
detect and respond to emerging drug problems. ONDCP established a
group to study the use of drug data that has recommended ways to
improve the nation's drug data collection system. In addition,
experts agree on the need for an overall strategy among key drug
control agencies for managing emerging drug problems--one that
addresses when and how best to respond to a potential drug crisis or
epidemic.
BACKGROUND
------------------------------------------------------------ Letter :2
The rapid and widespread increase in the use of crack--a smokable
form of cocaine--in the 1980s has frequently been referred to as a
drug epidemic. To identify emerging drug use problems, researchers
and government agencies look for changing patterns in drug use, some
of which may signal the onset of an epidemic. Primary among these
patterns are the use of a new illicit drug; a change in how a drug is
taken, such as smoking rather than inhaling--or "snorting"--cocaine;
a change in the level of use of an existing drug among populations
that routinely abuse drugs; and the use of a drug by a new population
group or in a different geographic area. Some experts argue that
national drug epidemics are rare, and many agree that local areas
more frequently experience emerging drug crises or epidemics before
they spread.
Many federal agencies fund activities and programs that implement the
nation's drug control strategy (see app. II). According to ONDCP,
about 25 percent of federal drug control resources are for
grants-in-aid or other forms of assistance provided to state and
local governments and private entities, which commingle such funds
with resources from other sources. In fiscal year 1997, federal
funding for drug control efforts was over $15 billion, and the fiscal
year 1998 request was for $16 billion. The President has requested
about $17 billion in funding for fiscal year 1999. About two-thirds
of federal drug control funds are channeled into efforts to reduce
the supply of illicit drugs; the remaining one-third supports efforts
to reduce drug demand. The Department of Justice obtains the largest
proportion--about 45 percent--and HHS gets about 16 percent.
Within HHS, NIDA and SAMHSA currently have primary responsibility for
health-related drug control problems. The Drug Abuse Office and
Treatment Act of 1972 (P.L. 92-255) created NIDA (effective in 1974)
and gave it broad responsibilities over most aspects of drug
research, prevention, and treatment activities. Essentially, NIDA
was responsible for planning and administering drug abuse prevention,
treatment, and rehabilitation programs and for developing and
conducting comprehensive research and research training (teaching
professionals about conducting substance abuse research). The act
also gave NIDA responsibility for creating a national community-based
treatment system to respond to the drug abuse problem.
In 1974, the same year NIDA was established, ADAMHA was created as an
umbrella agency to oversee the functions and operations of NIDA and
two other research institutes.\3 In 1981, ADAMHA was given additional
responsibility for (1) administering demonstration programs related
to the prevention and treatment of alcohol and drug abuse and mental
health disorders and (2) providing assistance and information about
such disorders to other federal agencies, states, health care
providers, and public and private organizations. The Alcohol, Drug
Abuse, and Mental Health Services (ADMS) block grant program was also
created in 1981 to provide funds to states for planning,
establishing, and evaluating programs for the development of more
effective prevention, treatment, and rehabilitation services.
In 1992, the ADAMHA Reorganization Act (P.L. 102-321) created a new
agency, SAMHSA, to replace ADAMHA and transferred NIDA and the two
other research institutes to NIH. NIDA retained primary
responsibility for substance abuse research activities, while SAMHSA
assumed primary responsibility for the service programs and some drug
use detection functions. SAMHSA also assumed responsibility for
overseeing state administration of the block grant programs.
--------------------
\3 The Comprehensive Alcohol Abuse and Alcoholism Prevention,
Treatment, and Rehabilitation Act Amendments of 1974 (P.L. 93-282)
gave ADAMHA responsibility for ensuring that programs carried out
through NIDA, the National Institute of Mental Health (NIMH), and the
National Institute on Alcohol Abuse and Alcoholism received
appropriate and equitable support and that these agencies cooperated
in the implementation of their programs.
NIDA-SPONSORED MECHANISMS WERE
USEFUL IN DETECTING AND
MONITORING SMOKABLE COCAINE
USE, DESPITE CERTAIN
LIMITATIONS
------------------------------------------------------------ Letter :3
In the 1970s, NIDA sponsored several surveys and convened a work
group of epidemiologists from cities around the country to help
identify and monitor changes in drug use patterns. Through these
mechanisms, NIDA was able to detect that cocaine was being smoked as
well as snorted--the more common method of cocaine use up to that
time. This change was later associated with the emergence of the
crack epidemic. NIDA was not able to collect information on the
national prevalence of crack use in the general household population
until the late 1980s because the survey NIDA used to collect these
data was not conducted annually and did not allow for timely
reporting of crack use. There also were other limitations in the
drug detection mechanisms NIDA used.
NIDA SPONSORED FOUR KEY DRUG
DETECTION MECHANISMS TO
IDENTIFY AND MONITOR ILLICIT
DRUG USE
---------------------------------------------------------- Letter :3.1
In the 1970s and 1980s, NIDA sponsored four major ongoing drug
detection mechanisms: the National Household Survey on Drug Abuse
(NHSDA), Monitoring the Future (MTF), the Drug Abuse Warning Network
(DAWN), and the Community Epidemiology Work Group (CEWG). (For other
drug use detection mechanisms sponsored by public health and law
enforcement agencies before the mid-1980s, see app. III.)
While the drug detection mechanisms were designed to collect
information on the use of a variety of drugs, including cocaine, they
generally targeted different populations and covered different
geographic locations and time periods. A description of the drug
detection mechanisms NIDA sponsored follows.
-- NHSDA, a nationally representative household survey established
in 1972, was used to estimate drug use in the general population
on the basis of a sample of permanent household members aged 12
and older. The survey was administered periodically, generally
every 2 to 3 years, and covered past-month, past-year, and
lifetime use of more than 10 drug types.
-- MTF, a nationally representative survey established in 1975 and
administered annually to 12th-grade students, measured drug use,
attitudes toward drugs, and perceptions about their availability
and ability to harm. Like NHSDA, it covered past-month,
past-year, and lifetime use of more than 10 drug types.
-- DAWN, established in 1972 by the Drug Enforcement Agency (DEA)
and transferred to NIDA in 1980, initially comprised a random
sample of hospital emergency departments within selected
metropolitan areas and medical examiners in metropolitan areas
who volunteered to participate. Emergency department
information captured types of drugs used, motives for use, and
whether the patient was treated. Medical examiner data also
captured drug type, as well as the form in which the drug was
used and whether the use was accidental or intentional.
-- CEWG, established in 1976, was originally composed of
epidemiologists from 18 major metropolitan areas. Three other
metropolitan areas were later added.\4 The group was established
to provide ongoing community-level surveillance of drug use
through the collection and analysis of epidemiologic and
ethnographic (culture-related) data. Changes in drug use
patterns are often captured by CEWG through its use of
law-enforcement surveillance data, street surveillance, and
other local public health drug detection sources.
--------------------
\4 The metropolitan areas now represented are Atlanta; Baltimore;
Boston; Chicago; Dallas; Denver; Detroit; Honolulu; Los Angeles;
Miami; Minneapolis; Newark; New Orleans; New York City; Philadelphia;
Phoenix; San Francisco; St. Louis; San Diego; Seattle; and
Washington, D.C.
TWO NIDA-SPONSORED
MECHANISMS DETECTED EARLY
WARNING SIGNS OF THE
EMERGENCE OF CRACK COCAINE
---------------------------------------------------------- Letter :3.2
Between the 1970s and early 1980s, NIDA tracked the change in cocaine
use through information reported by DAWN and CEWG. This change in
drug use pattern (from only snorting to also smoking cocaine) would
later be recognized as an early warning sign of the emergence of
crack cocaine. From DAWN data, NIDA found that, between 1976 and
1982, cocaine smoking accounted for about 2 percent of
cocaine-related emergency department episodes; however, by 1985,
cocaine smoking accounted for 8 percent of such episodes. It was not
until the late 1980s, however, that adjustments were made to DAWN
data that differentiated between freebasing--another form of cocaine
smoking--and crack cocaine smoking.\5 Moreover, CEWG began reporting
increased use of smokable cocaine in three major cities as early as
1981. In 1985--when crack first became generally recognized as a
specific form of smokable cocaine--crack use was reported to have
spread to at least seven of the CEWG coverage areas. Just 1 year
later, CEWG reported that crack use had spread to 17 of the
metropolitan areas covered.
--------------------
\5 Freebasing involves removing hydrochloride salt from street
cocaine; the "freed" cocaine is then mixed with a solvent such as
ether and heated, resulting in purified crystals, which are crushed
and smoked. Crack is inexpensively produced by cutting cocaine,
mixing it with baking soda, and heating the mixture to prepare the
crystals.
THE NATIONAL PREVALENCE OF
CRACK USE IN THE GENERAL
POPULATION WAS NOT KNOWN
UNTIL THE LATE 1980S
---------------------------------------------------------- Letter :3.3
Although NIDA was aware of the rapid spread of crack use from CEWG
reports starting in the mid-1980s, the national prevalence of crack
use in the general household population was not measured until the
late 1980s. (Prevalence of use data are utilized, in part, by
decisionmakers to establish drug control policy.) The 1985 NHSDA did
not include questions specific to crack use. Because the survey is
conducted generally every 2 to 3 years, questions about crack were
not included until the 1988 survey. As a result, survey data on the
national prevalence of crack use were not available until 1989--3
years after reports of the spread of crack to 17 major metropolitan
areas. Results from NHSDA showed that about 1 percent of household
populations had used crack in the past year.\6
--------------------
\6 In 1986, NIDA added questions to MTF to specifically measure crack
use among high school seniors and found that about 4 percent of high
school seniors had used crack in the past year.
LIMITATIONS IN DATA SOURCES
RAISED CONCERNS ABOUT THE
ADEQUACY OF INFORMATION ON
THE CRACK COCAINE CRISIS
---------------------------------------------------------- Letter :3.4
In two congressional hearings held in July 1986,\7 a number of
concerns were raised about the data that had been collected through
the NIDA-sponsored drug detection mechanisms. Specifically, NHSDA
data showed a leveling off of cocaine use nationally, while other
sources were indicating that local areas were experiencing epidemic
use of the drug. There was also a lack of data on crack use in the
general population. In addition, the latest NHSDA data being
reported had been collected 4 years earlier, in 1982.
These and other concerns about the adequacy of drug use data
reflected key limitations in each of the NIDA-sponsored mechanisms
used to measure drug use. Specifically, there were gaps in
populations surveyed that affected NIDA's prevalence of drug use
estimates. For example, NHSDA excluded institutionalized and
homeless populations. Similarly, high school dropouts--another
high-risk population--were excluded from MTF, thereby potentially
lowering national drug use estimates. NHSDA and MTF also relied on
self-reported drug use data, which were not validated.
There were also potential limitations in DAWN--one of the mechanisms
used to identify early warning signs of emerging drugs. For example,
since DAWN relied on hospital emergency personnel to record patient
mentions of substance abuse, there was concern about the accuracy of
the data, given the typically fast pace in hospital emergency
departments. In addition, there were concerns that, by the
mid-1980s, DAWN no longer provided a representative sample of
emergency departments, since many of the hospitals that had
participated in DAWN had either merged, closed down, or dropped out
of the study. Moreover, while CEWG was instrumental in reporting
early warning signs of crack use in the metropolitan areas it
covered, it did not collect and report information on rural areas or
cities with smaller population bases.
--------------------
\7 "Crack" Cocaine, Permanent Subcommittee on Investigations,
Committee on Governmental Affairs, U.S. Senate (July 15, 1986), and
The Crack Cocaine Crisis, Select Committee on Narcotics Abuse and
Control and the Select Committee on Children, Youth, and Families;
House of Representatives (July 15, 1986).
FEDERAL PUBLIC HEALTH RESPONSE
TO CRACK FOCUSED ON COCAINE
RESEARCH AND EDUCATION,
FUNDING, AND REESTABLISHING A
SERVICE FOCUS
------------------------------------------------------------ Letter :4
The federal public health response to crack in the 1980s primarily
focused on cocaine in general instead of on crack specifically.
NIDA's research was aimed at developing "best practice" prevention
and treatment approaches. The agency also launched several education
and outreach efforts specific to cocaine. Up to the late 1980s,
there was no significant change in block grant funding for state drug
prevention and service delivery activities. Federal involvement in
service delivery was through ADAMHA's oversight of state
administration of the ADMS block grant until congressional actions
changed the organization within ADAMHA to focus more on administering
prevention and treatment programs.
NIDA'S INITIAL RESEARCH
ACTIVITIES FOCUSED ON
COCAINE
---------------------------------------------------------- Letter :4.1
NIDA's research activities related to prevention and treatment
practices did not make clear distinctions between powdered cocaine
and its crystallized form, crack. According to NIDA officials, the
agency did not see a need to differentiate treatment practices for
powder cocaine and crack or to develop separate prevention approaches
for each of these drugs. NIDA officials stated that results from
later research on efficacy of treatment for cocaine and crack cocaine
showed that similar treatments were effective for both forms of
cocaine. NIDA's research activities included testing medications for
reducing cocaine craving and withdrawal symptoms. The agency also
investigated approaches for treating cocaine abuse, such as family
therapy, group psychotherapy, and therapeutic communities.
NIDA'S EDUCATION AND
OUTREACH EFFORTS FOCUSED ON
COCAINE
---------------------------------------------------------- Letter :4.2
As with its research efforts, NIDA did not initially target its
education and outreach efforts to address the use of crack. In the
1980s, as concerns about cocaine use increased, NIDA developed
several public education campaigns against drug use in general and
cocaine use in particular. The Drug Abuse Prevention Media Campaign,
launched in 1983, was targeted to people aged 18 to 35 and was
intended to motivate parents to learn about drugs, talk to their
children about problems associated with drug use, and join with other
parents to fight drug abuse in their communities. The initiative
also sought to help young people resist peer pressure and to just say
"no" to drugs, which became the theme of the campaign. In 1985, NIDA
introduced a second phase of this campaign that targeted inner-city
youth aged 10 to 14 and their families. In 1986, NIDA launched
"Cocaine: The Big Lie," a public education campaign that focused on
the dangers of cocaine and specifically targeted young adults, aged
18 to 35, in college and the workplace. The following year, the
campaign targeted crack as well as cocaine, sponsoring discussions of
the effects of crack on the brain and respiratory and cardiovascular
systems, as well as available treatments.
NIDA also established a national cocaine treatment hot line in 1985
to provide a toll-free referral service for people addicted to
cocaine and their families who sought treatment or counseling as well
as educational information about illicit drugs. Within the first
year of operation, more than 50,000 calls were received.
In addition, NIDA sponsored two national conferences, one in 1986 and
one in 1987, that collectively included sessions on drug abuse
prevention, research, and treatment. The purpose of these
conferences was to share information with drug epidemiologists,
health care providers, and the broader research community on the use
of illicit drugs.
BLOCK GRANT FUNDING FOR
SUBSTANCE ABUSE WAS FAIRLY
STABLE UNTIL THE LATE 1980S
---------------------------------------------------------- Letter :4.3
In 1981, before crack cocaine use was considered an epidemic, the
Congress consolidated its categorical and formula grant programs into
a substance abuse and mental health block grant to give states
greater flexibility in their use of funds for prevention and
treatment activities. This ADMS block grant program in effect
limited the federal role in service delivery to overseeing the
administration of the program and providing less direct assistance to
states. The 1982 initial appropriation for the ADMS block grant was
$428 million--a decrease of about 26 percent from the prior year's
appropriation for the categorical programs.
Total funding of the ADMS block grant program varied by less than 10
percent from fiscal years 1982 through 1988. However, starting in
fiscal year 1989, a greater proportion of block grant funding began
to shift to substance abuse. From fiscal year 1988 to fiscal year
1992, the allocation of ADMS block grant funds for substance abuse
increased from 51 percent of the total ADMS funding to 80 percent, as
the proportion for mental health decreased. Over this period,
funding for substance abuse increased from $249 million to more than
$1 billion.
ADAMHA'S STRUCTURE AND
FUNCTIONS WERE CHANGED TO
IMPROVE THE FEDERAL SERVICE
RESPONSE
---------------------------------------------------------- Letter :4.4
Some of the concerns raised at the July 1986 congressional hearings
on crack cocaine focused on the adequacy of federal responsiveness to
drug use problems. With the creation of the ADMS block grant
program, NIDA no longer had a leadership role in deciding with the
states what prevention and treatment activities to fund. While many
in the research community welcomed this change, others felt it left a
gap in federal leadership for prevention and treatment services.
Under the previous categorical and formula grant programs, the
federal government directly funded specific demonstration programs
related to prevention and treatment services. With the creation of
the ADMS block grant, however, states were given the flexibility to
design and fund programs specific to the needs of their local
communities. However, this change resulted in a smaller federal role
in deciding which drug abuse services to fund in a given geographic
area. Despite this shift, service-related constituency groups
continued to look to ADAMHA, which had been given responsibility for
overseeing state administration of the block grant, for national
leadership on substance abuse policy issues.
To focus more on service programs at the federal level, the Congress
authorized additional demonstration and service programs for special
populations to be administered by ADAMHA. ADAMHA's Office of
Substance Abuse Prevention (OSAP)--which was established by the
Anti-Drug Abuse Act of 1986 to strengthen the federal role in
effective drug abuse prevention--began awarding demonstration grants
to community agencies to provide prevention services to youth at high
risk of substance abuse. The Anti-Drug Abuse Act of 1988 (P.L.
100-690) raised OSAP to a status equal to ADAMHA's institutes and
authorized demonstrations that would support, among other efforts, a
major prevention services program for substance-abusing pregnant
women and improved treatment for substance abusers. The act also
authorized, for the first time, a federal set-aside from the ADMS
block grant program to be used by ADAMHA to conduct service
demonstrations and health services research and to collect data and
provide technical assistance to states. The 1988 legislation also
resulted in the creation of the Office for Treatment Improvement
(OTI) to administer many of these new programs as well as the ADMS
block grant program.
SUBSEQUENT ACTIONS WERE TAKEN
TO STRENGTHEN FEDERAL DRUG
ABUSE DETECTION AND RESPONSE
------------------------------------------------------------ Letter :5
To better identify and monitor changes in drug use activity,
including potential crises such as the crack cocaine epidemic
experienced in the 1980s, NIDA modified its drug detection
mechanisms, and new federal mechanisms were created. The
modifications and additions aimed at addressing some of the coverage,
timeliness, and methodological concerns raised by the Congress and
others.
The creation of ONDCP and organizational changes to HHS' drug abuse
agencies since the late 1980s were intended to strengthen the federal
response to drug abuse problems. The Anti-Drug Abuse Act created
ONDCP and charged it with, among other things, developing and
coordinating a national drug control strategy. SAMHSA was created 4
years later and charged with establishing and implementing a
comprehensive program to improve the provision of prevention- and
treatment-related services for substance abuse. At the same time,
NIDA was transferred to NIH to allow NIDA to concentrate on research,
research training, and public health information dissemination
related to the prevention and treatment of drug abuse. Recognizing
the need to improve research on the infrastructure that delivers
treatment, the Congress mandated in 1992 that NIDA obligate at least
15 percent of its budget to fund research that studies the impact of
the organization, financing, and management of health services on
issues such as access and quality of services.
While these changes were intended to strengthen the federal ability
to detect and respond to changing drug use patterns, the
effectiveness of these changes will depend largely on how well the
agencies carry out their roles and responsibilities. Under the
Government Performance and Results Act of 1993 (the Results Act)
federal agencies are required to set goals, measure performance, and
report on the degree to which the goals are met. The legislation was
enacted to increase program effectiveness and public accountability
by having federal agencies focus on results and service quality.
CHANGES TO DRUG DETECTION
MECHANISMS WERE INTENDED TO
PROVIDE BROADER COVERAGE,
MORE TIMELY DATA, AND BETTER
PREVALENCE ESTIMATES
---------------------------------------------------------- Letter :5.1
During the crack crisis of the 1980s, limitations in the drug
detection system hampered the identification and monitoring of drug
use activity in many geographic areas and for some high-risk
populations. Timely analysis and dissemination of drug use
prevalence data were also problems. Since the mid-1980s, a number of
changes have been made to the drug use detection mechanisms to
address some surveillance and monitoring limitations. New
information sources have also been added. (For many of the drug
detection mechanisms now available to the federal public health
service agencies and others, see app. III.)
The changes to the NIDA-sponsored drug use detection mechanisms were
intended to improve geographic and population coverage and timeliness
of drug use data.\8 To obtain and help ensure a representative sample
of hospital emergency departments in DAWN, a new representative
sample was drawn and provisions were made for including new hospitals
in the sampling frame each year. Adjustments for nonresponse
patterns were also made. MTF was expanded to include a
representative sample of 8th- and 10th-grade students in addition to
the 12th-graders and young adults already being surveyed. NHSDA was
expanded to include civilians living on military bases and people
living in noninstitutional quarters, such as college dormitories,
rooming houses, and shelters. NHSDA was also expanded to include
Alaska and Hawaii. To provide more timely national data, since 1990
NHSDA has been conducted every year, instead of every 2 to 3 years.
There are also plans, promoted by ONDCP, to expand NHSDA to collect
state-level drug use prevalence data. This expansion is expected to
provide annual estimates for each state's household population and,
specifically, for the population aged 12 to 17 and 18 to 25.
Steps were also taken toward improving the reliability of data by
correcting some of the problems with drug use prevalence estimates.
Drug use prevalence estimates had been dramatically affected by an
estimation technique known as "logical imputation" and by weighting
the estimates for certain drugs. Logical imputation calls for
revising a survey participant's initially negative drug use response
if one or more subsequent responses related to the same drug are
positive. For example, in the 1990 NHSDA, 40 percent, or 53 of 131
past-month positive cocaine use responses, were imputed--changed from
an initial response indicating no cocaine use. The initial "no drug
use" response was changed because of an apparently conflicting
response to another question in the survey. Although the problem
with logical imputation is still a concern, the probability of a
logical imputation error in estimating drug use has been lowered
somewhat by reducing the number of questions being asked about the
same drug on the survey, according to SAMHSA officials. Weighted
estimates of the national prevalence of drug use have also been
questioned in the past, given the limited number of surveyed cocaine
and heroin users from which to make projections. For example, in a
study in which the 1991 NHSDA age variable was weighted to account
for subject sampling probabilities and nonresponse rates, it was
discovered that, when projected to the nation, one 79-year-old woman
accounted for an estimated 142,000 heroin users, or about 20 percent
of all people who used heroin in the past year. SAMHSA officials
said that they have taken steps to try to limit such effects of
weighted estimates by assessing each outlier on a case-by-case basis
and using their judgment to decide when to truncate or reduce the
weights.
In addition to changes in DAWN, MTF, and NHSDA, several new drug use
detection mechanisms have been developed. SAMHSA has cited the
particular importance of two of these mechanisms: the Arrestee Drug
Abuse Monitoring (ADAM) program\9 and the Treatment Episode Data Set
(TEDS). ADAM, formerly the Drug Use Forecasting program, comprises
an ongoing quarterly study of the drug use patterns of new arrestees
at booking facilities in approximately 20 cities across the country.
TEDS is a database of substance abuse client admissions to those
publicly funded substance abuse treatment programs that receive some
of their funding through a state alcohol and drug agency. In
commenting on this report, SAMHSA officials stated that their
Violence Data Exchange Teams (VDET) are in the process of creating a
local-level system to track trends and changes in substance
abuse-related violence. When fully operational, VDETs will assist
local communities in the detection of drug abuse patterns as they are
manifested through violence-related data. SAMHSA officials believe
that such data can be used to serve as an early warning system.
In 1992, ONDCP initiated "Pulse Check," a telephone survey (as well
as a report of the survey results), to provide a quick and current
snapshot of drug use and drug markets across the country. According
to ONDCP officials, "Pulse Check," which was initially published
quarterly but was changed to a biannual report, typically includes
information on the availability of drugs, their purity, and their
street prices; user demographics; methods of use; and user primary
drug of choice. These data are obtained from different sources,
including telephone interviews with drug ethnographers and
epidemiologists, law enforcement agents, drug treatment providers
across the nation, and CEWG reports. ONDCP officials said that
surveillance data from "Pulse Check" and other sources have increased
ONDCP's capability to perform quick analyses and special studies of
changing drug use patterns as well as to identify problems in certain
population groups and geographic areas.
--------------------
\8 As part of the reorganization, DAWN and NHSDA were shifted from
NIDA to SAMHSA.
\9 The National Institute of Justice sponsors the ADAM program.
ONDCP provided the funding for the establishment of the first 10 ADAM
sites, with planned expansion to 75 cities.
ONDCP WAS CHARGED WITH
DEVELOPING AND COORDINATING
A NATIONAL DRUG CONTROL
STRATEGY
---------------------------------------------------------- Letter :5.2
Before the Anti-Drug Abuse Act of 1988, which created ONDCP, each
federal agency involved with drug control had its own set of goals,
objectives, targets, and measures, as well as congressional mandates.
To coordinate the federal drug control effort, ONDCP was charged with
developing an annual national drug control strategy.\10 ONDCP's 1997
strategy provided a common set of goals and objectives for drug
control agencies to use in addressing drug use problems and included
a 10-year federal commitment to reduce illicit drug use, which was
supported by 5-year budgets of the participating agencies. ONDCP
officials have pointed out that achieving the goals will depend not
only on federal agencies but also on state, local, and foreign
governments; private entities; and individuals.
To assess the effectiveness of its national drug control strategy in
limiting drug use, drug availability, and the consequences of drug
use, ONDCP has established, in consultation with federal drug control
agencies, a national performance measurement system to assess
results.\11 According to ONDCP officials, their approach to
developing goals, objectives, and performance measures for the
national drug control strategy is similar to the approach required by
the Results Act for individual federal agencies. ONDCP has
established a new program evaluation office to oversee the design and
implementation of its performance measurement system over the next
several years.
Consistent with the Results Act, ONDCP's fiscal year 1997 to 2002
strategic plan lists five long-range goals and objectives. Goals 1
and 3 are in part designed to reduce the demand for illegal drugs by
educating and enabling youth to reject illegal drugs and to reduce
the health and social costs of illegal drug use, respectively. While
the objectives of goal 1 generally focus on prevention activities, a
goal 3 objective is to support and promote effective, efficient, and
accessible drug treatment to ensure the development of a system that
is responsive to emerging trends in drug use. ONDCP's performance
targets and measures for these goals and objectives are discussed in
Performance Measures of Effectiveness.
Two of ONDCP's programs focus on addressing the trend in drug use
primarily among youth: a national media campaign and the Drug-Free
Communities Support Program.\12 Moreover, ONDCP has taken the
initiative to help focus attention on some recent changes in drug use
trends that have emerged as potentially problematic. For example,
ONDCP responded to changes in methamphetamine use in certain
geographic areas by publishing a special issue of "Pulse Check" on
these trends and cosponsoring a methamphetamine conference. In
addition, ONDCP is now developing a national methamphetamine
strategy. ONDCP officials admit, however, that they have no
systematic approach or strategy for specifically addressing emerging
drug use problems.
--------------------
\10 ONDCP was also given responsibility for establishing and
overseeing the implementation of policies, objectives, and priorities
for agencies that take part in its National Drug Control Program;
recommending to the president changes in the organization,
management, and budgets of agencies (including decertifying budgets);
and consulting with and assisting state and local governments in
their relations with National Drug Control Program agencies. The
Violent Crime Control and Law Enforcement Act of 1994 (P.L. 103-322)
gave ONDCP the responsibility for evaluating the effectiveness of
federal agencies' drug control activities.
\11 ONDCP, Performance Measures of Effectiveness: A System for
Assessing the Performance of the National Drug Control Strategy
1998-2007 (Washington, D.C.: ONDCP, 1998).
\12 ONDCP has requested $175 million for fiscal year 1998 to fund the
national media campaign. The Congress authorized approximately $144
million over 5 years, starting in fiscal year 1998, for the Drug-Free
Communities Support Program.
SAMHSA WAS CREATED TO
STRENGTHEN DRUG PREVENTION
AND TREATMENT SERVICES
---------------------------------------------------------- Letter :5.3
SAMHSA was created to address concerns related to the availability
and quality of drug prevention and treatment services.\13
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. In addition,
SAMHSA was to ensure, through coordination with NIDA, the
dissemination of relevant research findings to service providers to
improve the delivery and effectiveness of prevention and treatment
services. To carry out these responsibilities, SAMHSA initially
established demonstration grant programs that supported individual
grants, cooperative agreements, and contracts. SAMHSA also assumed
responsibility for administering the separate Substance Abuse
Prevention and Treatment (SAPT) block grant program.\14
In 1995, SAMHSA developed the Knowledge Development and Application
(KD&A) program, consolidating SAMHSA's individual demonstration grant
programs. According to SAMHSA officials, the program offers improved
ways of generating and disseminating knowledge on the prevention and
treatment of problems related to drug use and how to apply that
knowledge to delivering services. In fiscal year 1997, 17.4 percent
of SAMHSA's budget was devoted to KD&A program activities.
Since fiscal year 1992 when the SAPT block grant was established,
funding for substance abuse has continued to increase. SAPT block
grant funds to states gradually increased from about $1.04 billion in
fiscal year 1993 to more than $1.15 billion in fiscal year 1996. In
fiscal year 1997, the funding increased by $126 million.
According to SAMHSA officials, the agency is not yet adequately
positioned to deter emerging drug use that might result in future
epidemics. They told us that the SAPT block grant, which currently
comprises 60 percent of SAMHSA's funding, is not designed to provide
a rapid response to emerging drug problems. They also stated that it
is difficult to determine when an increase in a certain type of drug
use warrants attention and the type of response needed. SAMHSA
officials said, however, that they have planned several initiatives
to address emerging drug use trends. For example, CSAP plans to
continue its support of the HHS Secretary's Youth Substance Abuse
Prevention Initiative--including budgeting $5.0 million for two new
State Incentive Grant (SIG) programs.\15 SIGs are competitive grants
to states to coordinate disparate funding streams and facilitate the
development of effective local drug prevention strategies targeted to
youth. These programs serve as an incentive for governors to examine
and synchronize statewide prevention strategies with private and
community-based organizations.
Additionally, CSAT plans to test the feasibility of implementing new
approaches in treatment settings. For example, more individuals--
particularly on the West Coast and in the Southwest--are seeking
treatment for methamphetamine dependence; but, according to CSAT,
there are no well-established treatment approaches for this drug.
CSAT's Replicating Effective Treatment for Methamphetamine Dependence
study is designed to develop knowledge of psychosocial treatment for
methamphetamine dependence as well as to provide an opportunity to
determine the problems involved in transferring this knowledge.
To help states put the infrastructure in place to respond to emerging
drug use trends, CSAT plans to further strengthen its partnerships
with state and local governments as well as with community-based
treatment providers and the private sector to solve common problems.
For example, the Targeted Treatment Capacity Expansion Program is
designed to award grants to states, cities, and other government
entities to create and expand comprehensive substance abuse treatment
services and promote accountability. CSAT plans to support states,
cities, and other partners in their efforts to identify gaps in the
delivery system and, where current capacity within a treatment
modality is insufficient, provide for expanded access to treatment.
In an effort to disseminate information to service providers and
others, SAMHSA operates the National Clearinghouse for Alcohol and
Drug Information. SAMHSA, NIDA, and other public health agencies
provide posters, brochures, reports, booklets, audiotapes, and
videotapes to aid in drug abuse prevention and awareness efforts.
Under the Results Act, HHS is required to show that the use of
federal funds is yielding results by measuring how well HHS' programs
and efforts are working. In HHS' fiscal year 1999 Results Act
performance plan, however, SAMHSA does not provide sufficient
information about how it plans to meet some of its performance goals.
For example, under the general goal of providing funding to states in
support of the public sector substance abuse treatment system, one
performance measure is to increase to 80 percent the proportion of
block grant applications that include needs assessment data.
However, SAMHSA provides no information about the strategies it will
use to increase the proportion of states that will include needs
assessment data or how the validity of the data will be assessed.
Further, SAMHSA's performance plan does not mention how it will
address emerging drug use problems.
--------------------
\13 Several components within SAMHSA are responsible for drug abuse
issues: The Center for Substance Abuse Prevention (CSAP) is
responsible for administering many of the prevention programs of its
predecessor organization, OSAP, and for fostering the development of
comprehensive, effective, and culturally appropriate prevention
strategies, policies, and systems that are based on scientifically
defensible principles. The Center for Substance Abuse Treatment
(CSAT), which replaced OTI, is responsible for improving treatment
service delivery, including the administration of treatment
demonstration programs. The Office of Applied Studies is responsible
for leading the data collection and evaluation effort.
\14 In 1992, the Congress divided the ADMS block grant program into
two separate programs--the SAPT block grant and the Community Mental
Health Services block grant.
\15 SIGs have a key role in helping achieve the outcome targets
associated with this initiative for the year 2002, which are to (1)
reverse the upward trend in the use of, and reduce past-month use of,
marijuana among 12- to 17-year-olds by 25 percent; (2) reduce
past-month use of all illicit drugs among 12- to 17-year-olds by 35
percent; and (3) reduce past-month use of alcohol among 12- to
17-year-olds by 20 percent.
NIDA WAS TRANSFERRED TO NIH
TO STRENGTHEN DRUG ABUSE
RESEARCH
---------------------------------------------------------- Letter :5.4
With its transfer to NIH, NIDA was relieved of most of its direct
service delivery functions with the intent of having it focus on
conducting research on drug abuse and addiction. However, according
to NIDA officials, the nature of research and the research grant
approval process (which is often lengthy) limits the agency's
immediate response to emerging drug problems. That is, it takes time
to generate grants in a new priority area, conduct the research,
publicize the research findings, and move these findings from the
"lab" into practice. NIDA has a key role to play both in generating
research-based prevention and treatment approaches and in training
research scientists who potentially can be useful to the public
health community in addressing drug control problems. The move to
NIH also gave NIDA the opportunity to focus more on developing
initiatives in public education and research training.
According to ONDCP's National Drug Control Strategy, 1977, NIDA's
ongoing research portfolio supports more than 85 percent of the
world's research on the health aspects of drug abuse and addiction.
Most of the NIDA-funded research is conducted through extramural
research programs. However, a portion of NIDA's resources is
dedicated to its intramural program--that is, research conducted by
NIDA researchers. Currently, NIDA's research activities are
organized into four extramural research divisions and an intramural
research program, each of which plays a role in addressing issues
relevant to emerging drug problems.\16 For example, both the
intramural research program and the Division of Clinical and Services
Research are investigating the relationship of brain functions
(through neuroimaging techniques) to drug craving. Results of such
research may be useful in helping drug users reduce the craving or
need for specific illicit drugs. NIDA's Division of Medications
Development has been investigating the utility of cocaine medications
for the treatment of users of methamphetamine as well as examining
the clinical utility of buprenorphine to reduce the spread of heroin
use among youth and newly addicted individuals. The Division of
Epidemiology and Prevention Research continues to sponsor both MTF
and CEWG and funds promising treatment research in prevention.
NIDA's basic research division explores those behavioral and
biomedical mechanisms associated with drug abuse and addiction.
NIDA officials have indicated, however, that quickly focusing
research on newly emerging drug problems is difficult, in part,
because of the time it takes to generate grant applications and award
grants in a new priority area. The extramural research grant
application approval process has multiple stages and can take several
months to complete. In some cases, NIDA can reduce the time consumed
with the grant award process by administratively awarding supplements
to existing grants. These supplements must not exceed 25 percent or
$100,000 of a grantee's base award, unless an exception is approved
by the National Advisory Council on Drug Abuse. This approach was
recently used to encourage research related to the rise in marijuana
use among adolescents. In addition, NIH has made available a
l-percent set-aside for special research initiatives. Using this
set-aside, NIDA applied for and obtained an extra $2 million in
funding to support additional methamphetamine activities directed at
averting a crisis.
NIDA also supports research training activities to help build a
resource knowledge base for research on illicit drug use. Between
1986 and 1997, NIDA's research training budget grew sharply, from a
total of $1.43 million in 1986 to $11.7 million in 1997. However,
NIDA's research training budget, as a percentage of total extramural
research funds, has consistently been lower than those of both NIMH
and NIH throughout the 12-year period. In 1997, NIDA dedicated 2.6
percent of its extramural research budget to research training, as
compared with NIMH's 6.1 percent and NIH's 4.1 percent.
NIDA also conducts a number of public education activities to inform
the general public, providers, and researchers about ongoing efforts
to prevent and treat drug abuse. Moreover, NIDA provides research
updates through various publications--such as the research monograph
series, "NIDA Notes," and information booklets on the various drugs.
Recently, NIDA distributed more than 150,000 copies of a
research-based guide on preventing drug use among children and
adolescents to help control the rise in drug use among youth. NIDA
has also presented its findings at national drug conferences, CEWG
meetings, congressional hearings, and town meetings, as well as on
the Internet. The agency recently released Assessing Drug Abuse
Within and Across Communities, a science-based guide to helping
communities detect, quantify, and categorize local drug abuse
problems. In addition, as part of NIDA's Treatment Initiative
program, the agency intends to hold workshops with researchers, the
treatment community, and the general public to exchange information
about the treatment of drug abuse. The agency also plans to
distribute research-based treatment manuals to community-based
treatment providers.
NIDA has the opportunity to evaluate the effectiveness of its
activities under the Results Act. Because many of NIDA's efforts to
address changes in drug use patterns are research-oriented, however,
the results of the agency's performance could take a long time to
materialize. Similarly, the impact that NIDA's research efforts
would have on an immediate response to newly emerging drug problems
is questionable. On the basis of our work on implementing the
Results Act in science agencies, we concluded that measuring the
performance of science-related projects can be difficult because many
factors determine whether research will result in benefits.\17
Nevertheless, the Results Act provides a vehicle for NIDA to measure
its performance and improve its effectiveness.
--------------------
\16 The four extramural research divisions are (1) the Division of
Clinical and Services Research, which supports a program of medical,
etiological, neurobiological, treatment, and services research on
drugs; (2) the Division of Epidemiology and Prevention Research,
which focuses its research on the prevention of drug use and abuse,
associated conditions, and early interventions and services research;
(3) the Division of Basic Research, which consists of a biomedical,
behavioral, and neuroscience research program aimed at acquiring new
knowledge concerning the neurological sites and mechanisms underlying
drug abuse; and (4) the Medications Development Division, which
administers a national program to develop innovative biological and
pharmacological treatment approaches and supports training related to
the pharmacotherapeutic treatment of drug abuse. The intramural
research program plans, develops, and conducts intramural preclinical
and clinical research on the causes, hazards, treatment, and
prevention of drug abuse and addiction; the nature of the addiction
process; and the addiction liability of new drugs.
\17 Managing for Results: Key Steps and Challenges in Implementing
GPRA in Science Agencies (GAO/T-GGD/RCED-96-214, July 10, 1996).
DESPITE CHANGES, CONCERNS
REMAIN ABOUT OUR NATION'S
ABILITY TO DETECT AND RESPOND
TO EMERGING DRUG CRISES
------------------------------------------------------------ Letter :6
Despite changes to federal drug detection mechanisms and
congressional efforts to better position federal public health
agencies to respond to emerging drug crises, concerns remain. While
federal entities now have an array of tools to detect drug use, there
is concern about the overall efficiency and effectiveness of these
efforts. In addition, questions remain about when and how to best
respond to emerging drug use trends. This is also an issue for state
and local substance abuse authorities, who are challenged with
allocating resources to address both current and emerging drug use
problems. Given competing demands on federal, state, and local
resources, it is important that the most appropriate drug prevention
and treatment strategies are developed and effectively implemented.
EVALUATIONS OF FEDERAL DRUG
USE DETECTION EFFORTS
SUGGEST THE NEED FOR FURTHER
CHANGES AND A MORE
SYSTEMATIC DATA COLLECTION
APPROACH
---------------------------------------------------------- Letter :6.1
While a number of drug use detection mechanisms are now available,
the ONDCP-established Subcommittee on Data, Evaluation, and
Interagency Coordination of the Committee on Drug Control Research,
Data, and Evaluation; our expert panel; and others have raised
questions about the need for and quality of some of the data that are
collected. Under the Violent Crime Control and Law Enforcement Act
of 1994, ONDCP is required to assess the quality of mechanisms used
to measure supply and demand reduction activities and to determine
the adequacy of existing mechanisms to measure national drug use by
the casual drug user population and populations at risk for drug use.
The act also requires ONDCP to describe the actions it will take to
correct any deficiencies and limitations identified.
In 1995, ONDCP tasked the Subcommittee, composed of representatives
from 19 federal agencies, with evaluating the adequacy and ability of
federal drug-related data systems to inform the drug control policy
planning process. In its July 1997 draft report, the Subcommittee
concluded that a systematic approach for gathering drug-related data
must be developed to ensure that policymakers and analysts have
useful information for making public policy decisions. The
Subcommittee recommended that duplication of effort in drug-related
systems be identified and eliminated and that better use be made of
regional-, state-, and local-level data. The Subcommittee saw a need
for more accurate and complete information on chronic, hardcore drug
users\18 and for increased or enhanced information on illicit drug
consumption and the risks and consequences of drug use, including
expansion of such indicators beyond those obtained from hospital
emergency departments, arrestees, and domestic violence records. The
Subcommittee also recommended that data be made more available to
researchers to encourage more in-depth analyses of existing data sets
and broaden the dissemination of results. Our expert panel raised
some of the same issues about the nation's drug detection system that
led to the Subcommittee's recommendations. Moreover, officials in
the several states and cities we visited raised similar--and
additional--issues about the use of drug detection data, including
the limited usefulness of federally generated drug detection
information in monitoring most local changes in drug use patterns and
the poor use of drug detection information generated by state and
local substance abuse authorities. In commenting on this report,
ONDCP officials stated that they have already begun implementing some
of the "principles" in the Subcommittee's draft report.
Other assessments of the nation's drug data collection efforts
conducted in the early 1990s similarly concluded that drug-related
data systems could be improved. For example, a RAND study found that
policymakers have been handicapped by inconsistent and fragmented
information. A University of California at Los Angeles Drug Abuse
Research Center report concluded that the data systems were limited
by inadequate coverage of people at high risk of drug use. In a 1993
report, we also raised concerns about gaps in coverage and
methodological limitations of three major federal drug data
collection mechanisms.\19 Each of these three studies also questioned
the validity of self-reported drug use information.\20 Moreover, NIDA
recently released a monograph that raises questions about the
accuracy of some self-reported data on drug use.
--------------------
\18 ONDCP has described hardcore drug use as the use of heroin,
powder cocaine, or crack cocaine on 8 or more days during at least 1
of the preceding 2 months. (ONDCP, A Plan for Estimating the Number
of "Hardcore" Drug Users in the United States: Preliminary Findings
[Washington, D.C.: ONDCP, Fall 1997]).
\19 Drug Use Measurement: Strengths, Limitations, and
Recommendations for Improvement (GAO/PEMD-93-18, June 25, 1993).
\20 In GAO/PEMD-93-18, June 25, 1993, for example, we noted that
there are different approaches to determining the validity of
self-reported drug use data, including biological measures such as
hair analysis and urinalysis, each of which also has limitations.
A MORE DEFINED STRATEGY FOR
RESPONDING TO EMERGING DRUG
PROBLEMS IS STILL NEEDED
---------------------------------------------------------- Letter :6.2
The usefulness of better and more timely information on emerging drug
use problems is, in part, a function of the nation's ability to
respond to those problems, which itself is affected by demands on
federal, state, and local resources to address ongoing substance
abuse concerns. Still, a more defined strategy for responding is
needed. While we learned of different approaches the federal
government uses to respond to changing drug use patterns, some of
which address emerging drugs, we found that no overall defined
strategy for specifically addressing emerging drug use problems
exists. Also, there is no agreed-upon set of operational definitions
for key terms, such as "drug epidemic" or "drug crisis."
The experts we spoke with agree that determining an appropriate
response to emerging drug use problems involves considering
-- the timing of a response to a detected change in drug use
patterns;
-- the nature of the response--that is, the most effective
prevention and treatment approaches to address a drug use
problem at different stages; and
-- the magnitude of the response, taking into account resource
limitations and uncertainties about the potential scale of the
problem.
Determining the timing of a response is complicated by uncertainty
about what point above the normative pattern of use warrants a
response, either in a specific geographic area or nationwide.
According to our expert panel, several factors--including
availability of information, public opinion, and political
sensitivity--play a role in determining the timing of a response to a
detected change in drug use patterns. In addition, the most accurate
and useful data are not always available for immediate decisions on
when to respond to a particular change.
Determining the nature of the response requires a better
understanding of the extent to which various prevention and treatment
approaches are effective in controlling specific drug use problems.
A rise in marijuana use among youth and a shift in heroin use from
injecting to smoking may require different approaches because of the
drug, the population, or both. In a 1997 report, we highlighted the
varying prevention approaches and limitations in our knowledge about
the effectiveness of these strategies.\21 Similarly, as we reported
earlier this year, knowledge about the types of treatment
interventions that are most effective for specific drugs and
populations varies.\22 Even with limited knowledge, decisions about
the nature of a response must be made.
Determining the magnitude of a response is complicated by the risk of
misallocating scarce federal, state, and local resources to combat a
problem that may not warrant the investment. There is also the risk
of inadvertently promoting the use of a drug to risk-takers by
creating too much publicity addressing its dangers. Consideration
must also be given to the capacity of the system to treat those who
currently seek or will seek treatment. Our expert panel told us that
states and local communities barely have sufficient resources to meet
the present demand for drug treatment and thus might devote less
focused attention to addressing emerging drug use problems or
potential future epidemics. Moreover, we heard from SAMHSA and
officials in some of the cities we visited that there is a large
demand for substance abuse treatment. In two of the three cities we
visited, officials are trying to implement a treatment-on-demand
program to provide services for drug users when they need them most
and are most receptive to treatment; however, there is uncertainty
about how many drug users will seek help and the cost of providing
them treatment.
--------------------
\21 Drug Control: Observations on Elements of the Federal Drug
Control Strategy (GAO/GGD-97-42, Mar. 14, 1997).
\22 Drug Abuse: Research Shows Treatment Is Effective, but Benefits
May Be Overstated (GAO/HEHS-98-72, Mar. 27, 1998).
STRENGTHENING TIES BETWEEN
FEDERAL AGENCIES AND STATES
AND LOCALITIES COULD HELP
IMPROVE DETECTION AND
RESPONSE APPROACHES
---------------------------------------------------------- Letter :6.3
Some researchers believe that to improve the chances of deterring the
spread of emerging drug problems or epidemics, greater attention must
be given to changes in drug use patterns at the local level, where
such problems typically originate. Although SAMHSA has relationships
with states through the block grant program, experts in the drug
field describe less than adequate linkages between state and local
communities and the three major federal agencies involved in drug
abuse demand reduction efforts. ONDCP, SAMHSA, and NIDA do not
currently have a well-established network with the many local
entities associated with reducing drug use, and their relationships
with states and local communities might not facilitate a response to
an emerging drug problem at the local level. A defined strategy for
addressing emerging drug problems would benefit from better linkages
with state and local entities to capitalize on their experiences with
local drug crises or epidemics.
Although addressing drug use problems is not necessarily the same as
addressing infectious diseases, the networks and linkages with state
and local entities that have been established by CDC may be worth
considering for detecting and responding to emerging drug use
problems. CDC is responsible for detecting and responding to
potential health crises, such as outbreaks of infectious and chronic
diseases. The agency has established relationships with states and
local entities through a number of efforts, some of which follow:
-- CDC's Epidemic Intelligence Service enables the agency to
maximize its investigative capabilities. According to CDC
officials, each year the Service trains approximately 75
epidemiological investigators and requires that they engage in
at least one investigation at the state level and at
headquarters during a 2-year follow-up period. At any given
time, CDC has up to 150 epidemiologists to call on to assess a
potential public health epidemic or crisis. Through direct
on-site public health surveillance, CDC can gain rapid and
in-depth understanding of the initiation and spread of a public
health problem. These investigations enable CDC to target
specific individuals and groups affected and likely to be
affected, identify the circumstances under which infections take
place and spread, track the movement of the problem across
geographic areas, and establish the time parameters governing
the infection of each subsequent target group.
-- Through collaboration with the Council of State and Territorial
Epidemiologists, CDC is able to ensure broad geographic
coverage, since the group includes representatives from all 50
states and the U.S. territories.
-- CDC has established procedures with states for quick responses
to perceived health crises. If a state public health agency is
experiencing a problem in either identifying or managing a
public health problem, CDC can be called on to provide immediate
guidance and support. According to a CDC official, if the
problem is not one that can be handled over the telephone, CDC
is able to quickly dispatch appropriate staff to the scene to
provide on-site public health surveillance and response support.
CONCLUSIONS
------------------------------------------------------------ Letter :7
The public health agencies' approach to addressing drug use problems
in the United States has changed since the mid-1980s. Given changes
made in the drug use detection mechanisms, organizational changes in
HHS' drug control agencies, and the creation of ONDCP, the federal
capability to address emerging drug use problems has been enhanced.
However, the benefits of these changes depend largely on how drug
data are used and how well the agencies carry out their roles and
responsibilities. For example, the complement of drug use detection
mechanisms available to public health agencies and others now
provides more timely data and broader geographic and population
coverage. However, ONDCP's Subcommittee on Data, Evaluation, and
Interagency Coordination; our expert panel; and others have pointed
out weaknesses that need to be addressed to improve the accuracy of
drug data and to increase the efficiency and effectiveness of the
nation's drug data collection systems.
ONDCP, NIDA, and SAMHSA officials report that some of their efforts
are addressing emerging drug problems. However, these agencies have
no overall defined strategy that addresses factors such as how to
determine the timing, nature, and magnitude of a response to new
patterns of drug use identified through the nation's surveillance
systems. In addition, maintaining ongoing mechanisms with the
capacity to link surveillance knowledge from local and national
sources with knowledge about effective demand reduction approaches
should increase our nation's capability to deter future drug crises.
We recognize that developing a defined strategy for addressing
emerging drug problems will be challenging because of data
uncertainties and other factors, such as engaging federal, state, and
local entities in collaborative response actions. However, the CDC
approach to responding to emerging infectious diseases might offer
some insights on establishing linkages with state and local entities
and developing response protocols.
Since ONDCP is responsible for developing and coordinating a national
drug control strategy, it could take the lead in improving the
nation's drug data collection system and coordinating the development
of a strategy to address future emerging drug use problems.
RECOMMENDATIONS
------------------------------------------------------------ Letter :8
To improve the nation's drug use detection and response capability,
we recommend that the Director of ONDCP
-- implement any additional changes that would improve the
completeness, accuracy, and overall usefulness of data generated
by the nation's drug data collection mechanisms;
-- take action to further improve the federal drug data collection
system by determining what data should be collected and
developing a systematic approach for gathering, analyzing, and
disseminating information; and
-- develop a defined strategy for determining the timing,
magnitude, and nature of actions needed to appropriately respond
to potential drug crises or epidemics, taking into consideration
that emerging drug problems surface as local phenomena.
AGENCY AND OTHER COMMENTS
------------------------------------------------------------ Letter :9
We obtained comments on a draft of this report from ONDCP, SAMHSA,
NIDA, and CDC, as well as from most of our expert panel members.
With the exceptions noted below, the reviewers generally agreed with
the findings, conclusions, and recommendations in the report. Some
of them provided additional information and clarification and
suggested technical changes, which we incorporated where appropriate.
While concurring with the report's recommendations, ONDCP expressed
concern about the way the report framed some issues. Specifically,
the agency was concerned that the report and two of its
recommendations suggested that no action had been taken on the ONDCP
Subcommittee's recommendations to improve the nation's drug data
collection system. ONDCP commented that it has begun taking some
actions to change and evaluate certain drug use detection and
monitoring mechanisms even though its Subcommittee's report is still
in draft form. We were unaware of specific actions taken on the
Subcommittee's recommendations at the time of our review, and we
commend these initial steps. We continue to believe, however, that
ONDCP should take additional actions as recommended to address the
concerns raised about the accuracy and usefulness of the data and the
overall effectiveness of the federal drug data collection system.
ONDCP agreed with our recommendation that calls for a defined
strategy for addressing emerging drug problems and said that its
Performance Measures of Effectiveness system will possibly provide a
framework for developing such a strategy.
SAMHSA agreed with many of the findings in the report but raised a
concern that our recommendation to improve the completeness and
accuracy of drug data did not address the importance of maximizing
the usefulness of the data. We agree that the overall usefulness of
the data is important, and we modified our recommendation
accordingly. SAMHSA also wanted to elaborate on its statement to us
that the agency was not adequately positioned to deter emerging drug
use that might result in future epidemics. We added the information
the agency provided in the text of the report. SAMHSA disagreed with
our statement that it had not provided sufficient information in HHS'
Results Act annual performance plan about how SAMHSA would meet its
performance goals. However, the agency did not provide any
information to support its contention.
NIDA expressed some concern about issues that were not addressed in
this report. For example, NIDA stated that the report did not
sufficiently speculate on how the different entities involved in drug
control enhance or impede addressing emergent issues or how law
enforcement and interdiction agencies affect federal efforts to
detect and respond to emerging drug use problems. The agency also
stated that the report does not specify what the appropriate role of
each level of government should be. Although these issues were
beyond the scope of our review, we acknowledge that there are
multiple entities involved in detecting and responding to emerging
drug problems and that how their roles, responsibilities, and efforts
play out in an overall strategy for addressing the problems is
unclear. We recommended that ONDCP take the lead in developing a
defined strategy for addressing emerging drug problems. This would
give the entities involved in drug control activities an opportunity
to determine the appropriate roles each should play.
Both NIDA and SAMHSA reacted to our suggestion that CDC's approach to
addressing public health issues, which involves state and local
entities, might be a useful approach to consider in developing a
strategy for addressing emerging drug problems. NIDA thought that
the suggestion was reasonable but that developing networks and
linkages to deal with drug problems would not be quickly or easily
accomplished. SAMHSA felt that the CDC approach would be very
expensive to replicate and that there are factors associated with
drug abuse that do not fit the CDC model. SAMHSA concluded that
adopting the CDC approach would be an unwise expenditure of funds,
although it did not provide any cost analysis or other data to
support its statements. While we agree that the cost and other
implications, such as differences between drug abuse and other
disease models, should be taken into account, we continue to believe
that the CDC approach serves as a useful example of how linkages
among federal, state, and local entities can facilitate the detection
of and response to a problem.
---------------------------------------------------------- Letter :9.1
We are sending copies of this report to appropriate congressional
committees, the Director of ONDCP, the Secretary of HHS, and other
interested parties. We will also make copies available to others on
request.
Please contact me on (202) 512-7119 or James O. McClyde, Assistant
Director, on (202) 512-7152 if you or your staff have any questions.
Other major contributors to this report include Thomas J. Laetz,
Jared A. Hermalin, Andrea K. Kamargo, and Karen M. Sloan. Erwin
W. Bedarf contributed to the design of the project.
Marsha Lillie-Blanton
Associate Director
Health Services Quality and
Public Health Issues
EXPERT PANEL
=========================================================== Appendix I
An essential component of our research effort was an expert panel
that provided advice and offered opinions on the nation's
preparedness to address changing drug use patterns. The following
experts composed the panel:
M. Douglas Anglin, Ph.D., Director
UCLA Drug Abuse Research Center
John S. Gustafson, Executive Director
National Association of State Alcohol and Drug Abuse Directors
James Hall, Executive Director
Up Front Drug Information Center
Bruce Johnson, Ph.D., Director
Institute for Special Populations Research
National Development and Research Institutes
Henrick Harwood
The Lewin Group
Herbert Kleber, M.D.
Executive Vice President and Medical Director
Center on Addiction and Substance Abuse,
Columbia University, and Professor of Psychiatry,
Columbia University College of Physicians and Surgeons
A. Thomas McLellan, Ph.D., Scientific Director
DeltaMetrics in Association With Treatment Research Institute
University of Pennsylvania
Before convening the panel, we sent each panelist a discussion paper
containing a brief description of the current array of detection
mechanisms used by the public health service agencies and the Office
of National Drug Control Policy (ONDCP); the legislative
responsibilities of the National Institute on Drug Abuse (NIDA), the
Substance Abuse and Mental Health Services Administration (SAMHSA),
and ONDCP to address illicit drug use problems; and information these
agencies gave us about how they implement their responsibilities and
respond to changes in drug use patterns.
During the session, we asked the panelists to discuss the
effectiveness of the current detection mechanisms--that is, whether
new or modified mechanisms and data information sources are needed to
detect changes in illicit drug use patterns more quickly and
accurately. We also asked the panelists to discuss whether NIDA,
SAMHSA, and ONDCP were individually, and in conjunction, responding
appropriately to detected drug use patterns to prevent, deter, or
better manage potential drug epidemics and crises. Next, we asked
the panelists to comment on the extent to which past legislative
changes had improved or hampered federal response capacity and
whether additional legislative or mission statement changes were
needed to guide the activities of these agencies. Finally, we asked
the panelists to review a synthesis of the comments made during the
session and to offer any additional suggestions and recommendations
to improve the nation's drug detection and response system.
SELECTED FEDERAL AGENCIES THAT
FUND DRUG CONTROL ACTIVITIES
========================================================== Appendix II
Corporation of National Service
Department of Agriculture
Department of Defense
Department of Education
Department of Health and Human Services
Department of Housing and Urban Development
Department of the Interior
Department of Justice
Department of Labor
Department of State
Department of Transportation
Department of Treasury
Department of Veterans Affairs
Office of National Drug Control Policy
Social Security Administration
ILLICIT DRUG USE DETECTION
MECHANISMS
========================================================= Appendix III
Table III.1
Illicit Drug Use Detection Mechanisms
Available to Federal Public Health
Service Agencies Before 1985, One-Time
Studies Excluded
Sponsoring
Detection mechanism agency Target Frequency Year begun
--------------------- -------------- ------------------ -------------- --------------
Prominent drug detection mechanisms used by NIDA
-----------------------------------------------------------------------------------------
Community NIDA Drug use patterns Semiannually 1976
Epidemiology Work and trends in 18
Group (CEWG) geographic areas
Drug Abuse Warning NIDA Emergency room Ongoing 1972
Network (DAWN) patients and
medical examiner
cases
Monitoring the Future NIDA 12th-graders and Annually 1975
(MTF) young adults
National Household NIDA Household Every 2 to 3 1972
Survey on Drug Abuse population aged 12 years before
(NHSDA) and older 1990
Other data information sources
-----------------------------------------------------------------------------------------
National Youth National People aged 11 Annually for 1976
Survey: Institute on through 17 the first 5
Dynamics of Deviant Mental Health years
Behavior (NIMH) and
NIDA
Uniform Crime Reports Federal Bureau Drug arrestees Monthly 1930
(UCR) of
Investigation
(FBI)
Survey of Inmates in Bureau of Local jail inmates Approximately 1972
Local Jails Justice every 5 to 6
Statistics years
(BJS)
Survey of Inmates in BJS State correctional Approximately 1974
State Correctional facility inmates every 5 to 7
Facilities years
Census of Jails BJS Jail inmates Approximately 1972
every 5 to 6
years
National Corrections BJS Prisoners entering Annually 1983
Reporting Program and leaving prison
and parolees
System to Retrieve Drug Price, purity, and Ongoing 1971
Information From Drug Enforcement location of drugs
Evidence (STRIDE) Agency (DEA) seized or
purchased
National Narcotics Cooperative Estimates of the Annually 1978
Intelligence federal availability,
Consumers Committee effort volume, sources,
chaired by DEA and distribution
of illegal drugs
Worldwide Survey of Department of Military personnel Every 2 to 4 1980
Substance Abuse and Defense (DOD) years
Health Behaviors
Among Military
Personnel
National Longitudinal Bureau of Young men and Annually 1979
Survey of Youth '79 Labor women, aged 14 to before 1994
Statistics 22
(BLS)
-----------------------------------------------------------------------------------------
Table III.2
Illicit Drug Use Detection Mechanisms
Currently Available to Federal Public
Health Service Agencies, One-Time
Studies Excluded
Sponsoring
Detection mechanism agency Target Frequency Year begun
--------------------- -------------- ------------------ -------------- --------------
CEWG NIDA Drug use patterns Semiannually 1976
and trends in 21
cities
DAWN SAMHSA Emergency room Ongoing 1972
patients and
medical examiner
cases
MTF NIDA 8th-, 10th-, and Annually 1975
12th-graders and
young adults
NHSDA SAMHSA Household Annually as of 1972
population aged 12 1990
and older,
civilians living
on military bases,
and people in
noninstitutional
group quarters
Pulse Check ONDCP Ethnographers, Initially 1992
epidemiologists, quarterly; now
treatment biannually
providers, and law
enforcement agents
Treatment Episode SAMHSA Treatment clients Ongoing 1990
Data Set (TEDS) (part
of the Drug and
Alcohol Services
Information System)
Community Partnership SAMHSA 8th-and 10th- 1990-97 1990
Demonstration Program graders and adults
Surveys
Youth Risk Behavior Centers for School-aged youth, Every 2 years 1990
Surveillance System Disease grades 9 to 12
Control and
Prevention
(CDC)
National Maternal and National Maternal drug use Periodically 1988
Infant Health Survey Center for before and during
Health pregnancy
Statistics/
CDC
Drug Use Forecasting/ National Drug arrestees Quarterly 1986/1997
Arrestee Drug Abuse Institute of
Monitoring (ADAM) Justice
UCR FBI Drug arrests Monthly 1930
Survey of Inmates in BJS Local jail inmates Approximately 1972
Local Jails every 5 to 6
years
National Longitudinal BLS Young men and Annually 1979
Survey of Youth women, aged 14 to through 1994;
22 biennially
after 1994
Quarterly Report on Department of Job Corps Quarterly 1991
Testing for Alcohol Labor admissions
and Other Drugs of
Abuse
Survey of Inmates in BJS Correctional Approximately 1974/1991
State/Federal facility inmates every 5 to 7
Correctional years
Facilities
Census of Jails BJS Aggregate of jail Every 5 to 6 1972
inmates years
National Corrections BJS Prisoners entering Annually 1983
Reporting Program and leaving prison
and parolees
Survey of Adults on BJS People on Possibly every 1995
Probation probation 5 years
Residential Treatment Bureau of Inmates requesting Ongoing 1995
Eligibility Interview Prisons (BOP) admission to BOP
treatment programs
STRIDE DEA Price, purity, and Ongoing 1971
location of drugs
seized or
purchased
National Narcotics Cooperative Estimates of the Annually 1978
Intelligence federal effort availability,
Consumers Committee chaired by DEA volume, sources,
and distribution
of illegal drugs
Worldwide Survey of DOD Military personnel Every 2 to 4 1980
Substance Abuse and years
Health Behaviors
Among Military
Personnel
-----------------------------------------------------------------------------------------
*** End of document. ***