Testimony

June 15, 2004

Mr. Chairman and Members of the Subcommittee, good morning. I am Charles G. Curie, Administrator of the Substance Abuse and Mental Health Services Administration (SAMHSA), part of the U.S. Department of Health and Human Services (HHS).

Thank you for providing me the opportunity to describe how SAMHSA and our Federal, State, and local community-level partners are working to provide effective substance abuse treatment to people who want and need it, including young Americans.

Drug abuse and mental illness are major public health problems that affect us all. In terms of dollars, substance abuse, including alcohol, illicit drugs, and tobacco use, costs our Nation more than $484 billion per year. The economic costs of mental illness are also staggering. The President’s New Freedom Commission on Mental Health reports the cost in the U.S. from both direct (treatment-related) and indirect (productivity loss) expenses may exceed $150 billion per year with rapid annual increases, especially in the drug treatment area. Mental illnesses, including depression, account for four of the top six causes of disability among 15-44 year olds in the Western world.

Although not as well known as the deaths due to substance abuse, mental illnesses are a substantial source of mortality. Of the 30,000 Americans who die by suicide each year, 90 percent have a mental illness. The fact that deaths from suicide outnumber deaths from homicide (18,000) is often a surprising finding. Suicide rates are high among several ethnic minority groups, though it remains highest in older white males. Between 1952 and 1992, the incidence of suicide among adolescents and young adults nearly tripled; currently it is the third-leading cause of death in adolescents. We know that substance use increases the probability of a person with mental illness attempting suicide and increases the person’s likelihood of succeeding

Addiction’s toll on individuals, their families, and the communities they live in is a cumulative devastation with a ripple effect. This ripple effect leads to costly social and public health problems including HIV/AIDS, domestic violence, child abuse, and crime in general, as well as accidents and teenage pregnancies.

Addiction often begins during childhood and adolescence. Research has shown that substance use dependence, while once thought to be an adult-onset disease, is actually a “developmental disease.” It is developmental in terms of having its start during the early stages of adolescence and even childhood, when children use drugs or consume alcohol. The introduction of an illicit drug or of alcohol to the adolescent brain has a dramatic impact because of the changes occurring in the brain during this developmental stage.

The data from SAMHSA’s 2002 National Survey on Drug Use and Health provides the scope of the problem. In 2002, there were 2.3 million youths aged 12 to 17 who needed treatment for an alcohol or illicit drug problem. Of this group, only 186,000 received treatment. Without help, it is very likely that these young people, at the very beginning of their lives, will continue on a destructive path of addiction, disability, criminal involvement, and premature death.

Overall, there are an estimated 22 million Americans struggling with a drug or alcohol problem. There is a clear correlation between age of first use of drugs and alcohol and the potential for developing a serious problem. For example, in 2000, 18 percent of people age 26 and older who had begun using marijuana before age 15 met the criteria for either dependence or abuse of alcohol or illicit drugs, compared to 2.1 percent of adults who never used marijuana. Among past year users of marijuana age 26 and older who had first used marijuana before age 15, 40 percent met the criteria for either dependence or abuse of alcohol or illicit drugs.

The story is very similar for alcohol. One-third, 2.3 million, of alcohol-dependent adults age 21 or older in 2002, had first used alcohol before age 14. Over 80 percent, 5.8 million, had first used before they were age 18. And 96 percent, 6.6 million, had first used before age 21. The rate of dependence for those who first drank at age 21 or older was only 1 percent. Conversely, 99% of adults 21 and older who first drank alcohol at age 21 or older do not have a dependence problem.

It is plain to see why improving treatment services for adolescents and bolstering prevention programs targeted to this age group are top priorities for SAMHSA.

THE SAMHSA ROLE

SAMHSA is working to improve how we approach substance abuse treatment and prevention, not only at the Federal level, but also at the State and community levels. During my tenure, we have restructured our work around the vision of “a life in the community for everyone” and our mission of “building resilience and facilitating recovery.”

To focus and to guide our program development and resources, we have developed a Matrix of program priorities and cross cutting principles that pinpoints SAMHSA’s leadership and management responsibilities. These responsibilities were developed as a result of discussions with members of Congress, our advisory councils, constituency groups, people working in the field, and people working to attain and sustain recovery.

The Matrix priorities are also aligned with the priorities of President Bush and HHS Secretary Tommy Thompson, whose support for our vision of a life in the community for everyone we appreciate. The Matrix has produced concrete results by focusing SAMHSA staff and the field on planting a few “redwoods” rather than letting “a thousand flowers bloom.” I see my responsibility as Administrator to make solid program and management improvements that will last beyond my tenure.

I am proud of our success over the past two and half years since I came to SAMHSA. I believe the SAMHSA Matrix is the underpinning of our success and has helped us to focus on solid investments in the future of mental health and substance abuse prevention and treatment services. In particular, I will highlight the ways we support the prevention and treatment of adolescent substance abuse.

On our matrix you will see the program “Strategic Prevention Framework.” Through this Framework we are working to more effectively and efficiently align our prevention resources. The Framework is aligned with the President’s and Secretary Thompson’s HealthierUS initiative. HealthierUS is a plan to improve overall public health by capitalizing on the power of prevention to help prevent, delay, and/or reduce disability from chronic disease and illnesses, including substance abuse and mental illnesses.

I am pleased to report that the most recent data confirms that the President’s two-year goal to reduce illicit drug use among youth by 10 percent in 2 years has been exceeded, with an 11 percent reduction in the past two years. This is a clear indication that our work with our many Federal and State partners, along with schools, parents, teachers, law enforcement, religious leaders, and local community anti-drug coalitions, is paying off. But our work is far from over, and prevention is key.

Fortunately, we know more about what works in prevention, education, and treatment than ever before. Over the years, we have shown prevention programs can and do produce results. Currently, we have 60 model programs listed in our National Registry of Effective Programs. These programs yield, on average, a 25 percent reduction in substance use and affect a broad range of behavioral issues, from violence and delinquency to emotional problems. Primary access to the programs in the Registry is through the SAMHSA Model Programs website, www.modelprograms.samhsa.gov. The website describes and provides contact information for each of the programs in the Registry.

Unfortunately, as we all know, individuals, communities, or State and Federal agencies do not always translate, or make it easy to translate, into action what is known about prevention. To help provide a structured approach to substance abuse prevention and mental health promotion that is based on the best that science has to offer, Secretary Thompson launched the Strategic Prevention Framework during the national HealthierUS Prevention Summit in Baltimore on April 29. This new $45 million competitive grant program will enable States, Territories, and the District of Columbia to bring together multiple funding streams from multiple sources to create and sustain a community-based, science-based approach to substance abuse prevention and mental health promotion.

The Framework is based on the risk and protective factor approach to prevention. For example, family conflict, low school readiness, and poor social skills increase the risk for conduct disorders and depression, which in turn increase the risk for adolescent substance abuse, delinquency, and violence. Protective factors such as strong family bonds, social skills, opportunities for school success, and involvement in community activities can foster resilience and mitigate the influence of risk factors.

Clearly, these risk and protective factors exist at several levels – at the individual level, the family level, in schools, the community level, and in the broader environment. People working in communities with young people and adults understand the need to create an approach to prevention that is citizen centered, cuts across existing programs and system levels, and has common outcome measures.

Just as when we are promoting exercise and a healthy diet or advancing vaccination, when we speak about abstinence or rejecting drugs, tobacco, and alcohol and promote mental health, we really are all working towards the same objective – reducing risk factors and promoting protective factors. The challenge is to build a national framework for prevention on that common foundation.

Moving the framework from vision to practice will require the Federal government, States, and communities to work in partnership. Under the new grant program, States will provide leadership, technical support, and monitoring to ensure that participating communities are successful in implementing a five-step public health process that will promote youth development, reduce risk-taking behaviors, build assets and resilience, and prevent problem behaviors across the life span. The five steps are:

First, communities assess their mental health and substance abuse-related problems including magnitude, location, and associated risk and protective factors. Communities also assess assets and resources, service gaps, and readiness.

Second, communities must engage key stakeholders, build coalitions, and organize, train, and leverage prevention resources.

Third, communities establish plans that include strategies for organizing and implementing prevention resources. They must be based on documented needs, build on identified resources, and set baselines, objectives, and performance measures.

Fourth, communities implement evidence-based prevention efforts specifically designed to reduce risk and promote protective factors identified.

Finally, communities will monitor and report outcomes to assess program effectiveness and service delivery quality, and to determine if objectives are being attained or if there is a need for correction.

The success of the Strategic Prevention Framework will be measured by specific national outcomes that are true measures of whether our programs are helping young people achieve our vision of a life in the community, for example, whether they are in stable homes, in school, and are not involved with the criminal justice system. We are rapidly moving to implement these national outcomes across all of SAMHSA’s programs.

In the area of substance abuse treatment, we are already using national outcomes. This year we commenced the President’s Access to Recovery program with a $100 million investment. The Administration’s commitment to expand clinical treatment and recovery support services to reach those in need extends beyond the immediate fiscal year, with its FY 2005 request to double Access to Recovery’s appropriation to $200 million and to increase the Substance Abuse Prevention and Treatment Block Grant by $53 million for a total of $1.8 billion.

As you may know, Access to Recovery is based on the knowledge that there are many pathways to recovery. It empowers people with the ability to choose the path best for them - whether it is physical, mental, medical, emotional, or spiritual. In particular, we know that for many Americans, treatment services that build on spiritual resources are critical to recovery. Access to Recovery ensures a full range of clinical treatment and recovery support services are available, including the transforming powers of faith. Critically, Access to Recovery provides States the opportunity to target resources to providing treatment to adolescents.

Over the years, SAMHSA, through its Center for Substance Abuse Treatment (CSAT), has made significant strides in addressing the shortage of adolescent substance abuse treatment. Between 1970 and 1997, there were only 14 published studies of the effectiveness of adolescent substance abuse treatment. In response, SAMHSA funded the Cannabis Youth Treatment (CYT) Study in 1997. Its purpose was to explore whether proven adult models of intervention could be made developmentally appropriate for adolescents and achieve effective outcomes in real-world, community-based treatment settings. The CYT study of over 600 youth randomized to five different treatment interventions resulted in five effective treatment protocols that are now available in manuals that are in use across the country. The five volumes of the CYT Series are based on treatment approaches specifically designed for use with adolescents. The CYT manuals are part of SAMHSA’s larger Science to Services Initiative that is working to speed the delivery of effective, evidence-based programs into communities where clinical intervention and treatments are put into practice.

In 1999, a few years after the CYT study began, SAMHSA funded the Adolescent Treatment Models program. The purpose was to identify potentially exemplary programs that existed in the field and to have them rigorously evaluated to determine their effectiveness. The same core assessment and follow-up instruments, as well as data collection points from CYT, were used, which afforded the opportunity to draw critical comparisons. The outcomes of this study generated 10 treatment program manuals that include effective programs for intensive outpatient, short-term residential and long-term residential programs that are available on-line and are being adopted within the adolescent treatment field as we speak.

Having worked to identify effective treatment interventions, SAMHSA proceeded to develop the Strengthening Communities – Youth (SCY) program in 2001. With a $39 million investment, twelve sites were funded for five years to develop a continuum of adolescent services and a system of care for youth within their communities.

Although these programs have clearly and undoubtedly strengthened treatment programs for this age group, an identified weakness is the lack of continuing care models for youth after they complete the active phase of treatment. For example, too often when youth complete residential placements and return to their families and communities, they are cut-off from treatment services and quickly resume their substance abuse and other destructive behaviors. In response, SAMHSA awarded grants under its program to Improve the Quality and Availability of Residential Treatment and its Continuing Care Component for Adolescents (ART) during 2002. As a result, numerous residential programs have developed and implemented models of providing continuing care to youth.

Along with improving after-care services for adolescents, SAMHSA launched the Effective Adolescent Treatment (EAT) program in 2003 to assist the field in adopting a previously proven effective approach of the CYT initiative. This approach, Motivational Enhancement Therapy/Cognitive Behavioral Therapy, for adolescents with substance use disorders is now being implemented in 22 sites around the country. In 2004, an additional 16 sites will be funded, which will result in a total of 38 programs implementing a practice for which there is evidence of effectiveness and will directly impact success rates for adolescents who are in a battle for their very lives.

In tandem with improving and extending the continuum of care in residential settings, which often include court-adjudicated youth from the criminal justice system, CSAT also provides for critical treatment services through the Juvenile Justice Drug Treatment Court. Six programs are up and running smoothly, and others will be operational soon through our Youth Offender Re-entry Program, which will support 12-14 new programs in Fiscal Year 2004.

CSAT also supports treatment programs for adolescents through its Targeted Capacity Expansion program (TCE), Targeted Capacity Expansion/HIV (TCE/HIV), and HIV Outreach programs. These grantees are encouraged and supported to adopt only effective treatment practices. They are included in meetings and trainings to further facilitate the evolution and improvement of the field of adolescent substance abuse treatment.

Each of these efforts to expand treatment services for adolescents have been well thought out, and each resulting program has been funded based on the underlying and undeniable fact that all we can to do to help our Nation’s youth is what must be done – nothing less is acceptable. The treatment services afforded through the opportunities I just mentioned are improving services for adolescents, and we are improving and building upon the services for consumers of all ages -- children, adolescents, young adults, adults, and older adults alike.

I am particularly proud to tell you that improving services for all of these age groups, from this Nation’s elderly down through and including our youngest citizens, is the driving force behind achieving our agency goals – goals which are independent yet interconnected and goals which are clearly outlined in our Matrix of agency priorities.

Key to achieving our goals is developing an ability to report on meaningful outcomes. These outcome measures must be concise, purposeful, and useful. They must get at real outcomes for real people. We are changing the emphasis from, “How did you spend the money?” and, “Did you spend the money according to the rules?” to, “How did you put the dollars to work?” and, “How did your consumers benefit?”

Through an internal data strategy workgroup we are conducting a thorough examination of our data collection and analysis systems. The goal is to take steps now to ensure that decisions related to SAMHSA’s priorities are based on the most comprehensive and accurate information available.

As I mentioned previously, an essential component of SAMHSA’s data strategy is development of “National Outcomes” and related “National Outcome Measures.” Through collaboration with the States we have identified a set of key domains. These domains are:

• abstinence from drug use and alcohol abuse, or decreased symptoms from mental illness;
• increased or retained employment and school enrollment;
• decreased involvement with the criminal justice system;
• increased stability in family and living conditions;
• increased access to services;
• increased retention in services for substance abuse treatment or decreased utilization of psychiatric inpatient beds for mental health treatment; and
• increased social connectedness to family, friends, co-workers, and classmates.

As I mentioned, these national outcomes are already being implemented through the President’s Access to Recovery program and the Strategic Prevention Framework. Ultimately the National Outcomes will be aligned across all of SAMHSA’s programs, including the Community Mental Health Services Block Grant and the Substance Abuse Prevention and Treatment Block Grant. The National Outcomes are an attempt to provide greater flexibility and accountability while limiting the number of reporting requirements on the State. Ultimately we are confident this approach will ensure the data collected is relevant and useful and helps to improve services for the people we serve.

Putting the data to work is a responsibility that SAMHSA is happy to shoulder. We can now clearly and definitively demonstrate that Federal investments in prevention and treatment are beneficial. Prevention works. Treatment works -- it helps people triumph over addiction and leads to recovery. The vital treatment and prevention efforts and programs that I have discussed today are working to improve services for adolescents, and for people of all ages.

Mr. Chairman and Members of the Subcommittee, thank you for the opportunity to appear today. I will be pleased to answer any questions you may have.

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