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STATEMENT OF DR. FREDERICK K. GOODWIN

Mr. Chairman and Members of the Subcommittee:

I am pleased to appear before you to discuss the President's fiscal year

1992 budget request for the Alcohol, Drug Abuse, and Mental Health

Administration (ADAMHA).

As the principal source of support for the scientific study of disorders

that each year cost our Nation more than $66 billion in direct clinical care

costs, ADAMHA's core program is comprised of three research institutes--the

National Institute of Mental Health, the National Institute on Drug Abuse, and

the National Institute on Alcohol Abuse and Alcoholism.

In addition, ADAMHA

encompasses two Offices--for Substance Abuse Prevention (OSAP), and for

Treatment Improvement (OTI)--charged with ensuring that research-based

information is introduced in a timely manner into clinical and public health

practice. That is, while the task of the institutes is to support controlled

research and research demonstration programs, principal responsibilities of

OTI and OSAP are to apply research-based knowledge in actual practice

settings, to conduct field evaluations of the effectiveness of a given

intervention, and to identify and systematically refer to the institutes

researchable questions that arise in the "real world" of service delivery.

These core ADAMHA-conducted programs will account for $1.8 billion, or

60% of our total 1992 budget request of $3.1 billion. The other major

component of the request is the ADMS Block Grant, which we propose to maintain

at its current level of $1.3 billion in 1992.

Of those programs conducted by ADAMHA, basic and clinical research,

research demonstrations, and the research portion of the Block Grant set

aside account for the predominant share--69.2%--of ADAMHA's budget (Figure 1).

An increase of more than $81 million will bring the research total to $1.3

billion in 1992.

The request expands or maintains most activities, again with an emphasis

on initiatives launched or accelerated in recent years to capitalize on gains

in our knowledge of the brain and behavior. Significant among these is

ADAMHA's medications development program, which will increase by 50% to $68.3

million in 1992, an increase that will permit us to build on a new partnership

between ADAMHA and the pharmaceutical industry.

A factor critical in the ultimate yield of biomedical research will be a

citizenry able to understand and act on new research findings that have a

bearing on health and healthy behavior.

In the interest of enhancing public

awareness of the benefits that derive from the conduct of science, ADAMHA is.

requesting $2.4 million in 1992 for science education programs to be directed

at children in grades k through 12. This program will be sponsored jointly by

the NIH.

The primary thrust of ADAMHA's programs is to elucidate fundamental

processes involved in brain and behavioral disorders and to integrate that

information into new and enhanced treatments and preventive strategies. Given

this orientation toward research, the recently passed legislation establishing

the Senior Biomedical Research Service program should enhance the Federal

government's ability to attract and retain the best and brightest biomedical

and behavioral scientists.

In order to ensure that the wealth of new information that is being

accumulated about the basic workings of the brain and substrates of behavior

will be linked effectively to public health needs, the NIMH has developed a

series of strategic plans for research. The plans address opportunities and

needs in areas ranging from neuroscience, to schizophrenia and the brain, to

child and adolescent disorders, to research on the services required by

patients with severe mental disorders.

Looking again at the total ADAMHA request for 1992, one sees that fully

48%, or $1.5 billion, will continue and expand anti-drug abuse initiatives

(Figure 2). With an agency-wide increase of 4.5% over current year funding,

more than four out of five new dollars in the budget proposal--$107.2 million

-will be devoted to new anti-drug spending, with emphasis on research and

treatment programs.

In 1992, much of this growth will occur in programs

managed by ADAMHA's Office for Treatment Improvement, which has focused on

drug abuse treatment issues since its creation last year.

Slated initiatives include a new $99 million program that will expand

effective drug treatment services as a means of closing the gap between demand

for drug abuse treatment services and current national treatment capacity.

These Capacity Expansion Program (CEP) grants will increase the total number

of federally-funded treatment slots to 106,500, capable of providing drug

abuse treatment services next year to nearly 300,000 persons. Of the $99 million, $68 million is requested in budget authority from this subcommittee, and $31 million will be transferred to ADAMHA from the Office of National Drug

Control policy's Special Forfeiture Fund.

Members of the subcommittee likely are aware of the very encouraging trends evident in the most recent results of the National Household Survey on

Drug Use and the annual High School Senior survey. I suspect, too, that some

of you may be concerned about apparent disparities between these promising

survey results on the one hand and, on the other, the deaths,

hospitalizations, crime, and other tragic consequences of drug use-particularly among young Black males, among the families of drug users who are

put at high risk for AIDS, and in infants who are born addicted.

We are confident that the declines in drug use that we are reporting are real and quite significant from a public health perspective. Incremental annual declines in most categories of drug use are cumulatively convincing-in 1982, for example, 66% of all High School seniors had some illicit drug taking experience. By 1990, fewer than half of all seniors reported any lifetime drug use--that is a reduction of one fourth. Even more meaningful clinically are the drops we're seeing in past year use of drugs, between the year of "peak" use and 1990's rates. At 32.5%, "past year" use of any illicit drug in 1990 is down by 40% since the peak year 1979, when over half of all

seniors reported use. Past year cocaine use dropped by nearly two-thirds since 1985; crack is down by a half since 1986; and marijuana is down by half

since 1979.

These trends are the cutting edge of the future; conversely, the excessive morbidity and mortality that we are seeing today in many cities are

inevitable shadows of the past. For the addicts and victims of drug abuse for

whom primary prevention is not an appropriate response, as well as for persons with alcohol disorders and serious mental illnesses, research on fundamental

mechanisms of brain and behavior, and an array of effective treatments are needed urgently. Let me offer highlights of our progress toward these ends.

Concerned by reports that infants whose mothers used cocaine during

pregnancy have abnormal breathing patterns and may be at increased risk of

sudden infant death syndrome (SIDS), NIDA investigators ascertained that

infants and children with apnea have high levels of endogenous opioid peptide

beta-endorphin in their cerebrospinal fluid that might be involved in SIDS and

in the respiratory difficulties associated with the apnea of infancy. In

evaluations of a potential therapy using an opioid antagonist, naltrexone, no

abnormal respiratory events occurred following naltrexone therapy. The

therapy's potential needs to be evaluated in cocaine babies who have

respiratory difficulties during infancy.

In research demonstrations designed to study and change high-risk

behaviors of intravenous drug users (IVDUS) and their sexual partners, NIDA

investigators found that, over six months, educational outreach resulted in

decreased frequency of drug injection in 49- to 75% of users and cessation of

all IV use in 16 to 47%. These and other high risk behavior changes strongly.

support the effectiveness of outreach to IVDUS.

NIMH intramural scientists using positron emission brain imaging

techniques (PET scans) found specific abnormalities in adults who had a

childhood history of attention-deficit hyperactivity disorder (ADHD).

Affecting 3 to 5 percent of the Nation's youth under 13, ADHD is a risk factor

for juvenile delinquency and, for many, lifelong problems. Findings that a

significant number of children with ADHD have a parent with the condition

indicate that the disorder is a distinct, often inherited, neurological

problem rather than a result of poor parenting or character weakness.

NIMH investigators found that cocaine use, independent of any other drug

use, is an exceptionally strong risk factor for attempted suicide. Analyses

of data from NIMH's Epidemiologic Catchment Area study of the mental health of

Americans identified a major depressive episode, active alcohol

abuse/dependence, and separation or divorce as additional strong risk factors

that have a cumulative effect on the probability of attempted suicide.

An apparent marker of and possible contributor to the occurrence of AIDS

dementia has been identified by NIMH investigators.

Quinolinic acid,

a

metabolite of the naturally occurring brain amino acid tryptophan, is normally

present in the brain in low levels, but the high concentrations typically seen

in HIV-infected patients can cause convulsions and damage to brain tissue.

Animal studies have shown that in monkeys infected with simian

immunodeficiency virus (SIV), which resembles HIV infection, the key enzyme

responsible for the production of quinolinic acid is elevated up to 6800% over

uninfected control animals. Quinolinic acid levels diminish markedly

following AZT treatment.

Recently analyzed data from the ECA study show the median age of onset

for several forms of major mental illness, including depression and manic

depression, are considerably younger than previously known. Men and women

were two to three times more likely to develop major depression between the

ages of 15 and 19 than after the age of 19. Median age of onset for manic

depression (bipolar disorder) is 19 years; for phobia, 13 years, and for

substance abuse disorders, the late teens.

In addition to highlighting the urgency of early prevention,

identification and treatment, these findings will add impetus to research on

the comorbidity: or co-occurrence, of mental and addictive disorders.

An

analysis conducted last year of data on the prevalence of mental disorders and

substance abuse among the adult U.S. population indicate that 30% of adults

who have ever had a mental disorder also have had a diagnosable alcohol and/or

durg abuse disorder during their lives. More than half (53%) of adults who

have had drug abuse disorders have had one or more mental disorders. And 37%

of adults who ever have been alcohol abusers have had one or more mental

disorders. The findings underscore the importance for health care providers

to be alert to the need to treat more than one problem and, from a scientific

perspective, raise intriguing questions regarding the etiologic mechanisms

underlying these high rates of comorbidity.

NIAAA investigators last year clarified why women are more susceptible

than men to such effects of alcohol as blood alcohol concentrations and liver

disease. Although the liver is the primary site of alcohol elimination,

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oxidation of ethanol by alcohol dehydrogenase in the gastric mucosa also

contributes to the removal of alcohol.

This "first-pass" metabolism of

ethanol occurs to a lesser extent in women than in men, and is virtually non

existent in alcoholic women.

These findings, which help clarify many previous

apparently contradictory results on sex-related differences in blood ethanol

concentrations, are one reflection of ADAMHA's concern with women's health

issues.

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