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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
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 setaside 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 deve lopment 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 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
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 manicdepression, 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 manicdepression (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, 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 nonexistent 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